Emergency Care 3-27-08
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3-27-08
Mrs. Batton
Emergency Care Emergency Management •
Care given to clients with urgent and critical needs
•
An emergency is whatever the client or their family considers it to be
•
This type treatment is provided under the direction of a physician or Emergency Nurse Practitioner
Delivery of Emergency Care •
Hospital emergency department
•
Diagnosis, treatment, and stabilization of life threatening emergent conditions
•
Symptomatic care and referral of non-urgent conditions
•
Community Emergency Care- 911 EMS system in MS
Protection of Legal Rights •
Proper reporting to authorities o
GSW’s
o
Intentional injuries
o
Child and Elderly abuse
o
Certain diseases
o
Deaths
•
Trauma has potential legal implications
•
Preservation of Evidence o
Rape kit
o
Weapons
o
Clothing
o
Specimens
ED Classifications
•
•
•
Level 1 Trauma Center o
UMC
o
24-7 OR’s that are completely staffed
o
Physicians and nurses on call for OR and ED 24-7
o
Must have the ability to have transports in 24-7
Level 2 o
24 hour coverage by physician and RN
o
Specialty services can get there within 30 minutes
Level 3 o
•
24 hour coverage by RN
Level 4 o
All they can do is first aid care and enemas
ED layout •
Triage area-to sort out clients
•
Trauma Room-larger room assessable to multiple machines and people
•
Orthopedic room
•
Suture room
•
Observation area
•
Clinic area
•
ENT room
•
Psych Holding
•
X ray
•
Close proximity to OR
•
Waiting Room
Triage
3-27-08
Mrs. Batton
•
Means “to sort”
•
Advanced skill
•
Should occur 2-5 minutes from patients arrival to the ED
•
A systematic approach to assessment that allows the ED nurse to determine what clients need immediate treatment and those who can safely wait
•
Places clients in groups based on severity of problems and immediacy of needed treatment
•
Differs between ED and in the “field” (disasters).
Nurses Role in Routine ED Triage •
Collect data
•
Assess vital signs
•
Neurological assessments if indicated
•
In the hospital triage directs all available resources to clients who are the most ill
ED Triage Categories •
Emergent- highest priority o
Life threatening (symptomatic neonates)
o
Pregnant woman that has something life threatening to her or her baby
•
Urgent- serious sick but not about to die (can wait up to an hour in the waiting room)
•
Non-urgent- less serious not going to die anytime soon, could probably be seen at clinic
•
Fast-Track-first aide or basic care
Nursing Assessment in Emergencies •
Primary Survey o
A-airway
o
B-breathing
o
C-circulation
o
D-disability/ Neurological
o
E-exposure
Airway/ Breathing Maintenance •
Oropharyngeal
•
Endotracheal Intubation
•
Cricothyroidotomy
Circulation •
Always take care of airway/breathing first
•
Usually due to hemorrhage or shock
•
If external hemorrhaging-open airway and then control bleed, especially if arterial
•
Apply pressure and elevate extremity for bleed
•
Initiation of IV’s to restore volume
•
Tourniquet is always last resort unless traumatic amputation has occurred
•
Draw blood for cross match
•
Two large bore IV’s if actively bleeding
•
Anytime you’re giving lots of blood use blood warmer- start watching calcium levels-hypocalcemia
Disability/Neurological Assessment •
Assess mental status
•
Glasgow coma status
•
AVUP o
Alert
o
V -responsive to voice
3-27-08
•
Mrs. Batton o
U-Responsive to pain
o
P-Unresponsive
Assess anxiety level
Exposure •
Final component of primary survey-Check for exit wounds
•
Remove all clothing to allow for thorough assessment
•
Be aware of potential need for evidence collection
Pain •
Client’s complaining of severe pain should be moved up in priority
•
Sever pain is defined as client’s self rating of 8-10 on a scale of 0-10
Secondary Survey •
Complete health history
•
Head to toe assessment
•
Diagnostic and labs
•
Monitoring (EKG, Foley, Arterial Lines)
•
Splinting fractures
•
Clean/ dress wounds
•
Any other interventions based on client needs
Abdominal Trauma •
Goal-control bleeding and maintain blood volume
•
GSW-what kind and how far away they were when they got shot
•
Assess-what happened, when, how, How many times, did they stay conscious
•
Auscultate-bowel sounds
•
Palpate-rigidity, guarding, tenderness, measure abdominal girth
•
Insert foley
•
Labs- H and H
•
Urinalysis for hematuria
•
Left shoulder pain can equal ruptured spleen
•
Cut away clothes
•
Control bleeding
•
Start IV (be prepared to treat shock)
•
Cover with sterile dressing
•
Ng tube
•
Continuous vital signs
•
Neuro status
•
X-rays
•
Labs
•
Medicine
•
Peritoneal lavage
•
Prepare for OR
Crushing Injuries •
Assess o
Hypovolemia
o
Paralysis
o
Skin
o
Renal
o
Serum lactate want it less than 2.5
•
May require fasciotomy
•
Hyperbaric chamber sometimes used during recovery
Near Drowning Emergency Management
3-27-08
Mrs. Batton
•
Problem is hypoxia and acidosis
•
ABC’s
•
Arterial blood gases
•
100% O2 PEEP to improve gas exchange
•
Cardiac monitoring
•
IV o
Salt water=LR
o
Fresh water = INT
•
Labs
•
Meds
•
NG tube and foley
•
X-ray
•
Monitor vital signs
Decompression sickness •
Signs and symptoms o
Joint, extremity pain
o
Numbness
o
Loss of ROM
o
Neurological symptoms may mimic a stroke or spinal cord injury
•
Airway
•
Ventilate
•
100% O2
•
IV with LR or NS
•
Chest X-ray
•
If embolus suspected lower head of bed
•
Keep warm
•
Hyperbaric chamber ASAP
•
Antibiotics if aspiration
Poisoning Emergency Management •
•
•
Ingested (plants, drugs, foods, chemicals) o
ABC’s (v/s, o2, ABG’s, EKG)
o
Call poison control
o
May be corrosive (determine type of product ingested)
o
Position on left side
o
Monitor neurological status
o
NGT for gastric lavage
o
Give milk or water to dilute
o
Do not make vomit if caustic
o
If caustic assess for mouth, esophagus burns
o
Activated charcoal (PO-NGT)
o
Cathartic (mg. citrate)
o
Syrup of Ipecae (only if alert and able to swallow and no longer recommended)
Ingested Poisoning o
ABC’s vital signs, EKG, muscular activity
o
Place on side
o
IV
o
Treat signs and symptoms, nausea and vomiting
o
Determine source and type of food or ingestant
o
Reporting may be necessary
Inhaled poisoning
3-27-08
Mrs. Batton o
Carbon monoxide, gas, smoke, fumes
Carbon monoxide most common
Carboxyhemoglobin levels
•
•
100% o2
Monitor for deterioration of mental status
Notify Psych if attempted suicide and health department if indwelling
May cause permanent brain damage
Skin Contamination o
Remove clothes
o
Profuse amounts of water to flush all traces of chemical away from body (unless chemical was Lye or white phosphorus)
o
Manage as burn after removal of agent
Injected o
Bugs
o
Snakes
Pit vipers
Coral snakes
Inject poison through fangs-but fang marks don’t always equal venom
Signs and symptoms •
Pain at site
•
Petechiae
•
Metallic taste in mouth
Immobilize
Keep bitten body part below the level of the heart
o
Don’t apply tourniquet
Don’t apply ice
Don’t apply tourniquet
Give tetanus shot
Give anti venom, be sure they are not allergic •
Pre medicate with Benadryl or H2 blocker
•
Diluted will 500cc saline, given over 4-6 hours can be repeated
May I&D the area
May need fasciotomy for edema
No corticosteroids between 6-8 hours after bite
Spiders
Brown recluse bites •
Cytotoxic venum-kills the cells
•
Might not have symptoms at first, then gets painful later on o
Develops dark, hard, area after a few days
o
Bullseye necrosis causes hole
•
Will probably I&D it
•
May give corticosteroids and antibiotics, anti-histamines
•
Patient may need skin grafts
Black Widow Spider Bite •
Neuro toxic venum-causes neurological deficits
•
Patient has pain when they are bitten o
See edema in area
o
Start cramping and vomiting
3-27-08
Mrs. Batton o
•
Stomach may be rigid and tender
•
May give muscle relaxants
•
May need anti-venom o
Do skin test or eye test before you give it
o
Will prevent long term complications
o
Will give in piggy back
o
Give over at least 2 hours
o
May be repeated
Heat Injuries o
o
Heat exhaustion-moist and clammy, pupils dilated, normal or subnormal temp
Cool as rapidly as possible
Allow to rest
May give sodium and water (Gatorade)
Keep them still
Heat stroke- dry, hot skin
Life threatening
Happens in hot, humid, environment get hotter and hotter and hotter
Decrease core temperature
Body has given up, no longer perspiring
Patient may be dizzy or confused
Put ice packs on groin, neck
IV fluids to cool them
ABC’s
Foley
o
•
EKG monitoring
Heat cramps
Painful spasms due to sodium depletion
Seen a lot in high school atheletes
Cold injuries o
o
Hypothermia
Temp less than 95 degrees
Get confused, pulse and blood pressure start to drop
Not dead until they are warm and dead
Good chance of ventricular arrhythmias
Warm core first
Monitor closely on EKG
ABG’s
Foleys
May give bicarbonate
Frostbite
Cold, painful, discolored extremities
Pain gets worse as we warm them
Warm with tepid water very slowly, give pain med first
Elevate extremity
Never allowed to smoke because of vasoconstriction
Sexual Assault •
Check protocol
•
Consideration must be made for physical and emotional needs as well as collection of forensic evidence
3-27-08
Mrs. Batton
•
Assign SANE nurse to provide care
•
Do not use the word RAPE
•
Obtain witnessed, informed consent for examination, photographs, and release of information/ findings to police
•
Obtain history once-no repeats!
•
Never use lubricant for vaginal exam
•
If possibility of ghonnorea involved will have Rocephin prophylacticly
•
May be put on syphilis prophylaxus
•
May give morning after pill
Emergency Drugs •
O2
•
Epinephrine o
•
Atropine o
•
For hypoglycemia
Bicarb o
•
Reverses toxicity
D50W o
•
Vtach, v fib
Narcane o
•
Ventricular arrhythmias
Amniodorone o
•
Asystole, low heart rate
Lidocane o
•
Cardiac stimulate and bronchodilator
For metabolic acidosis
Magnesium
o •
Hypomagnesimia
Dopamine/ Dobutamine o
Increase BP
o
Increase cardiac output
Documentation •
Document everything o
Assessment
o
History
o
Vital signs
o
Allergies
o
Medications
o
Last meal eaten
o
How they arrived
o
Pertinent statements from client with quotations
After unsuccessful codes •
Family is notified
•
Family is supported o
Provide privacy
o
Spiritual guidance
•
Body is prepared
•
Donor agencies are notified
•
Coroner contacted
•
Staff debriefing
•
j
Mrs. Batton
Emergency Care Emergency Management •
Care given to clients with urgent and critical needs
•
An emergency is whatever the client or their family considers it to be
•
This type treatment is provided under the direction of a physician or Emergency Nurse Practitioner
Delivery of Emergency Care •
Hospital emergency department
•
Diagnosis, treatment, and stabilization of life threatening emergent conditions
•
Symptomatic care and referral of non-urgent conditions
•
Community Emergency Care- 911 EMS system in MS
Protection of Legal Rights •
Proper reporting to authorities o
GSW’s
o
Intentional injuries
o
Child and Elderly abuse
o
Certain diseases
o
Deaths
•
Trauma has potential legal implications
•
Preservation of Evidence o
Rape kit
o
Weapons
o
Clothing
o
Specimens
ED Classifications
•
•
•
Level 1 Trauma Center o
UMC
o
24-7 OR’s that are completely staffed
o
Physicians and nurses on call for OR and ED 24-7
o
Must have the ability to have transports in 24-7
Level 2 o
24 hour coverage by physician and RN
o
Specialty services can get there within 30 minutes
Level 3 o
•
24 hour coverage by RN
Level 4 o
All they can do is first aid care and enemas
ED layout •
Triage area-to sort out clients
•
Trauma Room-larger room assessable to multiple machines and people
•
Orthopedic room
•
Suture room
•
Observation area
•
Clinic area
•
ENT room
•
Psych Holding
•
X ray
•
Close proximity to OR
•
Waiting Room
Triage
3-27-08
Mrs. Batton
•
Means “to sort”
•
Advanced skill
•
Should occur 2-5 minutes from patients arrival to the ED
•
A systematic approach to assessment that allows the ED nurse to determine what clients need immediate treatment and those who can safely wait
•
Places clients in groups based on severity of problems and immediacy of needed treatment
•
Differs between ED and in the “field” (disasters).
Nurses Role in Routine ED Triage •
Collect data
•
Assess vital signs
•
Neurological assessments if indicated
•
In the hospital triage directs all available resources to clients who are the most ill
ED Triage Categories •
Emergent- highest priority o
Life threatening (symptomatic neonates)
o
Pregnant woman that has something life threatening to her or her baby
•
Urgent- serious sick but not about to die (can wait up to an hour in the waiting room)
•
Non-urgent- less serious not going to die anytime soon, could probably be seen at clinic
•
Fast-Track-first aide or basic care
Nursing Assessment in Emergencies •
Primary Survey o
A-airway
o
B-breathing
o
C-circulation
o
D-disability/ Neurological
o
E-exposure
Airway/ Breathing Maintenance •
Oropharyngeal
•
Endotracheal Intubation
•
Cricothyroidotomy
Circulation •
Always take care of airway/breathing first
•
Usually due to hemorrhage or shock
•
If external hemorrhaging-open airway and then control bleed, especially if arterial
•
Apply pressure and elevate extremity for bleed
•
Initiation of IV’s to restore volume
•
Tourniquet is always last resort unless traumatic amputation has occurred
•
Draw blood for cross match
•
Two large bore IV’s if actively bleeding
•
Anytime you’re giving lots of blood use blood warmer- start watching calcium levels-hypocalcemia
Disability/Neurological Assessment •
Assess mental status
•
Glasgow coma status
•
AVUP o
Alert
o
V -responsive to voice
3-27-08
•
Mrs. Batton o
U-Responsive to pain
o
P-Unresponsive
Assess anxiety level
Exposure •
Final component of primary survey-Check for exit wounds
•
Remove all clothing to allow for thorough assessment
•
Be aware of potential need for evidence collection
Pain •
Client’s complaining of severe pain should be moved up in priority
•
Sever pain is defined as client’s self rating of 8-10 on a scale of 0-10
Secondary Survey •
Complete health history
•
Head to toe assessment
•
Diagnostic and labs
•
Monitoring (EKG, Foley, Arterial Lines)
•
Splinting fractures
•
Clean/ dress wounds
•
Any other interventions based on client needs
Abdominal Trauma •
Goal-control bleeding and maintain blood volume
•
GSW-what kind and how far away they were when they got shot
•
Assess-what happened, when, how, How many times, did they stay conscious
•
Auscultate-bowel sounds
•
Palpate-rigidity, guarding, tenderness, measure abdominal girth
•
Insert foley
•
Labs- H and H
•
Urinalysis for hematuria
•
Left shoulder pain can equal ruptured spleen
•
Cut away clothes
•
Control bleeding
•
Start IV (be prepared to treat shock)
•
Cover with sterile dressing
•
Ng tube
•
Continuous vital signs
•
Neuro status
•
X-rays
•
Labs
•
Medicine
•
Peritoneal lavage
•
Prepare for OR
Crushing Injuries •
Assess o
Hypovolemia
o
Paralysis
o
Skin
o
Renal
o
Serum lactate want it less than 2.5
•
May require fasciotomy
•
Hyperbaric chamber sometimes used during recovery
Near Drowning Emergency Management
3-27-08
Mrs. Batton
•
Problem is hypoxia and acidosis
•
ABC’s
•
Arterial blood gases
•
100% O2 PEEP to improve gas exchange
•
Cardiac monitoring
•
IV o
Salt water=LR
o
Fresh water = INT
•
Labs
•
Meds
•
NG tube and foley
•
X-ray
•
Monitor vital signs
Decompression sickness •
Signs and symptoms o
Joint, extremity pain
o
Numbness
o
Loss of ROM
o
Neurological symptoms may mimic a stroke or spinal cord injury
•
Airway
•
Ventilate
•
100% O2
•
IV with LR or NS
•
Chest X-ray
•
If embolus suspected lower head of bed
•
Keep warm
•
Hyperbaric chamber ASAP
•
Antibiotics if aspiration
Poisoning Emergency Management •
•
•
Ingested (plants, drugs, foods, chemicals) o
ABC’s (v/s, o2, ABG’s, EKG)
o
Call poison control
o
May be corrosive (determine type of product ingested)
o
Position on left side
o
Monitor neurological status
o
NGT for gastric lavage
o
Give milk or water to dilute
o
Do not make vomit if caustic
o
If caustic assess for mouth, esophagus burns
o
Activated charcoal (PO-NGT)
o
Cathartic (mg. citrate)
o
Syrup of Ipecae (only if alert and able to swallow and no longer recommended)
Ingested Poisoning o
ABC’s vital signs, EKG, muscular activity
o
Place on side
o
IV
o
Treat signs and symptoms, nausea and vomiting
o
Determine source and type of food or ingestant
o
Reporting may be necessary
Inhaled poisoning
3-27-08
Mrs. Batton o
Carbon monoxide, gas, smoke, fumes
Carbon monoxide most common
Carboxyhemoglobin levels
•
•
100% o2
Monitor for deterioration of mental status
Notify Psych if attempted suicide and health department if indwelling
May cause permanent brain damage
Skin Contamination o
Remove clothes
o
Profuse amounts of water to flush all traces of chemical away from body (unless chemical was Lye or white phosphorus)
o
Manage as burn after removal of agent
Injected o
Bugs
o
Snakes
Pit vipers
Coral snakes
Inject poison through fangs-but fang marks don’t always equal venom
Signs and symptoms •
Pain at site
•
Petechiae
•
Metallic taste in mouth
Immobilize
Keep bitten body part below the level of the heart
o
Don’t apply tourniquet
Don’t apply ice
Don’t apply tourniquet
Give tetanus shot
Give anti venom, be sure they are not allergic •
Pre medicate with Benadryl or H2 blocker
•
Diluted will 500cc saline, given over 4-6 hours can be repeated
May I&D the area
May need fasciotomy for edema
No corticosteroids between 6-8 hours after bite
Spiders
Brown recluse bites •
Cytotoxic venum-kills the cells
•
Might not have symptoms at first, then gets painful later on o
Develops dark, hard, area after a few days
o
Bullseye necrosis causes hole
•
Will probably I&D it
•
May give corticosteroids and antibiotics, anti-histamines
•
Patient may need skin grafts
Black Widow Spider Bite •
Neuro toxic venum-causes neurological deficits
•
Patient has pain when they are bitten o
See edema in area
o
Start cramping and vomiting
3-27-08
Mrs. Batton o
•
Stomach may be rigid and tender
•
May give muscle relaxants
•
May need anti-venom o
Do skin test or eye test before you give it
o
Will prevent long term complications
o
Will give in piggy back
o
Give over at least 2 hours
o
May be repeated
Heat Injuries o
o
Heat exhaustion-moist and clammy, pupils dilated, normal or subnormal temp
Cool as rapidly as possible
Allow to rest
May give sodium and water (Gatorade)
Keep them still
Heat stroke- dry, hot skin
Life threatening
Happens in hot, humid, environment get hotter and hotter and hotter
Decrease core temperature
Body has given up, no longer perspiring
Patient may be dizzy or confused
Put ice packs on groin, neck
IV fluids to cool them
ABC’s
Foley
o
•
EKG monitoring
Heat cramps
Painful spasms due to sodium depletion
Seen a lot in high school atheletes
Cold injuries o
o
Hypothermia
Temp less than 95 degrees
Get confused, pulse and blood pressure start to drop
Not dead until they are warm and dead
Good chance of ventricular arrhythmias
Warm core first
Monitor closely on EKG
ABG’s
Foleys
May give bicarbonate
Frostbite
Cold, painful, discolored extremities
Pain gets worse as we warm them
Warm with tepid water very slowly, give pain med first
Elevate extremity
Never allowed to smoke because of vasoconstriction
Sexual Assault •
Check protocol
•
Consideration must be made for physical and emotional needs as well as collection of forensic evidence
3-27-08
Mrs. Batton
•
Assign SANE nurse to provide care
•
Do not use the word RAPE
•
Obtain witnessed, informed consent for examination, photographs, and release of information/ findings to police
•
Obtain history once-no repeats!
•
Never use lubricant for vaginal exam
•
If possibility of ghonnorea involved will have Rocephin prophylacticly
•
May be put on syphilis prophylaxus
•
May give morning after pill
Emergency Drugs •
O2
•
Epinephrine o
•
Atropine o
•
For hypoglycemia
Bicarb o
•
Reverses toxicity
D50W o
•
Vtach, v fib
Narcane o
•
Ventricular arrhythmias
Amniodorone o
•
Asystole, low heart rate
Lidocane o
•
Cardiac stimulate and bronchodilator
For metabolic acidosis
Magnesium
o •
Hypomagnesimia
Dopamine/ Dobutamine o
Increase BP
o
Increase cardiac output
Documentation •
Document everything o
Assessment
o
History
o
Vital signs
o
Allergies
o
Medications
o
Last meal eaten
o
How they arrived
o
Pertinent statements from client with quotations
After unsuccessful codes •
Family is notified
•
Family is supported o
Provide privacy
o
Spiritual guidance
•
Body is prepared
•
Donor agencies are notified
•
Coroner contacted
•
Staff debriefing
•
j
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