Emergency and Critical

Care
 Basic life support (BLS)
• A means of providing oxygen to the
brain, heart and other organs until help
arrives

• Also known as CARDIOPULMONARY

RESUSCITATION
 Basic life support (BLS)
• An adult is a person above age 8

• A child is any person age 1 to 8 years

old

• An infant is anyone under 1 year

 Basic life support (BLS)
• The BLS follows the A-B-C principle

– A= airway

– B= breathing

– C= circulation
 Basic life support (BLS)
• Causes of cardiac arrest
– Respiratory arrest
– Direct injury
– Drug overdose
– Cardiac arrhythmias
 Basic life support (BLS)
ADULT
• STEPS in CPR: First STEP!!!
– ASSESSMENT: determine
Unresponsiveness
– Assess for 5-10 seconds
– Shake the victim’s shoulder and ask: “are
you okay”
 Basic life support (BLS)
ADULT
• STEPS in CPR: Second Step
– Survey the area
 Basic life support (BLS)
ADULT
• STEPS in CPR: Third Step
– Call for HELP
– Activate emergency medical system

– Note: for child and infant this is done LAST

 Basic life support (BLS)
ADULT
• STEPS in CPR: Fourth step
– Place Victim in Supine position on a flat firm
surface

– Log roll the patient when moving

 Basic life support (BLS)
ADULT
• STEPS in CPR: Fifth step
– OPEN the airway

– Head tilt-Chin Lift method

– Jaw thrust maneuver if neck injury is

suspected
 Basic life support (BLS)
ADULT
• STEPS in CPR: Sixth step
– Assess BREATHING
• Place ear over the nose and mouth
• Look for chest movement
• Perform for 3-5 SECONDS
 Basic life support (BLS)
ADULT
• STEPS in CPR: Sixth step
– Assess BREATHING
• If breathing: place on side if no neck
injury; DO NOT move if with neck injury

• If NOT BREATHING: deliver INITIALLY 2

rescue breath via mouth to mouth
• Then deliver 10-12 breaths/minute
 Basic life support (BLS)
ADULT
• STEPS in CPR: Seventh step
– Assess CIRCULATION
• Check for the carotid pulse on the side
close to you for 5-10 SECONDS
• If with (+) pulse ; continue giving 10-12
breaths/minute
 Basic life support (BLS)
ADULT
• STEPS in CPR: Seventh step
– Assess CIRCULATION
• If withOUT pulse: START Chest Compression
• Correct hand placement: LOWER HALF of
sternum one hand over the other with fingers
interlacing
• Depress: 1 ½ to 2 INCHES
80-100 compressions/min
 Basic life support (BLS)
ADULT
• STEPS in CPR: Seventh step
– Assess CIRCULATION
• If withOUT pulse: START Chest Compression
• ONE-rescuer: 15 chest: 2 breaths

• TWO-rescuer: 5 chest: 1 breath

• DO FOUR cycles and re-assess for pulse

 Basic life support (BLS)
CHILD
1-8 years old
• AIRWAY: assess unresponsiveness and
keep airway patent by HTCL or JT
• BREATHING: assess for airflow and chest
movement
– If breathing: maintain patent airway
– If NOT breathing : deliver 2 rescue breaths by
mouth to mouth
– DELIVER 20 breaths/minute
 Basic life support (BLS)
CHILD
1-8 years old
• CIRCULATION: assess the carotid pulse
– If with pulse: continue to deliver 15-20
breaths/minute
– If WITHOUT pulse: start chest compression
– Correct hand placement: lower half of sternum
using heel of ONE HAND
– DELIVER: 1 to 1 ½ inches
80- 100 chest compressions/min
5:1 (do 20 cycles  EMS)
 Basic life support (BLS)
INFANT
Less than 1
• Determine unresponsiveness
• AIRWAY: Place head of infant in NEUTRAL
position
• BREATHING: assess for rise-fall of chest
and airflow
– If breathing: maintain patent airway
– If NOT breathing: initiate 2 rescue breathing
via mouth to mouth and nose
– DELIVER 20 breaths/min SLOWLY
 Basic life support (BLS)
Less than 1
INFANT
• CIRCULATION: assess for pulse: The
BRACHIAL pulse is utilized!!
– If with pulse: continue to deliver 20 breaths/min
– If WITHOUT pulse, start chest compression
– Correct hand placement: just below the nipple
line in the sternum using 2-3 fingers of one
hand!!
– DELIVER: ½ to 1 inch depth
100 chest com/min
5:1 ratio (do 20 cycles EMS)
 AIRWAY Obstruction
• Incomplete
– Crowing sound is heard encourage to
cough

• Complete
– Clutching of the neck
– Ask: “Are you choking?”
– Perform Heimlich’s
 AIRWAY Obstruction
• Complete
– If patient becomes unconscious:
• Place supine on flat surface
• Perform tongue-jaw lift maneuver
• FINGERSWEEP to remove object
• Open airway and attempt ventilation
• Perform Heimlich while supine
• Reattempt ventilation
• SEQUENCE: TJL finger-sweep rescue
breaths Heimlich’s TJL
 AIRWAY Obstruction
• Pediatric considerations:
• CHILD: NEVER DO Blind Finger sweep
 AIRWAY Obstruction
• Pediatric considerations:
• INFANT: never DO blind finger-sweep
• Give five back blows in the
interscapular area and turn the infant
with head lower than trunk then deliver
chest thrust below the nipple line
 AIRWAY Obstruction
• Obstetric considerations:
• Hand is placed over the middle part of
sternum: backward chest thrust

• If unconscious: place pillow below the

RIGHT abdomen to displace uterus
 Shock
• An abnormal physiologic state where
an imbalance exists between the
amount of circulating blood volume
and the size of the vascular bed.
 Pathophysiology of Shock
1. Cellular effects of shock
• In the absence of oxygen, the cell will
undergo Anaerobic metabolism to produce
energy source and with it comes numerous
by-products like lactic acid
• The cell will swell due to the influx of Na and
H20, mitochondria will be damaged,
lysosomal enzymes will be liberated, and
then cellular death ensues.
 Pathophysiology of Shock
2. Organ System Responses
• When the patient encounters
precipitating causes of shock, the
circulatory function diminishes there
is decreased cardiac output
Hypotension and decreased tissue
perfusion will result
 Shock Stages
There are three stages of shock
• Compensatory stage
• Progressive stage
• Irreversible stage
 Shock Stages
THE COMPENSATORY STAGE OF SHOCK
• In this stage, the patient’s blood pressure is within
normal limits.
• Patient’s blood is shunted from the kidney, skin and
GIT to the vital organs- brain, liver and muscles
• Manifestations of cold clammy skin, oliguria and
hypoactive bowel sounds can be assessed.
• Medical management includes IVF and medication
• Nursing management includes monitoring of tissue
perfusion & vital signs, reduction of anxiety,
administering IVF/ordered medications and
promotion of safety
THE PROGRESSIVE STAGE OF SHOCK
• In this stage, the mechanisms that regulate
blood pressure can no longer compensate
and the mean arterial pressure falls.
• The overworked heart becomes
dysfunctional. Heart rate becomes very rapid
(as high as 150 bpm)
• Blood flow to the brain becomes impaired,
the mental status deteriorates due to
decreased cerebral perfusion and hypoxia.
• Laboratory findings will reveal increased
BUN and Creatinine. Urinary output
decreases to below 30 mL/hour.
 Shock Stages
THE PROGRESSIVE STAGE OF SHOCK
• Decreased blood flow to the liver impairing
the hepatic functions. Toxic wastes are not
metabolized efficiently, resulting to
accumulation of ammonia, bilirubin and
lactic acids.
• The reduced blood flow to the GIT causes
stress ulcers and increased risk for GI
bleeding.
• Hypotension, sluggish blood flow, metabolic
acidosis (due to accumulation of lactic acid),
and generalized hypoxemia can interfere with
normal blood function.
 Shock Stages
THE IRREVERSIBLE STAGE OF SHOCK
• This stage represents the end point where
there is severe organ damage that patients
do not respond anymore to treatment.
Survival is almost impossible to maintain.
• Despite treatment, the BP remains low,
anaerobic metabolisms continues and
multiple organ failure results.
• Medical management is the use of life
supporting drugs like epinephrine and
investigational medications.
 Assessment of Shock
Assessment Findings
Skin : Cool, pale, moist in hypovolemic and
cardiogenic shock
: Warm, dry, pink in septic and neurogenic shock
Pulse
• Tachycardia, due to increased sympathetic
stimulation
• Weak and thready
Blood pressure
• 1. Early stages: may be normal due to compensatory
mechanisms
• 2. Later stages: systolic and diastolic blood pressure
drops.
 Assessment of Shock
Assessment Findings
Respirations: rapid and shallow, due to tissue
anoxia and excessive amounts of CO (from
metabolic Acidosis)
Level of consciousness: restlessness and
apprehension, progressing to coma
Urinary output: decreases due to impaired
renal perfusion
Temperature: decreases in severe shock
(except septic shock).
 Management of Shock
Nursing Interventions
• Management in all types and phases of
shock includes the following:
• Basic life support
• Fluid replacement
• Vasoactive medications
• Nutritional support
 Management of Shock
A. Maintain patent airway and adequate ventilation.
B. Promote restoration of blood volume; administer
fluid and bloodreplacement as ordered
C. Administer drugs as ordered
D. Minimize factors contributing to shock.
E. Maintain continuous assessment of the client.
F. Provide psychological support: reassure client to
relieve apprehension, and keep family advised
G. Provide Nutritional support
 Hypovolemic Shock
This is the MOST common form of shock
characterized by a decreased
intravascular volume
Risk factors: external Fluid Losses
• Trauma, Surgery, Vomiting,
Diarrhea, Diuresis, DI
Risk factors: internal fluid shifts
• Hemorrhage, Burns, Ascites,
Peritonitis, Dehydration
 Hypovolemic Shock

• Decreased blood volume decreased

venous return to the heart
decreased stroke volume decreased
cardiac output decreased tissue
perfusion
• Assessment findings: cold clammy
skin, tachycardia, mental status
changes, tachypnea
 Hypovolemic Shock
• MEDICAL MANAGEMENT:
– The major medical goals are to
restore intravascular volume, to
redistribute the fluid volume, and
to correct the underlying cause of
fluid loss promptly
 Hypovolemic Shock
• NURSNG MANAGEMENT:
– Primary prevention of shock is the most
important intervention of the nurse.
– General nursing measures include- safe
administration of the ordered fluids and
medications, documenting their
administration and effects. The nurse must
monitor the patient for signs of complications
and response to treatment. Oxygen is
administered to increase the amount of O2
carried by the available hemoglobin in the
blood.
 Cardiogenic shock
This shock occurs when the heart’s ability to
contract and to pump blood is impaired
and the supply of oxygen is inadequate for
the heart and tissues
• Risk factors: Coronary factor- Myocardial
infarction
• Risks factors: NON coronary:
– Cardiomyopathies
– Valvular damage
– Cardiac tamponade
– Dysrhythmias
 Cardiogenic shock
• Precipitating factors will cause decreased
cardiac contractility Decreased stroke
volume and cardiac output leading to 3
things:
• Damming up of blood in the pulmonary
vein will cause pulmonary congestion
• Decreased blood pressure will cause
decreased systemic perfusion
• Decreased pressure causes decreased
perfusion of the coronary arteries leading
to weaker contractility of the heart
 Cardiogenic shock
ASSESSMENT FINDINGS: Angina, hemodynamic
instability, dysrhythmias
• MEDICAL MANAGEMENT:
– The goals of medical management are to limit
further myocardial damage and preserve and to
improve the cardiac function by increasing
contractility.
• NURSING MANAGEMENT:
– The nurse prevents cardiogenic shock by early
detection of patients at risk.
– Safety and comfort measures like proper
positioning, side-rails, and reduction of anxiety,
frequent skin care and family education.
 Circulatory shock
• This is also called distributive shock. It
occurs when the blood volume is
abnormally displaced in the
vasculature.
– Septic Shock
– Neurogenic Shock
– Anaphylactic Shock
 Circulatory shock

• Massive arterial and venous dilation

allows pooling of blood peripherally
maldistribution of blood volume
decreased venous return decreased
stroke volume decreased cardiac
output Decreased blood pressure
decreased tissue perfusion.
 Circulatory shock
• Risk factors for Septic Shock
– Immunosuppression
– Extremes of age (<1 and >65)
– Malnourishment
– Chronic Illness
– Invasive procedures
 Circulatory shock
• Risk factors for Neurogenic Shock
– Spinal cord injury
– Spinal anesthesia
– Depressant action of medications
– Glucose deficiency
 Circulatory shock
• Risk factors for Anaphylactic Shock
– Penicillin sensitivity
– Transfusion reaction
– Bee sting allergy
– Latex sensitivity
 SEPTIC SHOCK
This is the most common type of circulatory
shock and is caused by widespread
infection.
The HYPERDYNAMIC PHASE
– High cardiac output with systemic
vasodilatation.
– The BP remains within normal limits.
– Tachycardia
– Hyperthermic and febrile with warm,
flushed skin and bounding pulses
 SEPTIC SHOCK
The HYPODYNAMIC or irreversible phase
– LOW cardiac output with
VASOCONSTRICTION
– The blood pressure drops, the skin is cool
and pale, with temperature below normal.
– Heart rate and respiratory rate remain
RAPID!
– The patient no longer produces urine.
 SEPTIC SHOCK
• MEDICAL MANAGEMENT:
– Current treatment involves identifying
and eliminating the cause of infection.
Fluid replacement must be instituted
to correct Hypovolemia, Intravenous
antibiotics are prescribed based on
culture and sensitivity.
 SEPTIC SHOCK

• NURSING MANAGEMENT:
– The nurse must adhere strictly to the
principles of ASEPTIC technique in her
patient care.
– Specimen for culture and sensitivity is
collected. Symptomatic measures are
employed for fever, inflammation and pain.
IVF and medications are administered as
ordered.
 Neurogenic Shock
This shock results from loss of
sympathetic tone resulting to
widespread vasodilatation.
• The patient who suffers from neurogenic
shock may have warm, dry skin and
BRADYCARDIA!
 Neurogenic Shock

• MEDICAL MANAGEMENT:
– This involves restoring sympathetic
tone, either through the stabilization of
a spinal cord injury or in anesthesia,
proper positioning.
 Neurogenic Shock

• NURSING MANAGEMENT:
– The nurse elevates and maintains the
head of the bed at least 30 degrees to
prevent neurogenic shock when the
patient is receiving spinal or epidural
anesthesia.
 Anaphylactic Shock

• This shock is caused by a severe

allergic reaction when a patient who
has already produced antibodies to
a foreign substance develops a
systemic antigen-antibody reaction
 Anaphylactic Shock
• MEDICAL MANAGEMENT:
– Treatment of anaphylactic shock
requires removing the causative antigen,
administering medications that restore
vascular tone, and providing emergency
support of basic life functions.
– EPINEPHRINE is the drug of choice given
to reverse the vasodilatation
 Anaphylactic Shock
• NURSING MANAGEMENT:
– It is very important for nurses to assess
history of allergies to foods and
medications!
– Drugs are administered as ordered and
the responses to the drugs are
evaluated.
 Triage
• “trier”- to sort

• To sort patients in groups based on the

severity of their health problem and the
immediacy with which these problems
must be addressed
 Triage in the E.R.
• Berner’s
1. Emergent

2. Urgent

3. Non-urgent
 Triage in DISASTER!
• NATO
1. Immediate

2. Delayed

3. Minimal

4. Expectant
 Triage
1. Emergent
– Patients have the highest priority
– With life-threatening condition
2. Urgent
– Patients with serious health problems
– Not life-threatening, MUST be seen in 1
hour
3. Non-urgent
– Episodic illness that can be addressed
within 24 hours
 Triage Priority Color Conditions

category Triage in Disaster

Immediate Chest wounds,
1 RED shock, open
fractures, 2-3
burns

Stable
Delayed 2 YELLOW abdominal
wound, eye and
CNS injuries
Minor burns,
Minimal 3 GREEN minor fractures,
minor bleeding
Unresponsive,
Expectant 4 BLACK high spinal cord
injury
 Preparing for terrorism
1. Recognition and Awareness
2. Use of personal protective equipments
3. Decontamination of contaminants
 Biological Weapons
ANTHRAX
• Drug of choice is Ciprofloxacin or
Doxycycline

SMALLPOX
• Supportive
 Chemical Weapons
Organophosphates
– Supportive care
– Soap and water
– Atropine
– Pralidoxine
Cyanide
– Sodium nitrite, Amyl Nitrite, Methylene Blue
– Sodium thiosulfate
– Hydrocobalamin
CYANIDE POISONING
 Radiation
Alpha Particles Cannot penetrate skin
Causes local damage

Beta Particles Moderately penetrate the

skin
Can cause skin damage and
internal injury if prolonged

Gamma Particles Penetrate skin

Can cause serious damage
X-ray is an example