Test 3 Flashcards
Triage is french for
To sort
Red tag characteristics
absent breath sounds with a pulse –> needs critical attention !
Yellow tag characteristics
Broken bone. needs to be seen but not immediately (would be sent to an outlying hospital)
Green card characteristics
Minor injuries–> send to another hospital
Black card
close to dying or already dead –> no hope
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
bleeding with open wound and absent breath sounds
Primary Survey
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)
You encounter a bad accident on the side of the road and decide to stop. Where do you park your car?
Put hazards on, drive past scene, and run back
Primary Survey “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
Primary survey B
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
Primary Survey C
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
Primary Survey D
(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
Primary Survey E
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.
Secondary Survey F
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 )
Secondary Survey G
Give comfort Pain management Reduce anxiety Reassurance/establish trust Environment control
Physical first! Meet physical needs then psychosocial
Secondary Survey H
Obtain History
– Head to Toe Physical Exam
Secondary Survey I
(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
trachea is deviated to the right. what can this indicate?
Possible tension pneumo which is life threatening!
Abdominal assessment
Inspect, auscultate, palpate
abdominal lavage
iced saline or ice to constrict blood vessels
what can loss of rectal sphincter tone indicate?
Spinal cord injury
Do you use NS or LR’s for resuscitation?
NS. LR contains electrolytes and you dont know their status.
For hypovolemic shock, which blood product are you going to give?
PRBCs because they carry O2
When would you give FFP?
Help with clotting deficiencies without adding extra volume
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
What are you watching for in a possible splenic lac?
Distended abd. Obtain ultrasound
universal donor
O-
who is at most risk for heat related injury?
athletes and elderly
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
Why do you give thorazine to someone with heat related injury?
Shivering increases tem–> bad
Someone is found down for an unknown amount of time, What are they at risk for?
rhabdomyolysis/myoglobinuria
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
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
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
Hypothermia
Elderly are more prone to hypothermia
Mild (90-95 degrees F)
Moderate (87 to 90 degrees F)
Profound (< 86 degrees F) life threatening
Cold related goals
Rewarm
Correct dehydration, acidosis
Protect Airway
Treat cardiac rhythms
Active core rewarming (profound)
Humidified oxygen Warm IV fluids Lavage (bladder, gastric) Peritoneal dialysis, Hemodialysis Cardiopulmonary bypass
Submersion injury goals
Correct hypoxia
Correct acid-base
Correct fluid
ABC
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)
What is the worst type of bite?
Human
What does activated charcoal do?
Binds to toxin neutralizing it and inducing diarrhea
If someone drinks antifreeze, what intervention will they need?
hemodialysis
poisoning medications
Mucomyst (Tylenol)
Ca+ channel blockers (Verapamil)
Emergency
extraordinary event requiring a rapid and skilled response
MCI
natural or manmade disaster that overwhelms the resources of a community
CERT
community emergency response team
DMAT
Disaster Medical Assistance Team
where do you level an ICP pressure transducer?
mid-ear or monroe foreaman
ICP range
0-15 mm hg
sustained =tx
total Volume in the skull
1900 ml
Monroe Kelly doctrine Factors influencing ICP
Arterial and Venous pressure Intraabdominal pressure Intrathoracic pressure Posture Temperature (hypo) CO2 level (ABG)
Monroe Kellie doctrine
Dura expansion Increase venous outflow Decrease CSF production Change blood volume Constriction Dilation Brain tissue compression Compensate – UP TO A POINT
how many mL flow through 100g of brain tissue in 1 minute ?
50 mL / min
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
Cerebra pulse pressure formula
CPP= MAP-ICP CPP= flow X resistance
What CPP indicates ischemia incompatible with life ?
<30 mm hg
Cushings triad
loss of auto autoregulation
Wide pulse pressure, bradycardia, and decreased RR are sx’s of what ?
Cushing’s triad
vasogenic cerebral edema
Most common
White matter
Cerebral cap endothelial lining leaks into extracellular space
cytotoxic cerebral edema
Gray matter
Cell membrane dysfunction
Extracellcular fluid shifts into cell
interstitial cerebral edema
Diffusion of ventricular CSF
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
IIP manifestations depend on what ?
Depend on location, cause and rate of pressure increase
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
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
Ventriculostomy
Measuring ICP
diagnostic tests for IIP
CT/MRI EEG cerebral angiogram cerebral blood flow transcranial doppler PET scan
Why can you not do an LP with IIP ?
CSF decreasing too quickly can cause cerebral herniation
Nursing goals for IIP
Identify cause/treat Adequate CPP Normothermic Pain control Recognize early changes Cognitive Motor Sensory Prevent complications, i.e., infection
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
Mannitol
Osmotic Diuretic
hypertonic solution to remove cerebral tissue fluid
25% Osmitrol (rapid administration, plasma expansion, osmotic effect)
Lasix, Bumex with IIP
loop diuretics decrease NACL reabsorption and CSF production
Corticosteroids
tumor / abscess, not head injuries
decadron
side effects: GI bleeding, hyperglycemia, infection
increased IIP interventions limited hyperventilation
Limited Hyperventilation
PaCO2 < 25 mm Hg
PaCO2 is a potent vasodilator
Suction – minimal (increase ICP)
IIP nutrition interventions
TPN/lipds (glucose)
Enteral Feedings
DBHT, NGT
Nutritional consult
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
increased IIP infection interventions
aseptic technique
psychosocial issues (patient and family ) with IIP
possible death, organ donation
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
scalp lac
minor, direct pressure; staples, sutures
skull fx
Linear or depressed
Simple, Comminuted, Compound
Open or closed
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?
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
major head trauma- contusions
Brain bruising at site
Level of Consciousness changes
Seizure (common complication)
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
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.
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
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
Skull fx interventions
Craniotomy
Remove or elevate loose fragments
Craniectomy/cranioplasty
Hematoma interventions
Craniotomy to control venous/arterial bleed site
Decompression via drain
Burr Hole (emergent cases)
Continuous monitoring Neuro
General head injury interventions
Tetanus toxoid
Antibiotics prophylactic
Chronic problems post brain injury
Bowel and bladder Nutrition (chewing, swallowing) Respiratory (trach) Speech Personality changes Seizures ABOVE (Temporary or Permanent)
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
Stroke
ischemia to part of the brain resulting in brain cell death
Brain attack
synonym used to convey the urgency necessary for recognition and treatment of clinical symptoms.
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
Types of ischemic stroke
thrombotic
embolic
ischemic cascade
Thrombotic stroke
Injury to a vessel and formation of a blood clot; most common cause of stroke
Embolic stroke
Embolus lodges and occludes an artery; Causes include: AF, MI, Endocarditis , ASD, RHD, Atherosclerosis
Ischemic cascade
metabolic events in response to ischemia; including inadequate ATP, release of AA & free radical formation and cell death
Two types of hemorrhagic strokes
- inter cerebra hemorrhage
2. subarachnoid hemorrhage
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
In an intercerebral hemorrhage, where is it the most serious if the bleeding is?
Bleeding into Pons is most serious
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
Pt states “I have the worst headache of my life.” What do you suspect they have ?
Subarachnoid Hemorrhage
What causes an anoxic brain injury?
Swelling the brain casques decreased perfusion
Clinical manifestations of hemorrhage: Motor functions
Mobility, Respiratory, Speech & Swallowing, Self-care abilities
Clinical manifestations of hemorrhage: communication
Aphasia and Dysphasia
Aphasia
I cant speak
Dysphagia
I cant swallow
Clinical manifestations of hemorrhage: Affect
Control of emotions
Clinical manifestations of hemorrhage: Intellectual funciton
memory and judgment
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
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
Clinical manifestations of hemorrhage: elimination
Both bladder and bowel
diagnostic studies for stroke
CT CTA MRI Angiography: Gold standard -Carotid Arteries TCD: Transcranial Doppler EEG LP
primary stroke prevention
Healthy Diet Weight Control Regular Exercise No smoking Limiting Alcohol consumption Routine check-up
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
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
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
Surgical therapy for stroke (Aneursyms and Hemmorhage)
Coiling done in interventional radiology
Clipping
Surgical resection of AVM
Removal of bone flap
Surgical therapy for ischemic stroke
Ischemic Stoke
-MERCI: Mechanical embolus retrival in cerebral ischemia
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
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
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.
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.
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
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)
Extubation death
Increased carbon dioxide levels quickly lead to loss of consciousness = peaceful death.
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.
Lazarus sign
probably triggered by hypoxia, in which certain spinal motor neurons fire and a brain dead patient may move or even sit up.
