Exam 1 Flashcards
primary goal of pre hospital mgmt
move pt to location that will provide definitive treatment
priorities in trauma situation (5) pre hospital
- Maintain airway
- Ensure adequate ventilation
- Control external bleeding and prevent shock
- Maintain spine immobilization
- Transport to appropriate facility
golden hour
first hour following trauma
what is the responsibility of the EMTs
stabilizing and resuscitating
3 Ts
Triage, treatment, transport
primary goal of in hospital mgmt
adhering to trauma Care protocol to allow for efficient ID of life threatening conditions
D2N
door to needle
TPA
60 minutes
D2B
door to balloon
PTI
90 minutes
3 things to diagnose STEMI
chest pain
EKG changes
elevated cardiac biomarkers (troponin, CK-MB)
what EKG changes do you see for ischemia
Can have ST depression and/or T wave inversion
what does ST elevation indicate
injury
QRS does not come back to baseline
what does Q wave indicate
infarct = death of tissue
usually happens in hours
what population may not complain of chest pain
diabetics
how to avoid ST elevation?
thrombolytic (TPA, alteplase)
how to know if a thrombolytic works?
ST will go back down
what is CABG?
Coronary artery bypass grafting
Healthy artery or vein is grafted to the blocked coronary artery –> One end is attached to the aorta with the other end attached to the block coronary distal to the occlusion → bypasses blocked portion of artery allowing blood flow to the cardiac tissue
why would you do a PCI vs. CABG?
PCI is for one area in one vessel
CBG - may be better for someone with weak heart that needs revascularization
normal troponin level
0.04
what is troponin?
Cardiac troponin I and T are proteins expressed exclusively in the heart, are a specific marker or muscle damage
Can be elevated within 4 hours of injury and can stay elevated for 10 days
what is creatine kinase
general marker of cellular injury
Released from cells in brain, skeletal muscle, and cardiac tissues after muscle damage has occurred
what is CK-MB and when does it show up
CK isoenzyme marker specific to cardiac tissue
When myocardial damage occurs, CK-MB is released from cells
Can show up 3-36 hours
what does ACS include
unstable angina, NSTEMI, STEMI
what does telemetry show
rate and rhythm only
when did triage start
Triage started in 1854 during Crimea war - Florence Nightingale
when/where/who created first US Clinical shock trauma unit
1961, Baltimore, R. Adams Crowley
who is R. Adams Crowley
father of the golden hour
when/where first civilian trauma unit
1966, Cook County, Chicago
where 3 levels of trauma were first identified
what did the 1966 highway safety act say
Said each state must include emergency medicine services as part of highway safety
Mobile intensive care unit EMS
what is the emergency medical services act
1973
15 components
Most important: identifies what type of emergency care an ED must have if designated as a trauma center
Trauma nurse certification course
what is included in primary survey during in hospital mgmt
Airway management
Breathing
Circulation
D - identify disability that is obvious to you (broken bone), neuro assessment
Exposure - measure to completely undress patient so that obvious and potential injuries
what is part of the tertiary survey (and ex)
Includes variables that will compact trauma
Ex: Pt over 75 or w/ substance abuse issue has a greater risk of not doing as well
5 priorities in hospital mgmt
primary survey
secondary survey
tertiary survey
fluid resuscitation
damage control/definitive care
ESI
emergency severity index, a five level system
ESI level 1
Presents with a life threatening condition at a resuscitation level
First is worst, most severe
ESI level 2
needs attention quickly, assessed by a nurse in 15 minutes
Examples: unstable, listless child, significant dehydration, severe pain
ESI level 3
urgent, has the potential to progress, assessed in 30 minutes.
Examples: acute abdominal pain, chest pain without diaphoresis
ESI level 4
less urgent, less potential for deterioration, needs to be assessed within an hour
Examples: burning on urination, elevated temp less than 101 degrees
ESI level 5
no acute problem
Examples: suture removal, medication renewal
what is part of RN triage assessment (5)
-history of presenting complaint
-pertinent medical history
-physical assessment
-vital signs with orthostatics, pulse ox
- current meds, allergies
orthostatics
BP lying, sitting, and standing with a minute b/w each reading
what does a + orthostatic mean
Positive orthostatics if greater than 10% difference
What would you look for? HR will go up and BP will go down
5 nursing interventions in triage
Fever medications as per protocol
All lacerations must be dressed
All suspected fractures need to be immobilized
Antihypertensive medications as per protocol
Pain medications as per protocol
possible causes of unconscious patient (7)
head and neck trauma,
drug/ETOH overdose,
meningitis,
metabolic conditions like hypoglycemia,
cardiac arrest,
toxins,
acute stroke
clinical manifestations of unconscious patient
unarguable, altered neuro assessment and vital signs, pupillary changes, involuntary movements
how to tx unconscious patient
NARCAN and glucose
LOC: alert and oriented
Name, where they are, month/date/year, why are they in the hospital
LOC: lethargic
Drowsy but will follow simple commands and makes sense
LOC: obtunded
Arousable with stimulation, can follow simple commands
LOC: stuporous
Hard to arouse, inconsistently following commands, limited spontaneous movements
LOC: semi comatose
Movements are purposeful when stimulated but not following commands or speaking coherently
LOC: comatose
Patient may respond with reflexive posturing
Can still be breathing on their own and maintain BP and HR
Light vs deep coma
level 1 trauma center
serves a region
level 2 trauma center
serves a community
level 3 trauma center
Stabilizes and transfers to trauma center
level 4 trauma center
is a clinic that serves as an entry into the system
blunt trauma
w/o penetration of skin- don’t know extent of injury
Common with MVAs, sports injuries, falls
CT scan is most valuable tool
penetrating trauma
Injury from moving object that interrupts the skin
Firearms, knives, etc.
Can’t tell extent of internal damage
Do not remove whatever is there - it is removed in OR
what age is injury rate the highest
15-24 y.o
is trauma more common in males or females
2.5x higher for males than females - more likely
is incidence of trauma higher in rural or urban areas
rural areas
is incidence of trauma higher in low income or high income areas
low income
3 mediators of injury response
Underlying medical conditions
Drug ingestion
Age related variances
what is AVPU
baseline evaluation of patient’s neurological status
A-V-P-U
A = alert
V = response to voice
P = response to pain
U = unresponsive
warning signs for airway
Stridor
A crowing noise on inspiration
Gurgling
Hoarseness
3 interventions for airway
c-spine immobilization
Jaw thrust maneuver
endotracheal intubation
purpose / dangers of removing all clothing (e- exposure)
Purpose: allow entire body to be examined for evidence of trauma
Important: preserve forensic evidence
Danger: hypothermia
automaticity
ability to spontaneously generate an electrical impulse
conductivity
transmission of electrical impulse to another cardiac cell
excitability
ability to respond to electrical impulse
contractility
ability to contract after impulse is received
rhythmicity
ability to send impulses in a regular, paced manner
refractory period
cells’ inability to respond to another impulse during a certain time in the cardiac cycle
conduction system transmission steps
SA node → AV node → into ventricles through Purkinje fibers and right and left bundles
which comes first: electrical or mechanical activity
electrical
CO equation
HR x SV
what is SV
Stroke volume = blood ejected from LV after ventricular contraction
normal CO for healthy adult
4-8L per minute
SA node intrinsic rate
60-100 bpm
AV node intrinsic rate
40-60bpm
ventricle intrinsic rate
20-40 bpm
purpose of EKG
register heart’s electrical activity
used to diagnose/look for ischemia and infarct
P wave
Positive deflection that appears in the beginning of the normal EKG complex
Represents atrial depolarization
QRS complex
3 different waves, represents ventricular depolarization
Q wave
an initial negative deflection
Q represents pathology
If you see a Q - means MI
R wave
positive deflection
S wave
any subsequent negative deflection
T wave
Positive deflection following QRS complex
Represents ventricular repolarization
Have to have T wave in order to stimulate the heart cells and start depolarization all over again
P-R interval
- Measured from the beginning of P wave to beginning of QRS
- Normal - 0.12 - 0.20 seconds
- Represents length of time for impulse from SA node to get through atria and to AV node to start ventricular depolarization
QRS complex
Measured from the beginning of the Q (or R if there is no Q) to the end of the S
Start from beginning of deflection
Normal is 0.05 - 0.11 seconds
-reflects the amount of time for ventricles to depolarize
what if the QRS is longer than .12 seconds?
there is some sort of pathology that is making the time it takes to get the ventricles ready to contract much longer (i.e. bundle branch block)
what is the QT interval
Measured from beginning of the Q to the end of the T wave
Indicates the total time interval from the beginning of depolarization and end of repolarization
normal is < .44 seconds
ST segment
Beginning of the end of the S to the beginning of the T
It is not measured but the shape and location are evaluated
elevated in STEMI
