Week 3 ED/Disaster Flashcards
Most common patient safety issues
patient identification, fall risks, skin breakdown, medication errors and adverse events
Core competencies of emergency nursing
assessment, priority setting, clinical decision making, multitasking and communication
Emergent triage
a condition poses immediate risk to life or limb
Urgent triage
should be treated quickly but a threat to life does not exist
ex: new onset pneumonia, renal colic, complex lacerations, displaced fractures or dislocations and fever over 101
Nonurgent triage
can tolerate several hours without care
ex: sprains, simple fractures, cold sx and rashes
Emergency severity index (ESI)
categorizes PTs from level 1 (emergent) to level 5 (nonurgent)
Canadian triage acuity scale (CTAS)
uses lists of descriptors to establish a triage level
Mistriage
a PT safety risk that can delay care or cause inadequate care
Example of intentional trauma
assault, homicide, suidice
Blunt trauma
results from impact forces like in a car crash or fall from a height
Injury is caused by rapid acceleration-deceleration
Penetrating trauma
results from sharp objects or projectiles
Primary survey
the initial assessment of the trauma victim
Based on ABC plus D (disability) and E (exposure)
Resuscitation efforts occur at the same time as the survey
Airway intervention for a breathing PT
Non-rebreather mask
Airway intervention for someone needing ventilatory assistance
Bag valve mask with 100% O2
Airway intervention for someone with significantly impaired respirations and cognitive status
Intubation with an ET tube and mechanical ventilation
Breathing assessment
determines if ventilatory efforts are effective, not just if the PT is breathing
What to do if CPR is necessary on a ventilated PT
Disconnect the ventilator and manually ventilate with a BVM
What is the main indication to perform chest decompression and how is it done?
Tension pneumothorax
a needle or chest tube is used to vent trapped air
S/Sx of a tension pneumothorax
decreased or absent breath sounds, respiratory distress, hypotension, JVD and tracheal deviation (late sign)
BP estimates in trauma situations: presence of radial pulse
BP at least 80
BP estimates in trauma situations: presence of femoral pulse
BP at least 70
BP estimates in trauma situations: presence of carotid pulse
BP at least 60
Best IV access gauge and site in trauma
16 gauge in the antecubital area (bend of the elbow) Central catheters (8.5fr) can also be used in femoral, subclavian or jugular veins
IV solutions of choice in trauma
Ringers lactate and NS 0.9% warmed before administration to prevent hypothermia
AVPU test
disability exam to provide neurologic baseline status A: Alert V: responds to Voice P: responds to Pain U: Unresponsive
Glasgow coma scale
A test to determine LOC based on eye opening, verbal response and motor response. Lowest score is 3 and a normal score is 15
Body temperature of hypothermia
=< 97F (36C)
Who is at risk for hypothermia?
Injured patients, especially with burns
S/Sx of hypothermia
vasoconstriction, difficulty with IV access, coagulopathy, increased bleeding and slowed drug metabolism
Interventions to prevent hypothermia
remove wet sheets/clothing, cover PT with blankets, infust warm IV solutions and blood, set room temp 75-80, use heating lamps and warming blankets
Glasgow coma scale of 8 or less
the PT is at risk for airway compromise, prepare for intubation and mechanical ventilation
Secondary survey
Done after immediate threats to life have passed to identify other injuries or issues that require tx
SBIRT
Screening
Brief Intervention
Referral to Treatment
A screening tool for alcoholics. Trauma centers are required to screen for alcoholics and refer/educate them
Delirium in the ED
older adults are most at risk, they need to be reoriented frequently
Undiagnosed delirium increases mortality risk
Proper maneuver to manually align the neck and open the airway
Jaw thrust maneuver
When to use O2 during resuscitation
All PTs receive O2 during resuscitation
When to remove PT clothing
Always remove clothing to allow for a through physical assessment
When to cut away PT clothing
When access to the body is needed rapidly
When limb manipulation would cause harm
When chemical burns have melted fabrics into skin
Disaster defined
an event in which illness or injury exceed resource capabilities of the health care facility or community
Internal disaster
event inside the healthcare facility that could endanger patients or staff such as fire. Evacuation is required and the desired outcome is safety
External disaster
Occurs in the community and activates the facilities emergency plan. The number of staff is not adequate for the number of incoming patients
Mulit vs mass casualty event
Multi casualty event can be managed using local resources
Mass casualty event overwhelms resources and requires collaboration of other agencies
Nurses roles in responding to a facility fire
D/C O2 for those who can breathe without it
Ventilate PTs manually while being moved
Ask ambulatory PTs to push PTs in wheelchairs
Who may perform triage in the field?
EMS providers like EMTs, paramedics, nurses and doctors
Disaster triage tag system
used in mass casualty triage and prioritizes patients by color and number
Function of the hospital incident commander
is responsible for implementing the disaster plan, they are usually an MD or hospital administrator
Function of the medical command physician
responsible for determining the number, needs and acuity of arriving victims and organizing appropriate specially trained providers for care such as trauma or burn surgens
Function of the triage officer
evaluates each person that comes to the hospital, even those with triage tags in place
MCI
mass casualty incident
NIMS
National incident management system
NRF
National disaster response framework
ICS
Incident command system
HICS
Hospital incident command system
NIMS functions
procedural preparedness resource management communication helps all responders know what to do when they get to the scene
Who is the incident commander
house supervisor or administrative lea son
First Responders scene assessment
looking for hazards in the environment
First Responders scene size up
look at type of incident, how many victims, severity of injuries
First Responders sending information
working to establish a command center
First Responders scent set up
establish staging and treatment areas, look at best ways to get emergency vehicles in and out
START triage step 1
Tell ambulatory PTs to walk away, they get a green tag
START triage step 2
Triage officer assesses patients in the order in which they are encountered Assess for spontaneous respirations If apneic, open airway If patient remains apneic, tag as Black If patient starts breathing, tag as Red
START triage step 3
Assess respiratory rate
If ≤30, proceed to Step 4
If > 30, tag patient as Red
START triage step 4
Assess capillary refill
If ≤ 2 seconds, move to Step 5
If > 2 seconds, tag as Red
START triage step 5
Assess mental status
If able to obey commands, tag as Yellow
If unable to obey commands, tag as Red
Who do you protect first in an exposure
yourself
S/Sx of Sarin nerve gas
Neuromuscular - pinpoint pupils (highly indicative of nerve agent exposure), muscle twitching, confusion, seizures, flaccid paralysis, coma.
Ach accumulation-runny nose, crying, drooling, defecating, urinating, and vomiting
Tx of Sarin nerve gas exposure
atropine IV/IM (IV preferred) or 2-PAM (Pralidoxime) IV/IM (IV preferred)
Decontamination after Cyanide exposure
PTs exposed to gas need only to remove their outer clothing and hair washed. Other patients require full decontamination.
Classification of Cyanide
Toxic asphyxiant
Cyanide S/Sx- CNS
CNS signs and symptoms are typical of progressive hypoxia including headache, anxiety, agitation, confusion, lethargy, seizures and coma.
Cyanide S/Sx- cardiovascular
Initially bradycardia and HTN, followed by hypotension and tachycardia. The terminal event is bradycardia and hypotension.
Cyanide S/Sx- Respiratory
increased RR, SOB, and chest tightness. With progression, respirations become slow and gasping.
Cyanide S/Sx- GI
abdominal pain, nausea and vomiting
Cyanide S/Sx- Skin
A cherry red skin color may be present as the result of increased venous hemoglobin oxygen saturation.
Cyanide Tx
100% oxygen STAT, sodium nitrite IV (or amyl nitrite) and sodium thiosulfate IV
Phosgene, Ammonia, Chlorine classification
Pulmonary Irritants
Phosgene, Ammonia, Chlorine early Sx
nose and throat irritation, cough, and chest pain, SOB & signs of pulmonary edema; signs of acute lung injury that are seen within four hours of the exposure predict a low likelihood of survival
Phosgene, Ammonia, Chlorine late Sx
choking, chest tightness, cough, severe dyspnea, production of foaming bloody sputum, and pulmonary edema. Non-respiratory symptoms include nausea and anxiety
Phosgene, Ammonia, Chlorine tx
rest
Sulfur Mustard, Lewisite category
Blistering agents
Sulfur Mustard, Lewisite early Sx
sore throat, cough, and hoarseness, skin redness, pain and itching
Sulfur Mustard, Lewisite Late Sx
SOB within 12 hours (bacterial pneumonia on days three to four); Blisters by 16 hours and reach a max by day three; damage to the ocular surface & corneal scarring, eye pain, and eyelid swelling occur
Sulfur Mustard, Lewisite Tx
steroids, antibiotic ointments, topical analgesics, keep skin clean, (it is a burn)
Cutaneous Anthrax Sx
fever, swollen lymph nodes, small, raised macules that become fluid filled & form a black center
Anthrax Tx
Combination antimicrobial therapy that must include Cipro
GI anthrax Sx
mouth ulcers, sore throat, trouble swallowing, N&V, bloody diarrhea, fever, abdominal pain, can progress to shock
Agent suspected when neurological sx are seeen
sarin or cyanide
Agent suspected when pulmonary sx are seen
phosphogene, sarin or cyanide if sx are immediate
inhalation anthrax if sx are more delayed
3 Sx seen with the use of a biologic agent
rash, GI bleeding, fever
Sx of poor perfusion
cool pale skin, delayed cap refil, cyanotic, bradycardic, low BP
Priority action with a suicidal Pt
find out if they have a feasible plan
4 questions of the emergency severity index
is the pt dying?
is this a pt who shouldn’t wait?
how many resources will they need?
what are the VS?`
Examples of ESI level 1
Cardiac arrest, anaphylactic reaction, flaccid baby, chest pain with poor perfusion,
Examples of ESI level 2
New onset confusion, suicidal, possible ectopic pregnancy, pain 10/10
Resource use with ESI level 3
2 or more
Resource use with ESI level 4
1 resource
Resource use with ESI level 5
none
Examples of resources
- Labs (blood, urine)
- ECG
- X-rays, CT-MRI-ultrasound, angiography
- IV fluids (hydration)
- IV, IM or nebulized meds
- Specialty consultation
- Simple procedure = 1 (lac repair, Foley cath)
- Complex procedure = 2 (conscious sedation)
Things that are not resources
- History & physical (including pelvic)
- Point-of-care testing
- Saline or heplock
- PO medications, Tetanus immunization, Prescription refills
- Phone call to PCP
- Simple wound care (dressings, recheck)
- Crutches, splints, slings
Antidote for benzodiazepines
flumazenil or romazicon
Antidote for narcotics
narcan
Antidote for heparin
protamine sulfate
antidote for coumadin
vitamin k
PAT RR needing intervention
> 60
PAT HR needing intervention
Child 180 bpm
Child >8: 160
