Test 3 Flashcards
1
Q
Triage is french for
A
To sort
2
Q
Red tag characteristics
A
absent breath sounds with a pulse –> needs critical attention !
3
Q
Yellow tag characteristics
A
Broken bone. needs to be seen but not immediately (would be sent to an outlying hospital)
4
Q
Green card characteristics
A
Minor injuries–> send to another hospital
5
Q
Black card
A
close to dying or already dead –> no hope
6
Q
at the scene of a disaster (plane crash) which of the following patients would get the CC bed?
- bruised and confused
- closed fx
- bleeding with open wound and absent breath sounds
- 4 month old lethargic and pulse of 30
A
bleeding with open wound and absent breath sounds
7
Q
Primary Survey
A
A: Airway & C-spine stabilization/immobilized
B: Breathing
C: Circulation
D: Disability (Pupil assessment, neuro assessment–> what is your name/ where are you?)
E: Exposure/Environmental Control (look for impalements)
8
Q
You encounter a bad accident on the side of the road and decide to stop. Where do you park your car?
A
Put hazards on, drive past scene, and run back
9
Q
Primary Survey “A”
A
Airway and C-spine stabilization
Obstruction (blood, saliva, vomit, direct trauma)
Primary S&S:
Cervical spine injury?- Jaw-thrust maneuver
Back board and/or rigid C-Collar/ head blocks
C spine–> houses brain stem. Use hands on side of face and hold still. Don’t move head if it is moved
Suction/removal of FB/ oral airway
Oxygen (least to most invasive)
NC to ETT (RSI) to cricohthyroidotomy
Depending if awake or not
10
Q
Primary survey B
A
Breathing – Stop, Look and Listen
100% oxygen via whatever route needed
Why? Fx ribs, PE, Pneumothorax, flail chest, Hemopneumothorax, direct injury
Interventions: O2 by assist BVM, needle decompression, intubation and treat underlying cause
11
Q
Primary Survey C
A
Circulation Note: No BP now, later Cardiac Output Pulses (carotid, femoral)? AMS? Cap refill? Neck Veins?
Think Bleeding!! Interventions Control hemorrhage/start IVs (two 14 G) External – direct pressure to site Internal – IV fluids, transport Consider Rapid infuser Obtain sample for T&C
12
Q
Primary Survey D
A
(D) Disabilty – Mental Status Exam (brief)
LOC: AVPU?
For baseline assessment of neuro dissabilty
Pupils: size/shape/reactivity
MINI Glasgow Coma Scale
Eye opening
Speech
Motor function
13
Q
Primary Survey E
A
Exposure/Environmental Control
Remove all clothing-May require cutting off
Watch for evidence (dont cut through GSW or stab would)
Assess blunt vs. penetrating trauma
- Impalement
NOTE: DO NOT REMOVE OBJECT
Cover with warm blankets/may need other warming measures
Monitor scene: Safety first.
14
Q
Secondary Survey F
A
Full Set of Vital Signs (Only have pulse and RR up to this point now you will get BP and O2 sat and temp)
Family presence Maybe saw what happened History Facilitate interventions EKG: O2 saturation: Portable CXR: Foley Catheter/NGT/OGT: to see if bleeding is present
Labs/Diagnostics Consider Tetanus ( ask when last one was )
15
Q
Secondary Survey G
A
Give comfort Pain management Reduce anxiety Reassurance/establish trust Environment control
Physical first! Meet physical needs then psychosocial
16
Q
Secondary Survey H
A
Obtain History
– Head to Toe Physical Exam
17
Q
Secondary Survey I
A
(I)- Inspect Posterior Surfaces
Look for pooling blood, bruises, exit wounds, burns, impailments. Do not move backboard until cleared by DR.
Rolling on a board you want at lest 4 people
18
Q
trachea is deviated to the right. what can this indicate?
A
Possible tension pneumo which is life threatening!
19
Q
Abdominal assessment
A
Inspect, auscultate, palpate
20
Q
abdominal lavage
A
iced saline or ice to constrict blood vessels
21
Q
what can loss of rectal sphincter tone indicate?
A
Spinal cord injury
22
Q
Do you use NS or LR’s for resuscitation?
A
NS. LR contains electrolytes and you dont know their status.
23
Q
For hypovolemic shock, which blood product are you going to give?
A
PRBCs because they carry O2
24
Q
When would you give FFP?
A
Help with clotting deficiencies without adding extra volume
25
what are you at risk for with a liver lac? What dont you want to give?
Liver is responsible for balancing lactic levels (broken down) if lactic acid is rising then you don’t want to give LR
26
What are you watching for in a possible splenic lac?
Distended abd. Obtain ultrasound
27
universal donor
O-
28
who is at most risk for heat related injury?
athletes and elderly
29
Heat Stoke
MOST SERIOUS
Failure of hypothalamus which regulates sweating/ temperature--> pt is dry because they don't sweat!
```
Initial S/S
Increased sweating, vasodilation & RR
Secondary S/S
105 degrees
LOC changes
No perspiration
Skin – dry, hot, ashen
```
30
Why do you give thorazine to someone with heat related injury?
Shivering increases tem--> bad
31
Someone is found down for an unknown amount of time, What are they at risk for?
rhabdomyolysis/myoglobinuria
32
heat related interventions
Oxygen
Fluids & Electrolyte balance correction
Cooling methods
Cooling blankets
Ice packs
Ice water lavage
Cold water peritoneal dialysis
Cardiopulmonary bypass
No antipyretic USED
A lot of times unconscious and need to be intubated
That high of a temperature proteins in your brain are denatured and cannot go back –leading to seizures
Cool as quickly as possible! Pack groin and underarms with ice.
Ice lavage is the best way to cool the body ice water in the stomach and then pull back out
33
Frost bite
Superficial (skin/subcutaneous tissue):
ears/nose/fingers/toes
Waxy yellow to blue mottled, crunchy tissue
Rx: Warm water immersion
```
Deep
bone, muscle, tendon
White, hard skin; insensitive to touch
Rx: Warm water immersion, edema reduction; tetanus shot; possible amputation
Amputation gangrene
```
34
If someone is hypothermic, why do you want to warm them slowly?
At risk for re-profusion arrythmia
| not dead until you are warm and dead
35
Hypothermia
Elderly are more prone to hypothermia
Mild (90-95 degrees F)
Moderate (87 to 90 degrees F)
Profound (< 86 degrees F) life threatening
36
Cold related goals
Rewarm
Correct dehydration, acidosis
Protect Airway
Treat cardiac rhythms
37
Active core rewarming (profound)
```
Humidified oxygen
Warm IV fluids
Lavage (bladder, gastric)
Peritoneal dialysis, Hemodialysis
Cardiopulmonary bypass
```
38
Submersion injury goals
Correct hypoxia
Correct acid-base
Correct fluid
ABC
39
Submersion injury interventions
Oxygen, consider vent?
LOC changes? Mannitol, Lasix?
Monitor 4-6 hours post
Delayed pulmonary edema (fluid shifting NOT cardio)
Fluid moving to the Alvioli aka area has been injured like when you bang your elbow and it swells -->dry drowning
Systemic inflammation response (fluid shifting)
40
What is the worst type of bite?
Human
41
What does activated charcoal do?
Binds to toxin neutralizing it and inducing diarrhea
42
If someone drinks antifreeze, what intervention will they need?
hemodialysis
43
poisoning medications
Mucomyst (Tylenol)
| Ca+ channel blockers (Verapamil)
44
Emergency
extraordinary event requiring a rapid and skilled response
45
MCI
natural or manmade disaster that overwhelms the resources of a community
46
CERT
community emergency response team
47
DMAT
Disaster Medical Assistance Team
48
where do you level an ICP pressure transducer?
mid-ear or monroe foreaman
49
ICP range
0-15 mm hg
| sustained =tx
50
total Volume in the skull
1900 ml
51
Monroe Kelly doctrine Factors influencing ICP
```
Arterial and Venous pressure
Intraabdominal pressure
Intrathoracic pressure
Posture
Temperature (hypo)
CO2 level (ABG)
```
52
Monroe Kellie doctrine
```
Dura expansion
Increase venous outflow
Decrease CSF production
Change blood volume
Constriction
Dilation
Brain tissue compression
Compensate – UP TO A POINT
```
53
how many mL flow through 100g of brain tissue in 1 minute ?
50 mL / min
54
what is the purpose of automatic alteration of cerebral blood vessels diameter in response to systemic arterial pressure changes
Consistent blood flow
Metabolic needs
Maintain CPP
55
Cerebra pulse pressure formula
```
CPP= MAP-ICP
CPP= flow X resistance
```
56
What CPP indicates ischemia incompatible with life ?
<30 mm hg
57
Cushings triad
loss of auto autoregulation
58
Wide pulse pressure, bradycardia, and decreased RR are sx's of what ?
Cushing's triad
59
vasogenic cerebral edema
Most common
White matter
Cerebral cap endothelial lining leaks into extracellular space
60
cytotoxic cerebral edema
Gray matter
Cell membrane dysfunction
Extracellcular fluid shifts into cell
61
interstitial cerebral edema
Diffusion of ventricular CSF
62
Increased Intracranial Pressures etiology
Mass Lesion: hematoma, tumor, abscess
Cerebral Edema: hydrocehpalus, inflammation
Metabolic Insult
Result: hypercapnia, impaired autoregulation,
acidosis, hypoxia and systemic hypertension.
Untreated could result in herniation and death
63
IIP manifestations depend on what ?
Depend on location, cause and rate of pressure increase
64
clinical manifestations of IIP
```
LOC Change
VS (esp temp)
Cushing’s triad (later)
Ocular signs
Cranial nerves
Pupils changes
Motor changes
Decorticate (flex = in)
Decerebrate (extend = out)
Brainstem involvement (more serious)
Headache
Vomiting
Spontaneous/projectile
```
65
complications of IIP
```
Inadequate CPP
Sustained ICP > 20 mm Hg
Decreasing CPP
Herniation
Cingulate
Lateral, Beneath Falx
Central/transtentorial
Downward
Uncal
Lateral, Downward
Reversible then Irreversible????
Fatal – compression of brainstem and CN = RR arrest
```
66
Ventriculostomy
Measuring ICP
67
diagnostic tests for IIP
```
CT/MRI
EEG
cerebral angiogram
cerebral blood flow
transcranial doppler
PET scan
```
68
Why can you not do an LP with IIP ?
CSF decreasing too quickly can cause cerebral herniation
69
Nursing goals for IIP
```
Identify cause/treat
Adequate CPP
Normothermic
Pain control
Recognize early changes
Cognitive
Motor
Sensory
Prevent complications, i.e., infection
```
70
Nursing interventions for IIP
```
ABC’s: Monitor Respiratory Pattern
ABG: (PaO2, PCO2, pH)
Elevate HOB 30 degrees
Proper alignment, no neck flexion
Neuro assessment
Glasgow Coma Scale: evaluation q 1h
Eye opening (1-4 scale)
Best Verbal response (1-5 scale)
Best Motor response (1-6 scale)
ICP monitor, EVD
SBP – diagnosis/patient specific: daily goals
F&E balance
Temperature management
(Hypothalamus)
decrease metabolic needs (89.6 – 91.4)
Quiet environment
Labs (frequent)
CBC, Lytes
ABG
Na, Osm (frequently)
ICU – Cardiac Monitor
PA, AL (MAP), ICP (CPP), EVD
I/O, foley
```
71
Mannitol
Osmotic Diuretic
hypertonic solution to remove cerebral tissue fluid
25% Osmitrol (rapid administration, plasma expansion, osmotic effect)
72
Lasix, Bumex with IIP
loop diuretics decrease NACL reabsorption and CSF production
73
Corticosteroids
tumor / abscess, not head injuries
decadron
side effects: GI bleeding, hyperglycemia, infection
74
increased IIP interventions limited hyperventilation
Limited Hyperventilation
PaCO2 < 25 mm Hg
PaCO2 is a potent vasodilator
Suction – minimal (increase ICP)
75
IIP nutrition interventions
TPN/lipds (glucose)
Enteral Feedings
DBHT, NGT
Nutritional consult
76
Increased IIP F&E interventions
```
Fluid/electrolyte balance
Fluid – ½ or .9 NS
Meds
Diabetes insipidus (DI)
DDAVP
Pitressin
Paralytics (Norcuron)
Sedation (Propofol, Fentanyl – short acting)
Decrease metabolic demand/anxiety
```
77
increased IIP infection interventions
aseptic technique
78
psychosocial issues (patient and family ) with IIP
possible death, organ donation
79
TBI
```
Craniocerebral trauma
Alteration in LOC
TBI: 1.1 million treated; 235,000 die
High potential for poor outcome
Immediate death
2 hours after injury
3weeks after injury
```
80
scalp lac
minor, direct pressure; staples, sutures
81
skull fx
Linear or depressed
Simple, Comminuted, Compound
Open or closed
82
CSF leakage
Glucose test strip, +
4 x 4 gauze, “halo” – yellow ring around blood area
Both - Blood in fluid, false +
Basilar skull fracture – fracture in skull floor
Battle sign? Raccoon eyes?
83
minor head trauma
```
Concussion
Sudden transient neural activity disruption
Headache
Retrograde amnesia
LOC change
No loss of LOC or Loss of LOC < 5 minutes
Short duration
Discharge instructions
```
84
major head trauma- contusions
Brain bruising at site
Level of Consciousness changes
Seizure (common complication)
85
Major head trauma - lacerations
Lacerations – Brain tissue bleeding at site = intracerebral hemorrhage
Blood slowly reabsorbed
Depth of injury
Unconscious, hemiplegia (contralateral) and dilated pupil (ipsilateral)
Increase ICP
86
blunt trauma
Penetrating
High velocity objects (I.e., bullet)
Low velocity object (I.e., pole, fence)
Coup-contrecoup
a coup injury occurs under the site of impact with an object, and a contrecoup injury occurs on the side opposite the area that was hit. Coup and contrecoup injuries are associated with cerebral contusions, a type of traumatic brain injury in which the brain is bruised.
87
epidural hematoma
Bleed between dura and skull inner surface
Venous (develops slow)
Arterial (develops fast)
+ LOC at scene, lucid, + LOC
Surgical evacuation
Commonly seen in elderly and ETOH patients
88
Subdural Hematoma
Bleed between dura and arachoid layer of meningeal brain covering
Usually venous (slower)
Acute: 24-48 hrs following an injury
Subacute: 2-14 days after injury
Chronic: weeks to months after injury
Tx: Surgical evacuation for large acute SDH
89
Skull fx interventions
Craniotomy
Remove or elevate loose fragments
Craniectomy/cranioplasty
90
Hematoma interventions
Craniotomy to control venous/arterial bleed site
Decompression via drain
Burr Hole (emergent cases)
Continuous monitoring Neuro
91
General head injury interventions
Tetanus toxoid
| Antibiotics prophylactic
92
Chronic problems post brain injury
```
Bowel and bladder
Nutrition (chewing, swallowing)
Respiratory (trach)
Speech
Personality changes
Seizures
ABOVE (Temporary or Permanent)
```
93
Brain death criteria
No spontaneous movement (paralytics, sedation off)
```
No brainstem reflexes
Fixed and dilated pupils
No corneal reflexes
No gag reflex
No vestibular response to caloric stimulation
```
No spontaneous RR on 100% O2 test, ABG
94
Stroke
ischemia to part of the brain resulting in brain cell death
95
Brain attack
synonym used to convey the urgency necessary for recognition and treatment of clinical symptoms.
96
modifiable risk factors for stroke
```
Hypertension- most important
Heart disease/Diabetes/Hyperlipidemia
Smoking
Excessive alcohol consumption
Obesity/Physical inactivity/Sleep Apnea
Drugs: Cocaine/ Birth Control pills
```
97
Types of ischemic stroke
thrombotic
embolic
ischemic cascade
98
Thrombotic stroke
Injury to a vessel and formation of a blood clot; most common cause of stroke
99
Embolic stroke
Embolus lodges and occludes an artery; Causes include: AF, MI, Endocarditis , ASD, RHD, Atherosclerosis
100
Ischemic cascade
metabolic events in response to ischemia; including inadequate ATP, release of AA & free radical formation and cell death
101
Two types of hemorrhagic strokes
1. inter cerebra hemorrhage
| 2. subarachnoid hemorrhage
102
intercerebral hemmorage
Intracerebral Hemorrhage: Bleeding within the brain caused by a ruptured blood vessel
Poor prognosis:
50% die within the first 48 hours
40-80% have 30 day mortality
Hemiplegia to complete paralysis
Coma: body posturing, fixed pupils hyperthermia
**by location and degree**
Intracereberal can be anywhere where you have vasculature which can erupt
103
In an intercerebral hemorrhage, where is it the most serious if the bleeding is?
Bleeding into Pons is most serious
104
Subarachnoid Hemorrhage
Bleeding into the CSF filled space between the arachnoid and pia mater membranes
Most commonly caused by rupture of a cerebral aneurysm
Also caused by AVM (arteriovenous malformation) , trauma, drug abuse
Patient c/o “Worst headache of one’s life”
Sx: N/V, focal deficits, seizures, stiff neck, light is nauseating
105
Pt states "I have the worst headache of my life." What do you suspect they have ?
Subarachnoid Hemorrhage
106
What causes an anoxic brain injury?
Swelling the brain casques decreased perfusion
107
Clinical manifestations of hemorrhage: Motor functions
Mobility, Respiratory, Speech & Swallowing, Self-care abilities
108
Clinical manifestations of hemorrhage: communication
Aphasia and Dysphasia
109
Aphasia
I cant speak
110
Dysphagia
I cant swallow
111
Clinical manifestations of hemorrhage: Affect
Control of emotions
112
Clinical manifestations of hemorrhage: Intellectual funciton
memory and judgment
113
Clinical manifestations of hemorrhage: **Spatial-perceptual alterations **
(NB**) homonymous hemianopsia --> same side of both eyes half without vision--> ex you don’t want a patient with this condition to turn their head to the door because that will increase ICP
114
homonymous hemianopsia
same side of both eyes half without vision--> ex you don’t want a patient with this condition to turn their head to the door because that will increase ICP
115
Clinical manifestations of hemorrhage: elimination
Both bladder and bowel
116
diagnostic studies for stroke
```
CT
CTA
MRI
Angiography: Gold standard -Carotid Arteries
TCD: Transcranial Doppler
EEG
LP
```
117
primary stroke prevention
```
Healthy Diet
Weight Control
Regular Exercise
No smoking
Limiting Alcohol consumption
Routine check-up
```
118
Stroke risk reduction
Drug Therapy
Antiplatlet drugs for TIA/atherosclerosis
ASA is most common
Also: Plavix/Persantine/Coumadin
Surgical Therapy
For know carotid disease:
-CEA(stripping of carotid arteries)/ Angioplasty/ Stenting/EC-IC Bypass
119
Acute care management (stroke)
```
ABC
NVS q 1 hr X 24-48 hrs (get them up and moving out of there to rehab)
Blood pressure management
Fluid & electrolyte balance
HOB @ 30 degrees
Head & Neck alignment
EVD
Pain management/Subarachnoid hemorrhage precautions
```
120
Drug therapy for stroke
```
Osmotic Diuretics -> mannitol
Hypertonic Saline
tPA – within 3 hours of onset of stroke 2 hours for hearts
ASA
Nimodipine
Tylenol
Anti-seizure
```
121
Surgical therapy for stroke (Aneursyms and Hemmorhage)
Coiling done in interventional radiology
Clipping
Surgical resection of AVM
Removal of bone flap
122
Surgical therapy for ischemic stroke
Ischemic Stoke
| -MERCI: Mechanical embolus retrival in cerebral ischemia
123
Coiling and clipping
Wall is thin so it is at risk for leaking or bursting. The neck has been determined to be narrow and then the coils of metal and glue are put in the pocket. If the neck is wide then if comes back out so you would clip it
124
AVM
Vessel walls are thin and they are high risk for bleeding. Commonly congenital and seen in pediatric patients. c/o headaches. Surgeon can come tie off and take out the middle
125
CT of brain should show _____
Cat scan should show symmetry … The picture on the power point shows a bleed with swelling which has smooshed the tissue to the other side. When the left side hits the bone it will herniate and drop down killing them.
126
Craniectomy
Must place a sign saying no bone flap on effected side. Do not turn patient on that side. Make sure space is protected and reflected.
127
collaborative rehab for stroke
```
Stable 12-24 focus shifts to rehab and disability prevention
PT/OT
Speech and Swallow assessment
Case Mgt/Social Worker
Family involvement and education
Rehab facility and/or home care
```
128
Orthodox Jewish law after death
orthodox Jewish law does not allow for anything to be removed from the body after death (if an endotracheal tube or any lines are in place the patient will be buried with them)
129
Extubation death
Increased carbon dioxide levels quickly lead to loss of consciousness = peaceful death.
130
dehydration and dying
Rather than causing suffering, dehydration can actually help dying patients to achieve a painless death.
-Feeding and hydrating during the actively dying phase can actually cause discomfort.
131
Lazarus sign
probably triggered by hypoxia, in which certain spinal motor neurons fire and a brain dead patient may move or even sit up.
