P. 1
FAEN Module Hand Outs

FAEN Module Hand Outs

|Views: 19|Likes:
Published by Zarlou Otamias

More info:

Published by: Zarlou Otamias on Mar 22, 2013
Copyright:Attribution Non-commercial


Read on Scribd mobile: iPhone, iPad and Android.
download as DOCX, PDF, TXT or read online from Scribd
See more
See less






COURSE HAND-OUTS First Aid and Emergency Nursing (Theory) (NUR 410


First Aid First aid is the provision of initial care for an illness or injury. It is usually performed by non-expert, but trained personnel to a sick or injured person until definitive medical treatment can be accessed. Certain self-limiting illnesses or minor injuries may not require further medical care past the first aid intervention. It generally consists of a series of simple and in some cases, potentially life-saving techniques that an individual can be trained to perform with minimal equipment. The key aims of first aid can be summarized in three key points: 1. Preserve life: the overriding aim of all medical care, including first aid, is to save lives 2. Prevent further harm: also sometimes called prevent the condition from worsening, or danger of further injury, this covers both external factors, such as moving a patient away from any cause of harm, and applying first aid techniques to prevent worsening of the condition, such as applying pressure to stop a bleed becoming dangerous. 3. Promote recovery: first aid also involves trying to start the recovery process from the illness or injury, and in some cases might involve completing a treatment, such as in the case of applying a plaster to a small wound The term Emergency Management traditionally refers to care given to patients with urgent and critical needs. Large numbers of people seek emergency care for serious life-threatening cardiac conditions, such as myocardial infarction, acute heart failure, pulmonary edema, and cardiac dysrhythmias. The need for professional nurses to be prepared in emergency and disaster nursing becomes more evident as the complexity of our lives increases owing to the discovering of new scientific knowledge and its application to the everyday world. Because Nurses represent the largest group of trained professional health worker available, their awareness of and preparation for emergency care of the ill and injured are essential. EMERGENCY NURSING The emergency nurse has had specialized education, training, and experience to gain expertise in assessing and identifying patients‟ health care problems in crisis situations. Nursing interventions are accomplished interdependently, in consultation with or under the direction of a licensed physician or nurse practitioner. The strengths of nursing and medicine are complementary in an emergency situation. Appropriate nursing and medical interventions are anticipated based on assessment data.


During the mid-1960 .The need for specialization of emergency services was identified as a national priority in order to reduce the associated morbidity and mortality resulting from catastrophic illness or injury. The scope of the services ranges from treatment of acute conditions that threatens the loss of life, limb or vision to management of non- urgent, chronic conditions.


The Ministry of Health bears primary responsibility for the Kingdom's health care program. It operates 62 percent of the country's hospitals and 53 % of its health care clinics and centers. Of the remaining hospitals and clinics, the majority are operated by the private sector. The functions of these facilities and the training of their staff are supervised and supported by the Ministry of Health. Other government agencies, such as the Ministry of Education and Defense, the National Guard and the Public Security Administration have their own hospitals and clinics. To meet all of the health needs of Saudi Citizens from preventive care through advanced surgery, the Kingdom has implemented a tier of health service plan. The first tier is a network of primary health care centers and clinics established throughout the country. A number of different facilities which provide preventive, prenatal, emergency, and basic health services. An important role in health care is played by the Saudi Red Crescent Society, which functions like the Red Cross, providing first aid and emergency medical services. The society operates 141 medical centers and branches throughout the country, and has four mobile clinics and more than 500 ambulances and medical evacuation helicopters. It also plays a special part in caring for the millions of Muslim pilgrims during the annual Hajj or pilgrimage to the holy sites in Makkah and Madinah. In 1993, the society set up 120 health care stations staffed by approximately 1,400 doctors, nurses, and technicians as well as hundreds of support personnel, for the pilgrims.

Medical Issues Emergency nursing was officially recognized as specialty in 1970. The National Association representing this nurse is the (ENA) Emergency Nursing Association. Definition of Emergency Nursing involves      Assessment , Diagnosis and treatment of perceived actual or potential, sudden or urgent, physical or psychosocial problem that are primary episodic or acute these may require minimal care of life support measure Education of patient and significant others Appropriate referral Knowledge of legal implications.  Nurses employed in an ED must be prepared to provide care to client of all age group who may have any possible illness or injury.  It often cited that emergency nurse must have an understanding of almost all disease process specific to any age group.


Legal Issues Nurses deal with a variety of legal issues in whatever specialty area they practice Federal Legislation Mandated   Any client who presents to an ED seeking treatment must be rendered aid regardless of financial ability to pay for services. Requiring ED personnel to stabilize any client considered medically unstable before transfer to another health care facility. This stabilization must occur regardless of the client financial ability to pay for services.

PROFESSIONAL AND ETHICAL ISSUES a. DOCUMENTATION OF CONSENT  Patient must consent to invasive procedures unless unconscious or in critical condition.  If unconscious and without family or friends, this fact should be documented. b. LIMITING EXPOSURE TO HEALTH RISK  Health care providers are at increased risk for exposure to communicable diseases through blood or other body fluids. This risk is further compounded in the ED because of the common use of invasive treatments. All emergency health care providers should adhere strictly to standard precautions for minimizing exposure.

c. PROVIDING HOLISTIC CARE    Sudden illness or trauma is a stress to physiologic and psychological homeostasis that requires physiological and psychological healing. Patients and families experience real and terrifying fear of death, mutilation, immobilization, and other assaults on their personal identity and body integrity. Assessment of the patient and family‟s psychological function includes evaluating emotional expression, degree of anxiety, and cognitive functioning.

C.1 Patient focused interventions a. Those caring for the patient should act confidently and competently to relieve anxiety. b. Reacting in a warm manner promotes a sense of security. c. Unconscious patient should be treated conscious C.2 Family-focused interventions a. Family is kept informed about where the patient is, how he or she is doing, and the care that is being given. b. Anxiety and denial (Family members are encouraged to recognize and talk about their feelings of anxiety. Asking questions is encouraged.)  After treatment, notations are made on the record about the patient‟s condition on discharge or transfer and about instructions given to the patient and family for follow-up care. Remorse and guilt (Expressions of remorse and guilt may be heard, with family members accusing themselves of negligence or minor omissions. They are urged to verbalize feelings. 3

c. Anger (Allow the anger to be ventilated, assist the family to identify their feelings or frustrations) d. Grief (Help family members to work through their grief and support their coping mechanisms.) THE ROLE OF THE NURSE IN THE EMERGENCY DEPARTMENT Emergency nurses specialize in rapid assessment and treatment when every second counts, particularly during the initial phase of acute illness and trauma. Emergency nurses must tackle diverse tasks with professionalism, efficiency, and above all—caring. Emergency nursing is a specialty area of the nursing profession like no other. To provide quality patient care for people of all ages, emergency nurses must possess both general and specific knowledge about health care to provide quality patient care for people of all ages. Emergency nurses must be ready to treat a wide variety of illnesses or injury situations, ranging from a sore throat to a heart attack. Roles:

Patient Care—Emergency nurses care for patients and families in hospital emergency departments, ambulances, helicopters, urgent care centers, cruise ships, sports arenas, industry, government, and anywhere someone may have a medical emergency or where medical advances or injury prevention is a concern. Education—Emergency nurses provide education to the public through programs to promote wellness and prevent injuries, such as alcohol awareness, child passenger safety, gun safety, bicycle and helmet safety, and domestic violence prevention. Leadership and Research—Emergency nurses also may work as administrators, managers, and researchers who work to improve emergency health care.


Specialties: Because emergency nurses must be prepared to provide patient care for almost any situation they may encounter, specialization is rare. However, common areas of specialization include trauma, pediatrics, geriatrics, and injury prevention. Qualifications: Emergency nurses are registered nurses. Many emergency nurses acquire additional certifications in the areas of trauma nursing, pediatric nursing, nurse practitioner, and various areas of injury prevention. Practice Settings: Emergency nurses may practice in one or more of the following areas:
       

             

Emergency Departments Hospitals Health Care Administration Education Research Urgent Care Centers (Episodic Care Centers) Schools of Nursing/Universities/Colleges EMS/Prehospital Transport Ambulances Helicopters Airplanes Poison Control Centers Telephone Triage Military Medical Equipment, Resources, and Pharmaceutical Companies Crisis Intervention Centers Prisons/Correctional Facilities Research Institutes Government/State EMS Offices/Boards of Nursing Community Cruise Ships Sporting Events and Concerts Camps Special Events Travel Facilities

FACTS ABOUT EMERGENCY DEPARTMENT UNITS     People age 75 years and older had the highest rate of ED visits. The national average is 39 visits per 100 persons per year. Stomach and abdominal pain, chest pain, and fever, were the most commonly recorded reasons for a visit in the ED. Ages 15-24 years had the highest injury visit rate. About 12% of patients seen in the ED were admitted to the hospital 5

Principles of Assessment and Emergency Management 1. Treat the potentially life threatening first. GOAL : a. Preserve life b. Prevent deterioration before definitive treatment can be given c. Restore patient to useful living 2. Stabilize the pulmonary cardiovascular and central nervous system a. Maintain a patent airway and provide adequate ventilation. Employing resuscitation measures when necessary. b. Control hemorrhage and its consequences c. Evaluate and restore cardiac output d. Prevent and treat shock; maintain or restore effective circulation. e. Carry out rapid initial and ongoing physical examinations. (The clinical course of the injured or seriously ill patient is not static). f. Assess whether or not the patient can follow command. Evaluate the size and reactivity of the pupils and motor responses. g. Splint suspected fractures h. Protect wound with sterile dressings i. Check to see if patient has a medic alert or similar identification designating allergies etc. j. Start a flow sheet of the patient vital signs BP, PR, RR to guide decision making

SCENE SIZE UP An Assessment of the scene and surroundings to assure the safety of the Emergency Medical Team (EMT) and to provide potentially useful information about the patient Objectives 1. Recognize hazards and potential hazards 2. Describe common hazards at the scene 3. Determine scene safety 4. Mechanism of Injury/Nature of illness 5. Identify number of patients 6. Rational for evaluating scene safety 7. Serve as a model for others FACTORS IN SCENE SIZE UP 1. Scene Safety  Personal protection-is it safe to approach the patient?  Look and listen for other emergency vehicle  Look for downed power lines


   

Observe traffic flow Watch for fire or smoke Look for clues to hazardous materials Sniff for odors

2. Patient Safety -can I work on my patient here or must I move him to a place of safety 3. Bystander Safety  Watch for pedestrians on the road  Curious onlookers pose many dangers 4. Establish a Danger Zone  No apparent hazard-50 ft. in all direction  Spilled fuel-100 ft. in all directions  Vehicle fire- 100 ft. in all direction 5. Special Consideration  Crime scene warning  Fighting or loud voices  Weapons visible  Signs of alcohol/Drug use  Unusual silence  Knowledge of prior violence Emergency Assessment 1. Primary Assessment Its purpose is to identify any client problem that poses a threat immediate or potential to life, limb or vision. If any abnormalities are found immediate intervention such as CPR and advance life support (ALS) must be instituted to aid in preserving clients‟ life. 2. Secondary Assessment Is performed to identify any other non-life threatening problems that client may be experiencing. It provides the emergency nurse with a methodological approach to help identify and prioritize patients‟ needs

ACTION IN AN EMERGENCY  Primary Survey (Initial assessment)  Get help  Secondary Survey (assessment)  Provide first aid  Reassess regularly  Transport to health care facility Primary Survey (assessment)  Danger  Response AVPU scale  Alert and aware 7

 Responds to Verbal stimuli  Responds to Painful stimuli  Unresponsive Level of consciousness 1. 2. 3. 4. 5.     Shout for Help Airway Breathing Circulation Alert – respond fully and appropriately to stimuli Lethargic- drowsy, respond to question then fall asleep. Obtunted – open eyes, responds slowly, confused Stuporous – Arouses from sleep only after painful stimuli. Comatose – unarousable with eyes closed

Secondary Survey (assessment)  Airway 1. Head tilt – chin lift method 2. Jaw thrust method  Breathing  Circulation  Disability 1. Mental status: Glasgow Coma Scale Eye opening Spontaneously To Speach To Pain None Verbal response Orientated Confused Inappropriate words Incomprehensible sounds None Motor response Obeys verbal commands Localising pain Withdraws from pain stimuli Flexing to pain Extension to pain No response 2. Pupil PEARL- Pupils Equal And Reacting to Light 4 3 2 1 5 4 3 2 1 6 5 4 3 2 1


3. Extremities CSM Circulation Sensation Movement  Exposure, Everything Else 1. Physical exam -Victim„s chief complaint -Head to toe examination DOTS Deformity Open wounds Tenderness Swelling 2. Victim„s history (SAMPLE history) Symptoms Allergies Medications Past medical history Last oral intake Events leading up to the illness or injury Expose / Enviromental control - it is necessary to remove the patient's clothing in order to identify all injuries, you must prevent heat loss by using warm blankets. ASSESS AND INTERVENE       Complete health history and head-to-toe assessment Diagnostic and laboratory testing Insertion or application of monitoring devices electrocardiogram (ECG) electrodes, arterial lines, or urinary catheters. Splinting of suspected fractures Cleaning and dressing of wounds Performance of other necessary interventions based on the individual patient‟s condition.

Once the patient is has been assessed, stabilized, and tested, appropriate medical and nursing diagnosis are formulated, initial important treatment is started, and plans for the proper disposition of the patients are made. Critical Thinking and Decision Making Emergency Department (ED) nursing is different from other kinds of nursing in that it requires a specific skill set related to the inherently unstable nature of many ED patients, the need for constant re-evaluation and openness to shifting priorities, quick but accurate assessment and prioritization, orderly and thorough documentation without traditional flow sheets and relevant communication skills necessary for both professional and determined advocacy for patients of all acuity levels.


Emergency nurses are at the front line of the most pressing and life-threatening health issues, and deal with patients who straddle life and death. Due to the seriousness of the nature of emergency nurse's jobs, there are often strict standards that must be followed. In nursing, critical thinking skills are related to the clinical decision making process. Nursing critical thinking skills are a systemic, logical, reasoned approach to the nursing process which results in quality patient care. The nurse is open to intellectual reasoning and a systematic approach to problem solving. Critical thinking in nursing is an active process involving the nurse in sifting data, choosing which components are vital and then assessing and filtering to form a vital decision process. Critical thinking is a part of the nursing process which adheres to a deep commitment to maintain intellectual discipline, as well as formulating decisions based on sound judgments and logical conclusions. Critical thinking will result in excellent clinical outcomes and patient safety. Communication and Documentation The emergency department (ED) is a fast-paced environment dealing primarily with short-term interventions. Because of this setting and the nature of this type of care, the importance of good communication is very important. COMMON EMERGENCY SITUATIONS REQUIRING SENSITIVE COMMUNICATION SKILLS The ED provider will inevitably encounter situations in which sensitive communication skills are important. These situations include such events such as:      Fetal death, Sexually transmitted diseases, Domestic violence, Rape, and Potentially serious diseases

Documentation Standards for nursing documentation in the emergency room should be established by the hospitals overall policies and procedures. The standards are reviewed, and amended on a yearly basis, the hospital should review its policies and procedures.Efficient, complete and legible ED nursing documentation is critical for patient care, legal protection and proper reimbursement.

UNIT III Principle of Basic Skills in First Aid and Emergency Nursing
1. MANAGEMENT IN AIRWAY OBSTRUCTION Assessment    Asphyxia occurs for various reasons: Inadequate oxygen in environment (e.g. smoke, toxic gases)obstruction of air passages (e.g. foreign bodies in airway, tongue falling back in pharynx, edema of respiratory tissue, laryngospasm) Secretions in air passages (e.g. near-drowning, pulmonary edema)


 

Interferences with respirations (e.g. chest trauma, depression of respiratory center [drugs]) Interference with circulation (e.g. electric shock, MI, carbon monoxide poisoning)

Sign and symptoms include the following:       Dyspnea and restlessness use of accessory respiratory muscles (prominent neck muscles, intercostals ribs retraction; nasal flaring) Wheezing or stridor from air moving through narrowed passageways Sucking noise in inspiration if an open wound is present Coarse rales (crackles) if fluid is present in alveoli Pale skin (ashen on blacks) Cyanosis (late sign)



Is airway obstruction caused by a foreign body that enters the Airway.

Assessment 1. Victim is grabbing the throat with one or both and look panicky 2. Determine whether the victim‟s airway is completely blocked 3. If the victim is able to speak, breath or cough with good air exchange, do nothing 4. If the victim is unable to speak, breath or cough with good air exchange, quick action is necessary to prevent suffocation. Interventions: 1. Position the person to ensure a maximal airway. 2. If the airway is obstructed by a foreign body the person may need assistance in its removal. A. FINGER SWEEP  Open the adult‟s mouth by grasping both the tongue and lower jaw between the thumb and fingers and lifting the mandible (tongue-jaw lift) B. THE HEIMLICH MANEUVER (SUBDIAGPHRAGMATIC ABDOMINAL THRUST) Steps in doing Heimlich Abdominal Thrust Maneuver For standing or Sitting Conscious patient: 1. Are you choking? 2. Can you speak? 3. Can I HELP you? 4. Provide inward and upward Abdominal thrust, just above the navel. Stand behind the patient, wrap your arms around the patients waist, and proceed as follows: • Make a fist with one hand, placing the thumb side of the first against the patients abdomen, in the midline slightly above the umbilicus and well below the xiphoid process grasp the fist with the other hand. • Press your fist into the patient‟s abdomen with a quick inward and upward thrust. Each new thrust should be a separate and distinct maneuver. For patient lying down 1. Position patient on the back.


2. Kneel astride the patient‟s thighs, facing the head. 3. Place the heel of one hand against the patient‟s abdomen, in the midline slightly above the umbilicus and well below the tip of the xiphoid; place the second hand on top of the first. 4. Press into the abdomen with a quick upward thrust. Unconscious Choking: (NO BLIND FINGER SWEEPS) 1. Call 911 2. Open the airway remove the object if you see it, then begin CPR 3. (30 compressions to 2 breaths) 4. Every time you open the airway to give breaths look for the object 5. Then continue CPR (30 to 2) Adult Rescue breathing:  It is done only when the victim is not breathing adequately but has a pulse. Rescue breathing for the adult is 1 breath  every 5 –6 seconds or 10‐12/min. Agonal Gasps are inadequate breaths associated with Cardiac Arrest not Choking. Child (1 year of age to puberty) Choking ‐ Child Conscious Choking: a. Are you choking? b. Can you speak? c. Can I HELP you? (ask the parent if you can help their child) d. Provide inward and upward abdominal thrust, just above the navel to relive the obstruction. Unconscious Choking: NO BLIND FINGER SWEEPS 1. Call for help, send bystander to call 911 or activate EMS 2. Open the airway, remove the object if you see it, then begin CPR, with a ratio of 30 compressions to 2 breaths 3. Every time you open the airway to give breaths look for the object 4. Then continue CPR with a ratio of 30 compressions to 2 breaths 5. If no one came to call 911 or activate EMS, you call after 2 minutes of CPR Rescue Breathing:  1 breathe every 3 to 5 seconds or 12 to 20/min (only enough air to make the chest rise over 1 second each) INFANT (0‐1 YEAR OF AGE) Choking ‐ Infant Infant Conscious Choking: a. Look for choking signs, like bluish skin, lips or nose, high‐pitched noise b. Pick up the infant and give 5 back blows between the shoulder blades, with the head supported and with the head c. lower then the infant‟s bottom d. Then flip the infant and provide 5 chest thrusts just below the nipple line, keeping the head lower that the infant‟s e. bottom f. Repeat until infants able to cry or becomes unconscious Unconscious Choking: NO BLIND FINGER SWEEPS 1. Call for help, send bystander to call 911 or activate EMS 2. Open the airway, remove the object if you see, begin CPR at a ratio of 30 to 2 12

3. Every time you open the airway to give breaths look for the object 4. Then continue CPR at a ratio of 30 to 2 5. If no one came to call 911 or activate EMS, you call after 2 minutes or 5 cycles of CPR Infant Rescue Breathing:  1 breath every 3 to 5 seconds or 12 to 20/min (only enough air to make the chest rise, each breath over 1 second) Nursing Diagnoses  Ineffective airway clearance related to inability to expel an aspirated foreign object  Risk for suffocation related to aspirated foreign object 2. BASIC LIFE SUPPORT (BLS) AND CARDIOPULMONARY RESUSCITATION (CPR) Basic life support – is the immediate care given to maintain Oxygenation of the brain until advance medical support is Available. CPR (Cardio Pulmonary Resuscitation) – is a basic emergency procedure of artificial respirations and manual External cardiac Compression. External Cardiac massage (compression) – is the rhythmic compression of the heart between the lower half of the sternum and the thoracic vertebral column. Cardiac arrest – when the heart stops beating. Pulmonary/ Respiratory arrest – when respirations cease. Cardiopulmonary arrest – is the absence of a heart beat and respirations and signifies a state of clinical death.  The cardiac and respiratory systems are so dependent on each other that when one fails the others quickly fail as well.   Nerve tissue is so susceptible to hypoxia (slow level of oxygen) that in most circumstances the brain cells begin to die after 4 minutes without oxygen or biologic death occurs. Permanent brain damage - occur if circulation and oxygenation are not restored quickly after cardiopulmonary arrest.

Characteristics of Biologic death  Unresponsiveness  Cessation of respirations  Development of pallor and cyanosis  Absence of heart sounds and Blood pressure  Loss of palpable pulse  Dilations of the pupils (Pupillary response can be misleading in patient who are receiving drugs such as atropine of opium derivatives or in the presence of corneal pathologic conditions)  Ventricular fibrillation or ventricular asystole will appear (if hospitalized patient is being monitored by means of ECG machine or cardiac monitor). CAB of CPR   To maintain Circulation To establish an airway 13

To initiate breathing

Causes of Cardiopulmonary Arrest 1. Myocardial infarction 2. Heart failure 3. Electrocution 4. Drowning 5. Drug overdose 6. Anaphylaxis 7. Asphyxia Nursing assessment In CP arrest, assessment and intervention are quickly interwoven. The steps of CPR therefore include assessment and intervention. Nursing Diagnosis  Ineffective tissue perfusion related to cessation of heart beat  Decrease Cardiac Out Put related to cessation of heart beat  Ineffective breathing pattern  Related to absent of respirations Outcome:  Adequate oxygenation until heartbeat and respiration are restored.  Improving skin color, palpable pulse, and spontaneous respirations. INTERVENTION

CPR ‐ Adult
1. Adult 1 rescuer CPR a. Determine Unresponsiveness (shake and shout), if no response b. Check for no breathing or normal breathing (minimum 5 seconds; maximum 10 seconds) c. Activate emergency medical system and call for an AED d. Check for carotid pulse for (minimum 5 seconds; maximum 10 seconds) e. If there is no detectable pulse, start chest compressions at the center of the chest, at the nipple line, with the heal of one hand on top of the other, at a ratio of: 30 compressions (Acceptable <18 seconds for 30 compressions) f. Give 2 breaths (1 second each) g. Deliver second cycle of 30 compressions at correct hand position (Acceptable >23 compressions) h. Give 2 breaths (1 second each) i. Continue CPR until help arrives Push Hard, and Push Fast: compress at a minimum rate of at least 100 compressions per minute and a depth of 2 inches, and allow full chest recoil after each compression. Minimize interruptions in chest compressions. 2. Adult 2 Rescuer CPR:  Ratio of 30 compressions to 2 breaths, Rate 100/minute or 5 cycles in 2 minutes – (Ventilator) the rescuer at the head, – (Compressor) the rescuer at the chest  Ventilator determines responsiveness, if no response 14

  

Ventilator checks for no breathing or normal breathing (minimum 5 seconds; maximum 10 seconds) Compressor or bystander activates emergency medical system (call 911) and call for an AED Ventilator checks for circulation, carotid pulse (minimum 5 seconds; maximum 10 seconds)

If the victim has circulation (pulse) Ventilator will rescue breath for them: ‐ 1 breath every 5‐6 seconds for about 10‐12 per minute (each breath should be delivered over 1 second making the chest rise) If the victim does not have circulation (no pulse) Compressor will start chest Compressions, with the heel of two hands at a ratio of: ‐ 30 compressions by the compressor to 2 ventilations by the ventilator at a rate of at least 100 per minute and a depth of 2” or deeper for larger person ‐ The ventilator can check for a pulse during compressions to make sure they are effective by feeling a pulse every compression. ‐ After every 5 cycles or 2 minutes of CPR switch to maintain effective CPR 3. Advance airway Once the advanced airway is in place do NOT stop compressions for breaths just DO CONTINUOUS COMPRESSIONS AND PERFORM 8 TO 10 BREATHS PER MINUTE (every 6 to 8 seconds), switch positions every 2 minutes or 150 compressions.

CPR ‐ Child
1. Child 1 rescuer CPR: a. Determine unresponsiveness b. Check for no breathing or normal breathing (minimum 5 seconds; maximum 10 seconds) c. Call for help‐send bystander to call 911 or activate EMS. If no one comes you begin CPR and after 5 cycles or two minutes, you should activate 911/EMS. d. Check for circulation at the carotid artery for 5 seconds minimum; 10 seconds maximum e. If there is no detectable pulse, or pulse is less than 60 beats/min., start chest compressions at the center of the chest, at the nipple line, with the heal of one hand on top of the other, at the depth of 1/3 of the child‟s body or 2” depth: f. 30 compressions (Acceptable <18 seconds for 30 compressions) g. Give 2 breaths (1 second each) h. Deliver second cycle of compressions at correct hand position (Acceptable >23 compressions) i. Give 2 breaths (1 second each) j. Continue CPR at a ratio of 30 to 2 until help arrives Push Hard, and Push Fast: compress at a minimum rate of 100 compressions per minute Allow full chest recoil after each compression. Minimize interruptions in chest compressions. 2. Child 2 rescuer: CPR Ratio = 15 compressions: 2 breaths, Rate = 100/min, 5 cycles per minute • (Ventilator) the rescuer at the head, (Compressor) the rescuer at the chest • Ventilator determines responsiveness, if no response • Check for no breathing or normal breathing (minimum 5 seconds; maximum 10 seconds)


• Compressor or bystander calls 911 or activates EMS number • Ventilator checks for circulation, carotid pulse > 60 beats/min. within 5‐10 seconds If the victim has circulation (pulse > 60 beats/min.) Ventilator will rescue breath for them: - 1 breath every 3 ‐ 5 seconds for about 12 ‐ 20 per minute (each breath should be delivered over 1 second making the chest rise) - Recheck pulse every 2 minutes If the victim does not have circulation (pulse < 60 beats/min.) Ventilator will start chest compressions, with the heal of one hand or two at a ratio of: 15 compressions by the ventilator and to 2 ventilations by the bystander at a rate of: 100 per minute and a depth of 1/3 of the child‟s body depth or 2” ‐switch/reassess after 5 cycles

CPR ‐ Infant
1. Infant 1 rescuer CPR a. Determine unresponsiveness, if no response no breathing b. Calls for help‐if a bystander is present send them to call 911 or activate EMS. If no bystanders respond or present precede to: c. Check for circulation for 5‐10 seconds: pulse (brachial or femoral) >60 beats/min. If the victim has circulation (pulse > 60 beats/min.) Rescue breath for them: - 1 breath every 3 ‐ 5 seconds for about 12 ‐ 20 per minute (each breath should be delivered over 1 second making the chest rise) - Recheck pulse every 2 minutes - You activate the EMS or call 911 if no‐one is around If the victim does not have circulation (pulse < 60 beats/min.) -Start chest compressions, 2 fingers one finger width below the nipple line, at a ratio of 30 compressions to 2 ventilations at a rate of at least 100 per minute and a depth of 1/3 of the infant‟s body depth or 1 ½” Reassess after 5 cycles of 30 to 2 - You activate the EMS or call 911 if no‐one is around after the first 5 cycles Then return to the infant & provide CPR 2. Infant 2 rescuer CPR: CPR Ratio = 15:2, Rate = 100/min, 5 cycles per minute • (Ventilator) the rescuer at the head, (Compressor) the rescuer at the chest • Ventilator determines responsiveness, if no response • Ventilator checks for no breathing or normal breathing (minimum 5 seconds; maximum 10 seconds) • Compressor or bystander calls 911 or activates EMS • Ventilator checks for circulation for 5‐10 sec: pulse (brachial or femoral) >60 beats/min.


If the victim has circulation (pulse > 60 beats/min.) Ventilator will rescue breath for them: - 1 breath every 3 ‐ 5 seconds for about 12 ‐ 20 per minute (each breath should be delivered over 1 second making the chest rise) - Recheck pulse every 2 minutes If the victim does not have circulation (pulse < 60 beats/min.) Ventilator will start chest compressions, with thumb encircling technique at a ratio of 15 compressions by the bystanders to 2 ventilations at a rate of at least 100 per minute and a depth of 1/3 of the infant‟s body depth or 1 ½”, switch after 5 cycles Push Hard, and Push Fast: compress at a minimum rate of 100 compressions per minute. Allow full chest recoil after each compression. Minimize interruptions in chest compressions 2 Methods of Chest Compression in Infant 1. Two thumb method 2. Two finger Method Two thumb method 1. Position both thumbs over the lower third of the sternum, one finger‟s breath below the inter-nipple line. The thumbs may be placed side by side or overlapping in smaller babies. 2. Encircle the chest with both hands, giving support to the babies back. 3. Apply pressure to the thumbs only. Do not put pressure on the rib cage using a squeezing action as this makes compressions inefficient and may cause trauma 4. Perform compressions at the depth and rate prescribed. Two Finger Method 1. The baby must be on a firm, flat surface. 2. Place the index and middle finger on the lower third of the sternum. 3. The finger must be perpendicular to the chest 4. Perform compressions at the depth and rate prescribed above AED USE  An Automated External Defibrillator (AED) is used when the heart stops beating normally and needs to be reset by an electric shock.  The sooner the shock is delivered the better, since the probability of successful defibrillation diminishes rapidly over time. AEDs are designed for adults but most can be adapted for children and infants with pediatric pads.  Provide 5 cycles of CPR, 30 compression to 2 breaths, for 2 minutes before using an AED on a child from 1 year to 8 or on an infant 1<of age. Special Considerations:  Hairy chest‐remove enough hair to get good contact with the skin.  Dry chest if visibly wet.  Implanted device‐place pad at least 1 inch away from implant, never place pad on top of device.  Medication patch‐remove it and wipe area before pad placement.


FYI: AEDs and Infants For infants (<1 year of age), a manual defibrillator is preferred. If a manual defibrillator is not available, an AED with a pediatric dose attenuator is desirable. If neither are available, an AED without a dose attenuator may be used. Note: Adult AED pads can be used on children and infants but pediatric pads are preferred. Pediatric pads cannot be used on adults. Documentation When emergency assistance arrives, provide information about the victim and the incident, including time that elapsed, intervention performed and victim response. Identify yourself and tell how you can be reached if additional information is needed. In hospital Cardiac Arrest Many hospitals have prepared teams of personnel, including physicians, nurses, anesthesiologists, and technicians who can be called to give immediate and complete care in the event of cardiac arrest Discontinue CPR 1. EMS arrived 2. The rescuer is too exhausted 3. The length of initiation of CPR is 30 minutes Complications of CPR 1. 2. 3. 4. 5. Fracture of the ribs Fractured sternum Costochondral separation Lung contusion Lacerations of the liver

Signs to be reported to the physicians after CPR 1. 2. 3. 4. Labored breathing Paradoxical pulse Muffled heart sounds Drop in blood pressure

3. ADMINESTERING ARTIFICIAL RESPIRATION 1. Mouth- to – Mouth – pinch victim‟s nostrils with thumb and Index finger and occlude mouth with nurse‟s mouth. 2. Mouth to Nose – Keep victims head tilted with one hand on forehead. Use other hand to lift the jaw and close mouth. Seal rescuers lips around victim‟s noses, and blow. 3. Ambu- bag – Use proper size face mask and apply it under chin up and over victim‟s mouth and nose.


4. TRIAGE The word triage comes from the French word trier, meaning “to sort”. In the ED, triage is used to sort patients into groups based on the severity of their health problems and the immediacy of with which these problems must be treated. In emergency care, triage is a process that is used to determine the severity of a patient‟s illness or injury. History  Medical triage evolved during war where battles resulted in lots of casualties and resources were limited.  Florence Nightingale used the triage concept during theCrimeanWar.  Shewent out after the daily fighting and sorted out those who might or might not survive and provided much needed care (Thomas, Bernardo,& Herman, 2003).  During the 20th century, battlefield triage consisted of a primary assessment and the performance of critical interventions such as control of bleeding and then rapid transport to MASH units.  During the Korean and Vietnam wars, helicopter transport was introduced to enhance the rapidity of patient care (Bracken, 2003).  In the 1960s, as emergency department censuses began to grow, the need for triage was recognized. Initially triage was performed by a physician or nurse physician team.  Today, triage is generally performed by experienced emergency department nurses (Gilboy, Travers, & Wuerz, 1999).  Triage is performed in both the prehospital and hospital environments.  Triage is a fluid process and is based on the number of patients, the amount of resources available, and the care that is available.  Triage is an important component of emergency nursing practice as patient censuses continue to increase and more has to be provided with less. The goals of triage include:
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Early and brief patient assessment Determination of the patient‟s urgency for care Documentation of findings Control of patient flow through the emergency department Assignment of patients to the appropriate care area Initiation of diagnostic measures Initiation of limited therapeutic interventions Infection control Promotion of public relations Health education for patients and families

Types of Triage  The type of triage that is used in an emergency department is dependent on several things including patient census, department layout, and number and type of staff.  As previously stated, triage is usually performed by an experienced registered nurse.


Components of Triage Triage begins with an “across the room assessment.” This involves what the triage nurse sees, smells, or sometimes even feels when first evaluating the patient. For example: • Is the patient‟s airway open or is he drooling? • Is the patient breathing and, if so, is the breathing effective? • What is the patient‟s skin color: normal, pale, flushed? • Are there any obvious signs of illness or injury? Gerontological Considerations
   adults who were 70 years of age or older used approximately 70% of the total bed days, and in 2005, those 75 years of age and older had an ED admit Rate of approximately 37%, compared to an average admit rate for all ages of 15% (Sendecki, 2007). For this reason the hospital need to develop a course that applied geriatric/geropsychiatric knowledge, skills, and abilities the ED nurse can implement into their daily practice.

 

A minimal amount of information should be gathered about why the patient has presented to the emergency department. Several mnemonics can be used to gather data depending on the patient‟s chief complaint or reason why she came to the emergency department. The following pages contain mnemonics that can assist with collecting historical data in triage. Even though the CIAMPEDS mnemonic is directed more at collecting data for a pediatric patient, it can easily be adapted for the adult patient as well

 


 A brief, but focused physical assessment should be performed.  Objective data can be collected by using a primary assessment that includes airway, breathing, circulation, and disability.  A secondary assessment may be required in some cases to better differentiate the severity of a patient‟s condition. The secondary assessment should include exposure with environmental control, a full set of vital signs and family presence, provision of comfort, additional history, and a head-to-toe assessment as needed using inspection, palpation, and auscultation. Triage Urgency Categories
        Once an initial evaluation has been made related to the patient‟s physical condition and chief complaint, the triage nurse will assign the patient an urgency category. Urgency categories rate patient acuity and assist in prioritizing care. Generally, an emergent patient is one who has an immediate life-threatening problem, for example, an airway obstruction. An urgent patient can wait a little longer, but would need to be seen as soon as possible. An example is a patient with chest pain, cardiac risk factors, and stable vital signs. Finally, a non-urgent patient can wait for care. Many emergency departments use a three-level urgency category, but the continued increase in emergency department censuses , the augmented acuity of patients who are being cared for in the emergency department, and the numbers of patients who use the emergency department for primary care have prompted the use of additional levels of urgency. The Charts next, summarize four- and five-level triage urgency scales.


2 SYSTEM OF TRIAGE 1. ED Triage 2. Field Triage Three categories of ED TRIAGE a. Emergent- has the highest priority, conditions are life threatening, and they must be seen immediately. b. Urgent- has serious health problems, but not immediately life threatening ones: they must be seen within 1 hour. c. Non- urgent- has episodic illness that can be addressed within 24 hours without any increasing morbidity. FIELD TRIAGE  Used during disaster. When health care providers are face with a large number of casualties, the fundamental principle guiding resource allocation is “To do the greatest good for the greatest number of people.” Decisions are based on the likelihood of survival and consumption of available resources.

The North Atlantic Treaty Organization (NATO) triage system is the widely use. It consist of 4 colors and signifies different level of priority. Triage Categories Immediate – Injuries are life threatening but survivable with minimal intervention. Individual in this group can progress rapidly to expectant is treatment is delayed Delayed – Injuries are significant and require medical care but can wait hours without threat to life. Yellow 2 Color Red Priority 1 Typical Condition Sucking chest wound,Pneumothorax, Incomplete amputation, unstable abdominal wound.

Stable abdominal wound without evidence hemorrhage, fracture requiring open reduction, debridment and external fixation

Minimal – -Injuries are minor and treatment can be delayed hours to days Green 3 Minor burns, sprains, small lacerations without bleeding, upper extremity fixation, psychological disturbance.

Unresponsive patient, profound shock, agonal respiration, fixed dilated


Expectant – -Injuries are extensive chances of survival are unlikely even with definitive care. -Comfort measure should be given



pupils, negative pulse and BP.

5. DISATER MANAGEMENT DISASTERS Are sudden catastrophic events that disrupt patterns of life and in which there is possible loss life and property in addition to multiple injuries. Disaster can be either natural phenomena or caused by people. THE GOAL OF DISASTER NURSING - is ensuring that the highest achievable level of care is delivered through identifying, advocating, and caring for all impacted populations throughout all phases of a disaster event, including active participation in all levels of disaster planning and preparedness.
Nursing in the Phases of Disasters 1. Preparedness This phase involves the planning and preparedness activities performed prior to a disaster. Mitigation initiatives are specific preparedness strategies designed to reduce the losses from disasters, e.g., building earthquake-resistant hospitals.

2. Relief Response The healthcare relief response to a disaster encompasses the broad scope of those actions intended to provide immediate health care to the community and begins with the initial notice of an impending or actual event.

3. Recovery The focus of relief response efforts is the delivery of health care throughout the time of the community’s immediate needs. Gradually, this phase will give way to the recovery phase of the disaster, with a decline in the number of patients in urgent need of care, and the arrival of outside resources to augment the healthcare capacity of the community. Recovery efforts are directed to rebuilding the basic societal functions of the community, including rebuilding the healthcare system to ensure adequate mechanisms are in place to effectively provide and monitor the on going health needs of the community.

ASSESSMENT During Triage There are essentially two different approaches to triage during a disaster. 1. Military triage system


Which may be initiated during a mass casualty disaster, is based on the philosophy of doing “the best for the most with the least by the fewest” Priority is then given to those victims with the greatest chance of survival. 2. Civilian triage system It is the more commonly used with multiple patients or multiple casualties. Persons with critical or life threatening injuries are given the highest priority for treatment and transportation. FOUR-COLOR CODED TRIAGE SYSTEM 0- Black: Dead 1- Red: Critical or life-threatening 2- Yellow: Serious 3- Green: Minimal DISASTER SYNDROME The behavior of victims after the impact of disaster can be characterized as progressing through phases of shock, awareness, euphoria, and anger. The victims are experiencing loss; therefore the phases are similar to those experienced by others during any kind of loss (grieving).  Shock phase, may last only a few minutes or for several hours after impact. The victim is dazed and unable to comprehend what is occurring; and cannot follow even simple directions. Persons prepared to function in emergencies are less apt to spend much time in the shock phase. Awareness phase, may last up to several days. Victims become aware of survival and try to help others, minimizing their own injuries or losses. During this stage guilt feelings may arise because others died and they survived. The victim is highly suggestible, can follow simple directions, but not carry out problem solving effectively. Euphoria phase, may last for several weeks. The victims feels a sense of brotherhood with the community and participates willingly in helping others with plans for recovery. Anger phase, occurs before resolution, the victim may go through the “why me?” because of the experienced loss. The anger is often projected against helping persons who were not personally affected by the disaster. It is especially important for nurses who may be assisting victims during the recovery phase to understand that the anger is part of the loss experience. As the victim cope with the losses incurred by the disaster and life returns to more normal patterns, the anger will disappear.

 

INTERVENTION Emergency aid stations The number, size and staffing of emergency aid stations depend on the type and extent of the disaster. One person in each aid station is designated for triage. One person must be designated the leader and is responsible for making decisions for maximal effectiveness of the unit. In the absence of the physician, a nurse assumes leadership of emergency care. 24

Victims are not transported until first aid care has been given, as in any emergency. If hemorrhage has not been controlled or fractures splinted, the victim may arrive at the medical center in shock that could have been prevented or minimized; surgical intervention will not take place until measures to treat shock are instituted and the patient‟s condition is stable. If first aid measures are instituted before transportation, the victim can be taken to surgery at the earliest opportunity. Records of all treatment given at an emergency aid center must accompany a victim who is referred or transported to a medical center or any other healthcare facility. Shelters Most shelters are set up in schools, which can house a large number of people. The role of the nurse in a shelter is to assess and provide for health needs of the shelter population. Some nursing functions include the following: 1. isolate persons with suspected infectious diseases 2. identify persons with chronic illnesses and ascertain whether prescribed drugs are available 3. monitor shelter occupants for signs of developing health problems 4. identify persons having problems coping with the disaster and provide emotional support and guidance as necessary 5. make arrangement for care of pregnant women and infants 6. assist with necessary immunizations Adaptation to loss Adaptation to loss after large-scale community disasters may differ from adaptation to losses under normal life situations because of the lack of individual support systems as a result of: (1) Death of usual support persons or (2) Inability of usual support persons to provide help because of their own personal losses. There may also be a loss of community support systems resulting from the disaster.




Multiple Patient

< 10 Multiple vehicle accident, bus accident, Bomb, Explosion, Fire, Airplane crash, Riot, Tornado, Hurricane, Earthquake, Severe hurricane, Major earthquake, War, Bombing

Multiple Casualty

10 – 100

Mass Casualty

> 100


Roles of Nurses in Disaster The actual role is assume by a given nurse at a disaster will depend on the ability of the nurse and the specific situation. Nurses can participate in many ways. A nurse may be the only health care provider in a given area and be responsible in giving initial first aid treatment or supervising the activities of others. Because of their education and experience, professional nurses can be especially helpful in aiding the victim to cope with their emotional reactions to the disaster. Nurse may be asked to serve at emergency morgues for supports for families experiencing the loss of love ones. Prevention Community planning is necessary to identify and, if possible, prevent disasters, and to educate the public to minimize the number of casualties. Community Planning Most states have disaster service agencies that act as coordinating units for the local agencies. Every community should have a disaster planning group as part of the local emergencies medical committee. There should be representation by all groups who will be active participants if disasters occur. The disaster planning committee has the following functions and responsibilities: Identify the types of disasters that may occur in the local community. Organize a disaster plan to be followed for different situations. Arrange for simulated drills to test the effectiveness of plans. Determine need for education or updating of necessary skills of participants. Nurses need to be active participants in the planning, implementation, and evaluation phases of community disaster preparedness. In addition, nurses need to develop their own nursing response plan to determine role of community health, institutional and volunteer nurses in the event of a disaster in their community. During a disaster local hospital become actively involves and need their own disaster plan to cope with sudden influx of person needing emergency care. Any time a large number of injured person are in need of emergency care, hospital disaster plans are put into effect. Testing of hospital disaster plans at specified intervals by simulated drill is necessary for determining whether the plan are effective and what changes, if any are needed. Public Education Public awareness of potential community disasters is needed for effective community preparedness. Disaster planning committees need support of participation of community members. Individual need to know what they should do in the event of disaster most radio and television stations regularly notify communities of potential


1. SOFT TISSUE INJURY It is a type of physical trauma where in the skin is torn, cut or punctured (an open wound), or where blunt force trauma causes a contusion (a closed wound). In pathology, it specifically refers to a sharp injury which damages the dermis of the skin. Types of Wounds 1. Abrasions- also called scrapes, they occur when the skin is rubbed away by friction against another rough surface (e.g. rope burns and skinned knees). 2. Avulsions-occur when an entire structure or part of it is forcibly pulled away, such as the loss of a permanent tooth or an ear lobe. Explosions, gunshots, and animal bites may cause avulsions. 3. Contusions- also called bruises, these are the result of a forceful trauma that injures an internal structure without breaking the skin. Blows to the chest, abdomen, or head with a blunt instrument (e.g. a football or a fist) can cause contusions. 4. Crush wounds- occur when a heavy object falls onto a person, splitting the skin and shattering or tearing underlying structures. 5. Cuts- Slicing wounds made with a sharp instrument, leaving even edges. They may be as minimal as a paper cut or as significant as a surgical incision.

6. Lacerations- also called tears; these are separating wounds that produce ragged edges. They are produced by a tremendous force against the body, either from an internal source as in childbirth, or from an external source like a punch. 7. Missile wounds- also called velocity wounds; they are caused by an object entering the body at a high speed, typically a bullet. 8. Punctures- these are deep, narrow wounds produced by sharp objects such as nails, knives, and broken glass. Signs of Wounds    Bleeding Loss of feeling or function below the wound site Pain

Management FOR MINOR CUTS 1. Wash your hands with soap to avoid infection. 2. Wash the cut thoroughly with mild soap and water. 3. Use direct pressure to stop the bleeding. 4. Apply an antibacterial ointment. 5. If the cut is likely to get dirty or be re-opened by friction, cover it (once the bleeding has stopped) with a bandage that will not stick to the injury.


FOR MINOR PUNCTURES 1. Wash your hands. 2. Use a stream of water for at least five minutes to rinse the puncture wound. Wash with soap. 3. Look (but DO NOT probe) for objects inside the wound. If found, DO NOT remove -- go to the emergency room. If you cannot see anything inside the wound, but a piece of the object that caused the injury is missing, also seek medical attention DO NOT:       DO NOT assume that a minor wound is clean because you can't see dirt or debris inside. Wash it. DO NOT breathe on an open wound. DO NOT try to clean a major wound, especially after the bleeding is under control. DO NOT remove a long or deeply embedded object. Seek medical attention. DO NOT probe or pick debris from a wound. Seek medical attention. DO NOT push exposed body parts back in. Cover them with clean material until medical help arrives.

Call your doctor immediately if:         The wound is large or deep, even if the bleeding is not severe. You think the wound might benefit from stitches (the cut is more than a quarter inch deep, on the face, or reaches bone). The person has been bitten by a human or animal. A cut or puncture is caused by a fishhook or rusty object. You step on a nail or other similar object An object or debris is embedded -- DO NOT removes by you own self. The wound shows signs of infection (warmth and redness in the area, a painful or throbbing sensation, fever, swelling, or pus-like drainage). You have not had a tetanus shot within the last 10 years

To avoid infection and aid healing:       Apply pressure with a clean cloth to stop bleeding Clean the wound with water Use an antibiotic ointment to prevent infection Bandage the wound if it's in an area that might get dirty Watch for swelling and redness Get a tetanus booster if you are due for one

2. Musculoskeletal Injuries Musculoskeletal injuries can occur from both blunt and penetrating trauma. Injuries may include contusions, cramps, dislocations, fractures, spasm, sprains, strains and/or subluxations. Early proper treatment of these injuries may prevent long term morbidity and disability. Major injuries to the musculoskeletal system ( e.g., pelvic fractures and hip dislocations) may cause shock due to hemorrhage, injury to adjacent nerves and blood vessels and infection due to the presence of an open fracture. Fractures of the humerus, pelvis or femur take priority over other musculoskeletal injuries as do fractures or dislocations involving circulatory or neurologic deficits


ASSESSMENT / TREATMENT PRIORITIES 1. Maintain appropriate body substance isolation precautions. 2. Maintain an open airway and assist ventilations as needed. Assume Spinal injury when appropriate and treat accordingly. 3. Administer high concentration oxygen. 4. Determine patient's hemodynamic stability and symptoms. If indicated, continually assess using O-P-Q-R-S-T model, and the Level of Consciousness, ABCs and Vital Signs. 5. Assess the neurovascular status (motor, sensory and circulation) distal to the injury before and after proper immobilization. 6. If no palpable, distal pulse is present, apply gentle traction along the axis of the extremity distal to the injury until the distal pulse is palpable and immobilize in place. Note: This does not apply to dislocations. 7. Immobilize all painful, swollen and/or deformed extremity injuries (e.g. fractures, sprains, strains and/or dislocations) involving joints, in the position found. 8. All jewelry should be removed from an injured extremity. 9. Obtain appropriate S-A-M-P-L-E history related to event. 10. Prevent / treat for shock. 11. Monitor and record vital signs TREATMENT BASIC PROCEDURES 1. Maintain appropriate body substance isolation precautions. 2. Maintain an open airway and assist ventilations as needed. In cases of suspected head/neck injury, assure cervical spine stabilization/immobilization. Airway may include repositioning of the airway, suctioning or use of airway adjuncts (or pharyngeal airway / nasopharyngeal airway) as indicated. 3 Administer high concentration oxygen. 4. Control/stop any identified life threatening hemorrhage (direct pressure, pressure points, etc.). 5. Assess the neurovascular status (motor, sensory and circulation) distal to the injury before and after proper immobilization. 6. If no palpable, distal pulse is present apply gentle traction along the axis of the extremity distal to the injury until the distal pulse is palpable and immobilize in place. Note: This does not apply to dislocations. 7. Immobilize painful, swollen and/or deformed extremity injuries (e.g. fractures, sprains, strains and/or dislocations) involving joints, in the position found. Bones adjacent to each injured joint must be fully immobilized, as well as supporting and immobilizing the injured joint. Joints adjacent to each injured bone must be fully immobilized, as well as supporting and immobilizing the injured bone(s). 8. All jewelry should be removed from an injured extremity. 9. For hemodynamically unstable patients, showing signs and/or symptoms of shock, with suspected pelvic fracture(s), contact MEDICAL CONTROL. 10. Activate ALS intercept, if deemed necessary and if available. 11. Initiate transport as soon as possible with or without ALS. 12. Monitor and record vital signs every 5 minutes at a minimum, if unstable, or every 15 minutes if stable. 13. If patient‟s BLOOD PRESSURE drops below 100 systolic: treat for shock. 14. Notify receiving hospital.


INTERMEDIATE PROCEDURES 1. Maintain appropriate body substance isolation precautions. 2. Maintain an open airway and assist ventilations as needed. In cases of suspected head/neck injury, assure cervical spine stabilization/immobilization. Airway may include repositioning of the airway, suctioning or use of airway adjuncts (oropharyngeal airway / nasopharyngeal airway) as indicated. 3. Administer oxygen by nasal cannula or mask as determined by patient's condition. 4. Control/stop any identified life threatening hemorrhage (direct pressure, pressure points, etc.). 5. Assess the neurovascular status (motor, sensory and circulation) distal to the injury before and after proper immobilization. 6. If no palpable, distal pulse apply gentle traction along the axis of the extremity distal to the injury until the distal pulse is palpable and immobilize in place. Note: This does not apply to dislocations. 7. Immobilize painful, swollen and/or deformed extremity injuries (e.g. fractures, sprains, strains and/or dislocations) involving joints, in the position found. Bones adjacent to each injured joint must be fully immobilized, as well as supporting and immobilizing the injured joint. Joints adjacent to each injured bone must be fully immobilized, as well as supporting and immobilizing the injured bone(s). 8. All jewelry should be removed from an injured extremity. 9. ALS STANDING ORDERS a. Provide advanced airway management (if indicated). b. Initiate IV Normal Saline while in transport. (if indicated). c. If patient‟s BLOOD PRESSURE drops below 100 systolic: treat for shock. Administer a 250 cc bolus of IV Normal Saline. 10. Contact MEDICAL CONTROL. Medical Control may order: a. administration of additional fluid. b. application/inflation of PASG/MAST. 11. Activate Paramedic intercept, if deemed necessary and if available. 12. Initiate transport as soon as possible with or without Paramedics. 13. Notify receiving hospital. PARAMEDIC PROCEDURES 1. Maintain appropriate body substance isolation precautions. 2. Maintain an open airway and assist ventilations as needed. In cases of suspected head/neck injury, assure cervical spine stabilization immobilization. Airway may include repositioning of the airway, suctioning or use of airway adjuncts (or pharyngeal airway / nasopharyngeal airway) as indicated. 3. Administer oxygen by nasal cannula or mask as determined by patient's condition. 4. Control/stop any identified life threatening hemorrhage (direct pressure, pressure points, etc.). 5. Assess the neurovascular status (motor, sensory and circulation) distal to the injury before and after proper immobilization. 6. If no palpable, distal pulse apply gentle traction along the axis of the extremity distal to the injury until the distal pulse is palpable and immobilize in place. Note: This does not apply to dislocations. 7. Immobilize painful, swollen and/or deformed extremity injuries (e.g. fractures, sprains, strains and/or dislocations) involving joints, in the position found. Bones adjacent to each injured joint must be fully immobilized, as well as supporting and immobilizing the injured joint. Joints adjacent to each injured bone must be fully immobilized, as well as supporting and immobilizing the injured bone(s). 8. All jewelry should be removed from an injured extremity 9. ALS STANDING ORDERS a. Provide advanced airway management (if indicated). b. Initiate IV Normal Saline, titrate IV infusion rate to patient's hemodynamic status. c. Application/inflation of PASG/MAST (if indicated). d. If patient‟s BLOOD PRESSURE drops below 100 systolic: treat for shock. 30

Administer a 250 cc bolus of IV Normal Saline. 10. MEDICAL CONTROL may order: a. Administration of additional IV Normal Saline. b. Morphine Sulfate 2-5 mg IV Push for pain control related to an isolated long bone injury may be repeated at discretion of Medical Control. 11. Initiate transport as soon as possible. 12. Notify receiving hospital. FRACTURES - is a break in the continuity of the bone. Classification According to the appearance of the part and according to whether there is soft tissue wound is associated with the break   Closed (simple) fracture – the skin has not been broken Open (compound) fracture – bone has broken through the skin or there is a wound which extends to the fracture site. According to the appearance of the broken bone in Open or close fracture  Green stick fracture - This is an incomplete fracture that occurs only in a child  Transverse fracture- The fracture line is straight across at a right angle to the long axis of the bone  Oblique fracture – the fracture line cross the bone at an oblique angle  Spiral fracture – The fracture line twists around and through the bone  Comminuted fracture - The bone is broken into more than two pieces  Impacted fracture -The broken end of the bone are jammed into each other‟s  Complicated fracture -this means there is another associated injury along with the fracture. That damage may include nerve, blood vessels and vital organs, e.g. when a casualty has a broken rib it may puncture the lung and that is the complication to the fracture.

Signs: 1. Deformity – An arm or leg may be in an un natural position or may be angulated where there is no joint. The chest wall of the skull is caved in 2. Tenderness – is usually sharply localized at the site of the break. This valuable sign is known as “point tenderness”. The point tenderness can be located gently pressing along the bone with the tip of the finger 3. Grating or crepitus – this is a sensation that can be felt when the broken ends of the bone rub together. 4. Swelling and dislocation – o Swelling may be due to edema (increase fluid in soft tissue) and may not become obvious in several hours. o Swelling may be due to hemorrhage (increase blood in the tissue) 31

5. Loss of use 6. Exposed fragment – In the open or compound type of fracture bone fragments may protrude through the skin or be seen in the depths of the wound Dislocation – is the displacement of the bone ends at a joint so that the joint surface is no longer in contact.     A joint consists of opposing ends of bone, covered by cartilages which are held together by a joint capsule, ligaments and tendons. The capsule and the ligaments help provide stability to the joint When there is a dislocation. The joint capsule is torn and one of the bone ends is dislodged from its normal position. A complete dislocation causes tearing of the ligaments.

Frequently dislocated joint A. B. C. D. E. S/Sx of dislocation 1. 2. 3. 4. Deformity of the joint Pain or pressure at the joint Pain on any attempted motion of the joint Complete or nearly complete loss of movement of the joint Shoulder Elbow Fingers Hip Ankle

Signs of compress or lacerate nearby vessels in facture or Dislocation 1. Numbness or paralysis below the fracture or dislocation 2. Loss of the pulse below the fracture 3. Feel cold Sprain – is a partial tear of a ligament.  Caused by a sudden twisting or stretching of the joint beyond the normal range of motion.  Two common areas of sprain are the ankle and knees  Ankle injury is usually caused by a sudden twisting of the foot being turned inward Treatment: Immobilized the joint


Fracture and dislocation may be caused in many ways: 1. Direct injuries – Falling on an arm, being struck by an auto mobile 2. Indirect injuries – A blow received at some distance from a break usually in line with the axis of the bone. Example a hip can be fractured when the knee strikes a dashboard. a. Twisting injuries – a severe twisting force may result in a bad sprain, fracture or dislocation may be seen in the ankle and knees. b. Powerful muscular contraction- sometimes muscles can contract so powerful that they actually avulse or pull away a small piece of bone. 3. Fatigue fractures- bones of the feet are particularly prone to fractures when they cannot tolerate repeated stress, as in a long march and they simply crack 4. Pathological fractures – these fractures are due to localized disease process such as cancer which has weakened the bone. Fracture treatment Goal: To regain and maintain correct position and alignment To regain the function of the involved part To return the patient to his usual activities in the shortest Time and at the least expense Process: 1. Reduction- setting the bone; refers to restoration of the fracture fragments into anatomic position and alignment 2. Immobilization – maintains reduction until bone healing occurs 3. Rehabilitation – regaining normal function of the affected part. Management         Control external bleeding and protect the wound Ask the casualty not to move, make them comfortable Avoid twisting of the neck or spine, maintain the alignment of the spine Check for circulation into the limb beyond the facture Handle gently, do not attempt to straighten fractured limbs Immobilize the fracture with pillows and blankets or use splints if necessary Seek medical assistance for transportation of the casualty Manage shock.

Strain - involve injury to the muscles and tendons caused by Excessive force, stretching or overuse If in doubt as to whether the casualty has a sprain, strain, fracture or dislocation – always treat the injury as a fracture and never apply a compression bandage over a suspected broken bone


Management REST: Decreases the pain.


This applied to the injury for 15-20 minutes intermittently for 12-36 hours minutes. Ensure there is a barrier between the ice and the skin. Ice helps to control the swelling and relieve pain. After 24 hours, apply mild heat (15-30 minutes 4 times a day).


A firm supportive figure 8 bandage is used to give even pressure over the injured area.


This reduces swelling as it slows the bleeding.

Splint – can be any material or appliance which prevent movement of a fractured or dislocated extremity. Objective: To prevent motion of fragments of bone or of Dislocated Joints during transportation to Medical Facility. Splint may prevent the following complications: 1. Damage to muscles, nerves, or blood vessels caused by broken ends of the bone. 2. Laceration of skin by broken bone, creating an open fracture (far more dangerous because of possible contamination of infection). 3. Restricted flow of blood as a result of pressure of bone ends on blood vessels 4. Excessive bleeding into the tissue around the fracture as a result of unstable bone ends 5. Paralysis of extremities due to fractured or dislocated vertebrae 3. HEMORRHAGE Hemorrhage- is an uncommon yet serious complication of surgery that can result in death. Classification of hemorrhage: A. Time Frame.  Primary - hemorrhage occurs at the time of surgery  Intermediary -hemorrhage occurs during the first few hours  after surgery when the rise of Bp to its normal  level dislodges insecure clots from untied  vessels.  Secondary- hemorrhage may occur some time after surgery if a o ligature slips because a blood vessel was o insecurely tied, became infected, or was eroded o by a drainage shock 34

B. Types of Vessel a. Capillary- hemorrhage is characterized by slow, general ooze. b. Venous- darkly colored blood bubbles out quickly. c. Arterial- blood is bright red and appears in spurts with each heartbeat. C. Viability a. Evident- hemorrhage is on the surface and can be seen b. Concealed- hemorrhage is in a body cavity and cannot be seen. Clinical Manifestation when there is a blood loss:        Apprehensive Restless Thirsty The skin is cold, moist and pale Increase pulse rate Decrease temperature Respiration is rapid and deep

Sign and Symptoms of Hemorrhage 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. apprehension, restless Cold, clammy skin Temperature drops Sweaty Pale skin Rapid, Thready pulse Thirst Rapid and deep respirations Circumoral pallor, spots appear before the eyes Dizziness Hypotension Weak Decreasing alertness

Signs and symptoms of internal bleeding 1. 2. 3. 4. 5. Pain Hematemesis Dyspnea Decreasing alertness Pale skin

If hemorrhage progresses untreated:   Cardiac output decreases Arterial and venous BP and Hgb level fall rapidly 35

    Management

Lips and conjunctiva become pallid Spots appear before the eyes Tinnitus Patient grows weaker but remain conscious

(External bleeding) 2. 3. 4. 5. Management: (Hemorrhage) 1. 2. 3. 4. Cut the patient‟s clothing away quickly and carry out a rapid physical examination Apply firm pressure over the bleeding area of the artery involved Apply a firm pressure dressing. Elevate and immobilize an injured part. Place patient in the most physiologically desirable position for shock a. Elevate the head to a pillow b. Keep the trunk horizontal c. Elevate lower extremities about 20 to 30 degrees keeping knees straight. 5. Insert an intravenous cannula to provide means of blood replacement. a. Withdraw blood sample for analysis, typing and cross matching b. Give replacement fluids, isotonic electrolyte solution, blood 1. Fresh blood is infused when there is massive blood loss. 2. Additional platelets or clotting factors are given. 3. Warm the blood (commercial warmer or basin of water) c. Rate of infusion depends on the severity of blood loss and clinical evidence of hypovolemia 6. Take the following step for internal bleeding a. Suspect internal bleeding in patient with Hypovolemic Shock with no external signs of bleeding. b. Give whole blood or plasma expanders at the rate of blood Loss. c. Apply a tourniquet only as a last resort when the hemorrhage cannot be controlled by any other method. Tag the patient (with a skin marking pencil or adhesive on his forehead) with a “T” stating the location of the tourniquet and the time applied. 7. Watch for cardiac arrest. Epistaxis – nosebleed  Blood may come from the anterior or posterior portion of the nose.  Most anterior nosebleeds respond to pressure. Direct continuous pressure Sterile dressing is placed over the wound or clean cloth Elevate and immobilize the injured part (unless fracture is suspected) Apply indirect pressure, that is pressure to the main artery


Intervention 1. Instruct the patient to sit down and lean the head forward. 2. Pinch the nostrils shut for at least 10 minutes 3. Advise the patient not to blow or pick at the nose for several hours. 4. SHOCK It is a condition in which systemic blood pressure is inadequate to deliver oxygen and nutrients to support vital organs and cellular function.Is a life threatening condition with variety of underlying causes.It is characterized by inadequate tissue perfusion that, if untreated results in cell death. CLASSIFICATION OF SHOCK 1. Hypovolemic Shock - occurs when there is a decrease in the intravascular volume. It is the most common type of shock; it is characterized by a decreased intravascular volume of 15% to 25%. This represents a loss of 750 to 1,300 ml of blood in a 70kg person. Risk factors: External: Fluid losses      Vomiting Diarrhea Diuresis Diabetic insipidus Trauma Surgery

Internal: FluidShifts      Hemorrhage Burns Ascites Peritonitis Dehydrartion

Categories of Causes of Hypovolemic Shock 1. Absolute hypovolemia – occurs as a result of external losses of fluid. 2. Relative hypovolemia – occurs as a result of the internal shifting of fluid between the body‟s two compartments, which is known as third spacing. “Third spacing is when the fluid of the intravascular space relocates to the extra-vascular space, causing edema” Sign and Symptoms per Stage 1. Compensatory Stage  Occurs with a fluid loss of 15% to 30% or 750 to 1500 ml 37

 

The goal of this stage is to restore oxygenation and perfusion to the cells Patient may exhibit:  Normal BP reading and narrowed pulse pressure (the difference between the systolic and diastolic BP which is normally 40 mmHg  Tachycardia  Tachypnea  Hypoxia  Decrease Urinary Output  Thirst  Pale  Cool skin  Delayed Capillary refill  Changed in LOC (confusion, restlessness, anxiousness)

2. Progressive Stage of Shock    Occurs with the fluid loss of 30% to 40% or 150 to 200 ml In this stage the compensatory mechanism fail and tissue perfusion becomes ineffective for the body organ to function. Patient may exhibit: o Heart rate continues to increase o Vasoconstriction o Hypotensive o Narrowed pulse pressure o Oliguria worsen o Increasingly lethargic, confused and comatose During this stage, organs become dysfunctional and all body system is affected. As one organ fails, the others eventually become dysfunctional, leading to multi-organ dysfunction syndrome (MODS)

3. Refractory or Irreversible Stage of Shock    The body organ are no longer responsive to treatment and multi-pleorgan failure ensures The compensatory mechanism completely and organ failure occurred The patient exhibit: o Severe tachycardia becomes bradycardia o Continued hypotension o Cardiopulmonary arrest o Unresponsive o Edema o Oliguria at Anuria Failure of other body system, the patient has 90% to 100% mortality rate when only 3 body system fails

 GOAL: 

Restore homeostasis and intra-vascular volume

Medical management:   Treatment of the underlying cause Fluid and blood replacement 38

 

Redistribution of fluid Pharmacologic therapy

Nursing Management:      Ensuring safe administration of prescribed fluids and medications Documenting their administration and effects Monitoring for signs of complication and side effects of treatment Reporting signs early in treatment Administering blood and fluids safely

2. Cardiogenic Shock occurs when the heart has an impaired pumping ability; it may be coronary and no coronary origin. It also 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.

Causes:   Coronary Cardiogenic Shock Non coronary Cardiogenic Shock

Clinical Manifestations:    Angina Dysrhythmias Hemodynamic instability

Medical management:   Correction of underlying causes Initiation of first line treatment involves the ff:  Supplying supplement oxygen  Controlling chest pain  Administering Vasoactive medication  Controlling heart rate with medication Implementing mechanical cardiac support Mechanical assistive devices

Nursing Management:      Preventing cardiogenic shock Monitoring hemodynamic status Administering Medications and Intravenous fluids Maintaining intra-aortic balloon counterpulsation Enhancing safety and comfort

Goal of Treatment  To restore blood flow and oxygenation 39

Treatment Cardiac revascularization  Thrombolytic therapy  Angioplasty  Bypass surgery  Circulatory support for mechanical devices  Intra aortal Balloon Pump (IABP)- works by inflating during diastole and deflating during systole  Left ventricular Assist Device (LVAD)- increases CO by helping the left ventricle pump blood to the periphery. Allows the heart to rest and not work so hard while the body tries to repair the body.  Pharmacologic Intervention  Dopamine (Intropin) – Increases renal perfusion at lower doses and causes an increase in CO, heart rate and, and systemic arterial pressure at higher doses, which increases the pumping action of the heart (positive inotropic).  Dobutamine (Dobutrex) – Increases the pumping action of the heart (positive inotropic) and CO and decreases ventricular filling pressure.  Norepinephrine (levophed) – A profound vasoconstrictor that is used to patient with extremely low systolic pressure (<70mmHg) to prevent total circulatory collapse.  Milrinone (Primacor) – Promote arterial vasodilations and reduces preload and afterload while increasing the pumping action of the heart (positive inotropic).  Sodium Nitroprusside (Nipride) – Decreases arterial resistance and is often used to decrease systemic vascular resistance (SVR), afterload, and systolic BP.  Nitroglycerin (nitrol, Tridil) – Decreases venous resistance and increases coronary artery dilation to assist with decreasing anginal pain.  Diuretics – Decreases body water, pulmonary edema, and systemic fluid overload  Goal Oxygen Therapy -

To improve arterial blood oxygenation To help oxygen supply to the tissue.  A measurement of oxygen tension in the arterial blood (PaO2) of >80mmHG on blood gas analysis an Oxygen saturation of >90% are both therapeutic goals.  Patient condition may require use of mechanical ventilation. 3. NUEROGENIC SHOCK  Also known as the spinal shock.  It is a rare shock.  The SNS is disrupted.  Caused by a loss of sympathetic tone.  Patient exhibit:


 Bradycardia  Decreased cardiac output  Hypotension  Hypothermia Goal: To improve tissue perfusion Management:  Maintain patient ABCs  IV fluid for volume replacement  Initiating vasopressor to control BP  Administer atropine sulfate for bradycardia  Provide rewarming measures 4. SEPTIC SHOCK - Is a shock state that occurs when sepsis is present in a patient. - Severe infection Characteristic:  Tachycardia  Hyperthermia or hypothermia  Hypotension  Increase RR  Tachypnea  Fatigue  Skin lesions  Agitated, confused, lethargic, disoriented, unarousable  Multiorgan dysfunction syndrome Treatment:         Maintain a patent airway Administer oxygen Monitor Hemodynamic Provide IV access Support BP with fluid and medications Obtain cultures Administer appropriate antibiotic therapy Administer an antipyretic

Conditions Predisposing to Septic Shock  Malnutrition  Large open wounds  Infection with resistance microorganism  Receiving chemotherapy 6. ANAPHYLACTIC SHOCK Is caused by a severe allergic reaction when a patient who has already produced antibodies to a foreign substance develops a systematic antigen-antibody reaction Risk factors:  Penicillin sensitivity  Transfusion reaction 41

 Insect stings allergy  Latex sensitivity Medical Management:     Requires removing the causative antigen Endotracheal intubation or tracheotomy IV lines are inserted Nebulized medication given in IV

Nursing Management:    5. BURN BURN – are a group of conditions with outcomes that include the removal of skin by thermal(heat or radiation), chemical, electrical means. Assessment of burns includes: 1. The type of burn (thermal, electrical, chemical, radiation) 2. The severity of the burn includes the depth of the burn (superficial, partial thickness or full thickness) 3. The extent of the burn based on percent of body area burned (rule of nine) Four major types of burn: 1. Heat burn – The seriousness of a heat burn depends upon the degree of the burn and the amount of the body surface involved. Classification of Heat burn according to Degree

Assess pt. for allergies Assess the patients understanding of previous reaction and steps taken by the patients Observe for any allergic reaction

First degree – It is limited to the most superficial layer of the epidermis. They are characterized by redness, mild swelling and pain. Sunburn is considered to be a first degree burn. Second degree – Results in blisters. With some damage to the deeper layer of the skin. They are most painful because the nerve endings are usually intact. Third degree – Is a full thickness of the skin and is the most serious. There is loss of pain sensation in the burned area due to destruction of the sensory nerve. The symptoms of a third degree burn can include the following: redness, swelling, a lot of pain, painful skin, ashen, charred or leathery looking skin. Victims of third degree burns may also exhibits signs of shock (pale, clammy skin, weakness, bluish lips, and finger nails).

  


Care of Heat burn For first or second degree burn 1. 2. 3. 4. Immersed the burned pat in cold water for 5 – 10 minutes Cover the burn with e sterile dressing or a clean sheet. Use cold water application for pain relief Transport the patient to the ED, continuing cold application en route.

For extensive first or second degree burns and all third degree.
   

Examine for relieve any respiratory distress. Always anticipate respiratory difficulty when there are burns around the face or if the patient has been exposed to hot gases or smoke. Cover the burned area with a sterile dressing or a clean sheet. Treat the patient for shock if necessary Transport the patient to the ED Severe pain is best relieved by injection, which must be given by a qualified personnel. And should be ordered by a physician.

2. Chemical burn- is common in industry. It can cause by acids or alkalis, such as kitchen and bathroom cleaning products. Care for chemical burn
 

Flush the area at once with water for at least 20 minutes. Continue to flood the area while clothing is being removed. A solution of a mild acid may then be used to neutralize alkali (sodium hydroxide or potassium hydroxide) burns of the skin. One or two tsp of vinegar (acetic acid) in one pint of water may be flushed over the burned area after it has been thoroughly washed with water. With acid such as sulfuric, nitric, hydrochloric, trichloroacetic (most corrosive) and carbolic (phenol), flushed the burned area with water and removed all the clothing. After flushing thoroughly with water it would be advisable to pour a solution made of one teaspoon of baking soda per pint of water over the affected area to neutralize any acid remaining in the body. Cover with a clean dressing or sheet and immediately transport the victim to a medical facility

Carbolic acid (phenol) is not water soluble, ethyl alcohol (gin and whiskey are both satisfactory (should be use for first washing. 3. Electrical burn (including those caused by lightning) – The entrance wound may be small, but the electricity continues to burn as it penetrates deeper and may burn a greater area below the surface that is suspected from surface appearance. There may be two burns, because the current can enter the body in one place and leave by another, burning each area. Be sure to look for a second burned area. Care for electrical burn 1. Cover the site with a dry (preferably sterile) dressing and transport the victim to the ED 2. Do not attempt to remove the victim from the source of electricity unless trained to do so.


Four types of injury with electrical burn A. Entrance wound – caused by electric current into the body and might appear a flat, black or depressed. B. Exit wound – caused by electric current exiting the body and might appear as black, charred and “blown out” as the current exits the body. C. Arc wounds – caused by the electric current crossing a specific body part (e.g. Knee, elbow, axilla) and an increase in temperature occurs that elicits a “petechiae type” appearance. D. Thermal wounds- caused by electrical current that ignites a person‟s clothing in a thermal burn. 4. Radiation burn – are of two types:
 

Nuclear burns – injury due to nuclear radiation. When radiation injury and burn injury occurs simultaneously, each tend to make the other worse. Solar burns- ordinary sunburn. The person who exposed himself to the sun for a prolonged period of time can sustain a near total body first degree burn. The effect of this should pass in a matter of twenty-four or forty eight hours, for this period of time the patient may require treatment as for a moderate burn and will experience severe discomfort.

The severity of the burn includes the depth of the burn: 1. Superficial burns- Epidermis only – pain and redness, average recovery time is one week. 2. Partial-thickness burn – Epidermis plus dermis- pain and blistering, average recovery is two months. 3. Full-thickness burns – All skin layers involved, may include subcutaneous tissue, bones muscles and organs, painless if nerve are burnt; average recovery time is 6 months to year 6. TRAUMA The unintentional or intentional wound or injury inflicted on the body from a mechanism against which the body cannot protect itself, is the third leading cause of the deaths in children and adults younger than 44 years old in other countries. Types of Trauma 1. HEAD TRAUMA Is a trauma to the head, that may or may not include injury to the brain. Signs and symptoms      Severe head or facial bleeding Change in level of consciousness for more than a few seconds Black-and-blue discoloration below the eyes or behind the ears Cessation of breathing Confusion


    

Loss of balance Weakness or an inability to use an arm or leg Unequal pupil size Repeated vomiting Slurred speech

If severe head trauma occurs:    Management   Immobilize the patient to insure no further damage to the spine or nervous system Insert an airway to insure uninterrupted breathing, and perform endotracheal intubation if indicated. One or more IVs will be inserted to maintain perfusion status. In some cases medications may be administered to sedate or paralyze the patient to prevent additional movement which may worsen the brain injury. Primary treatment involves controlling elevated intracranial pressure. This can include sedation, paralytics, cerebrospinal fluid diversion. Second line alternatives include decompressive craniectomy (Jagannathan et al. found a net 65% favorable outcomes rate in pediatric patients), barbiturate coma, hypertonic saline and hypothermia Keep the person still. Until medical help arrives, keep the person who sustained the injury lying down and quiet in a darkened room, with the head and shoulders slightly elevated. Don't move the person unless necessary and avoid moving the person's neck. Stop any bleeding. Apply firm pressure to the wound with sterile gauze or a clean cloth. But don't apply direct pressure to the wound if you suspect a skull fracture. Watch out for breathing changes and alertness. If the person shows no sign of circulation (breathing, coughing, or movement) begin CPR

2. CHEST TRAUMA (or thoracic trauma) Is a serious injury of the chest. Thoracic trauma is a common cause of significant disability and mortality. Thoracic injuries account for approximately 25% of all trauma-related deaths. TYPES OF CHEST TRAUMA INJURY Rib Fracture Flail Chest CAUSE Blow to chest Rib fractured in more than one place, chest wall becomes unstable S/SX Pain on inspiration, local tenderness Paradoxical respiration, Respiratory distress, Chest pain FIRST AID Transport Apply external pressure, Sand bed pillow, Give O2, transport with flail side down


Open Pneumothorax

Penetrating trauma to chest, loss of negative intra-thoracic pressure as air moves in & out of wound

Sucking sound on chest wall during inspiration tracheal deviation

Cover wound with occlusive dressing exhalation given O2.

Single Pneumothorax

Laceration of lungs, Hyperinflation (blast injuries, driving accident) Loss of negative intra-thoracic pressure

Sudden onset of chest pain, Decreased breath sound of affected area, dyspnea, tachypnea

Semi-fowler‟s or fowler‟s position, Give O2.

Tension Pneumothorax

Complication of another type of pneumonia, air enters to the pleural cavity but cant escape

Respiratory distress, paradoxical chest movement, neck vein distention, tracheal deviation to unaffected side

Maintain airway breathing, give oxygen


Blunt and penetrating injuries, injuries to major blood vessels and heart,Blood collects to the pleural cavity

Decreased breath sounds and dyspnea

Treat shock give oxygen


INJURIES A. Intra Abdominal Injuries Categories: 1. Penetrating abdominal injury – this results in a high incidence of injury in hollow organs particularly the small bowel. 2. Blunt abdominal injury- results from motor vehicle crashes, falls and blows. This is commonly associated with extra abdominal injury to chest. Head and extremities B. Crash Injuries Crash injuries occur when a person is caught between objects run over by moving vehicle or compressed by machinery. Assessment       The patient is observed for the following: Hypovolemic shock Paralysis of the body Erythema and blistering part Damaged body part Renal dysfunction

. Management    

Maintain patent airway Observed for renal insufficiency Elevate extremities to relieve swelling and pressure. Medication for pain and anxiety

C. Multiple injuries Multiple injuries are associated with increased severity, higher mortality and often require more complex care and facilities. Previous data summary methods included selecting a primary injury, predefining injury combinations and recording them and coding “multiple injury” with no further detail. These methods all have serious flaws. Management 1. Maintain patent airway. 2. Loose patients clothing. 3. Assess head and neck for injury. 4. Splint fractures 5. Prevent and treat hypovolemic shock


Unit V Emergency Management of Specific Medical Condition
1. Respiratory Emergencies Failure of:  Ventilation: air in/ air out  Diffusion: movement of gases  Perfusion: movement of blood Assessment Initial Assessment Mental status Position - (Tripod) Facial expression Speech (1 or 2 word dyspnea) Skin color Mucus membranes Suction if necessary Chest - Look, Auscultate, Feel  Respiratory rate - Adequate - Inadequate  Priority patient Signs and Symptoms                           Restlessness and anxiety Increased or irregular heart rate Tachypnea Bradyapnea Cyanosis Abnormal airway sounds Audible wheezing Diminished ability to speak Retractions Diaphragmatic breathing Shallow breathing Coughing Tripod position Barrel chest (emphysema) Altered mental status Chest trauma Pursed-lip breathing 48

Emergency Care/Inadequate Breathing         Establish airway Begin positive pressure ventilation with supplemental oxygen Expeditiously transport Oxygen 15 lpm. Assess baseline vitals Administer patients Metered Dose Inhaler (MDI) with Med. Control order Complete focused history/physical exam Transport in Fowlers or semi-Fowlers position

Chronic Obstructive Pulmonary Disease (COPD)  Obstruction to airflow in the lungs  Common causes - Chronic bronchitis - Emphysema  Most patients are aware of the problem and will report it during the SAMPLE history Emphysema  Destruction of alveolar walls along with distension of air sacs  Elasticity is lost  Reduction of surface in contact with capillaries  Air becomes trapped causing build up of CO2.  Breathing becomes difficult  Barrel chested appearance due to trapped air Sign & Symptoms  Thin barrel chest appearance  Coughing, but with little sputum  Prolonged exhalation  Diminished breath sounds  Wheezing and rhonchi  Pursed-lip breathing  extreme SOB on exertion  Pink complexion  Tachypnea  Diaphoresis  Home oxygen Chronic Bronchitis  Inflammation, swelling, excessive mucous in the bronchi & bronchioles  Productive cough for last 3 months out of the year for at least 2 years  Does not affect alveoli, however they can‟t expand fully because air can‟t get past the diseased bronchi or bronchioles  Recurrent infections cause scar tissue 49

Signs & Symptoms  Typically overweight  Chronic cyanotic complexion  Difficulty in breathing less prominent than emphysema  Productive cough (sputum)  Course rhonchi Emergency Care  Ensure airway  Position of comfort  Administer supplemental Oxygen  Hypoxic drive  High CO2 levels in blood cause receptors to respond  If receptors pick up high levels of O2 patient may stop breathing  MDI if patient has one (Med control)  Never withhold oxygen from any patient who needs it! Asthma     Increased sensitivity of lower airway to irritants. Causes Bronchospasms Edema Increased production of mucous Attacks are usually acute or periodic Usually no or very few signs & symptoms between attacks

Status Asthmaticus  True emergency  Prolonged attacks that doesn‟t respond to oxygen or medication  Consider ALS back-up Extrinsic Asthma  Allergic asthma  Dust, pollen, smoke  Often in children  Seasonal  May subside after adolescence Intrinsic Asthma  Infection, emotional stress, or strenuous exercise  Exhalation becomes difficult  Air becomes trapped in alveoli  Exhalation becomes active process  Respiratory arrest may soon follow Sign And Symtoms  Dyspnea  Productive cough  Wheezing 50

    

Tachypnea Tachycardia Anxiety and apprehension Possible fever Runny nose, blood shot eyes, or stuffy nose

Severe Signs and Symptoms  Extreme fatigue or exhaustion  Inability to speak  Cyanosis to core of body  Tachycardia greater than 130 bpm.  Quiet or absent lung sounds Emergency Care  Ensure airway  oxygen mask or positive pressure ventilation  Assess circulation  Try to calm the patient to reduce breathing workload  Patients MDI (Med control order)  Transport Note:   

All that wheezes is not asthma. Patient may be suffering from an obstructed airway Never assume anything

Pneumonia  Acute infectious disease  Bacteria or virus  Irritants or aspiration  Affects lower respiratory tract  Lung inflammation and fluid or pus-filled alveoli  Poor gas exchange or hypoxia Signs and Symptoms  Malaise and decreased appetite  Fever  Cough productive or non-productive  Dyspnea  Tachypnea & tachycardia  Chest pain made worse when breathing  Shallow respirations  Splinting of thorax with arms  Rales and rhonchi Emergency Care  Ensure airway  Ensure adequate oxygenation  Position of comfort


 Consult med-control or follow protocol concerning MDI Pulmonary Embolism  Blockage of pulmonary artery or branches  Blood clot, fat particle, air bubble, foreign body  Decreased blood flow  Interrupts breathing and heart rhythm Factors      

Surgery Prolonged immobilization Thrombophlebitis Birth control pills Chronic atrial fibrillation Multiple fractures

Signs & Symptoms  Sudden onset of unexplained dyspnea  Respiratory distress, rapid breathing  Sudden onset of sharp, stabbing chest pain  Cough (may cough up blood)  Tachypnea & tachycardia  Syncope  Cool moist skin  Restlessness and anxiety  Decreased BP (Late sign)  Cyanosis (Late sign)  Distended neck veins (Late sign) Emergency Care  Ensure airway  Ensure proper oxygenation  Monitor the patient  Rapid transport Acute Pulmonary Edema o Fluid collects in space between alveoli and capillaries Two Kinds 1. Cardiogenic 2. Non-cardiogenic Cardiogenic  Inadequate pumping action of the heart  Increased pressure in the pulmonary capillaries  Fluid is forced to leak into the space between alveoli and capillaries  Eventually fluid will enter the alveoli Non-Cardiogenic  Destruction of the capillary bed allows fluid to leak out 52

Pneumonia, aspiration, near-drowning, narcotic overdose, inhalation of smoke or other toxic gases, high altitudes, trauma

Signs & Symptoms  Dyspnea (especially on exertion)  Difficulty breathing while laying flat  Frothy pink or white sputum (late sign)  Tachycardia  Anxiety, Confusion, combativeness  Tripod position  Fatigue  Rales, possible wheezing  Cyanosis  Pale moist skin  Distended neck veins  Swollen lower extremities Emergency Care  Ensure airway  Ensure proper oxygenation ( big O‟s).  Position patient in Fowlers position  Transport without delay 2. Cardiac Emergency Cardiac Compromise May include one or all of the following:  Squeezing, dull pressure, chest pain commonly radiating down the arms or to the jaw  Sudden onset of sweating  Difficulty breathing  Anxiety, irritability  Feeling of impending doom  Abnormal pulse rate (may be irregular)  Abnormal blood pressure  Epigastric pain  Nausea/vomiting Causes of cardiac compromise  Coronary Artery Disease-narrowing or blocked coronary arteries  Aneurysm-weakened sections in the arterial walls  Electrical malfunctions-an irregular, or absent, heart rhythm  Mechanical malfunctions-mechanical pump failure  Angina Pectoris- a pain in the chest  Acute myocardial infarction- heart muscle that dies due to oxygen starvation  Congestive heart failure-excessive fluid build-up  Hypertensive Crisis- High blood pressure


Emergency Care Equipment should include o Oxygen o Oxygen adjuncts o Suction equipment o Equipment to assess vital signs o Defibrillator Treatment Priorities 1. ABC‟s 2. Oxygen 3. Vital signs 4. Nitroglycerin 5. Rapid Transport Assessment Onset Provocation Quality Radiation Severity Time Signs and symptoms Allergies Medications Past medical history Last meal Events leading up to the illiness Medication Nitroglycerin Trade Name Nitrostat ™ Nitrolingual ® Spray Acute Coronary Syndromes (Chest Pain)       Primary ABCD Survey Body Substance Isolation procedure Assess responsiveness Open airway Assesses pulse Attaches monitor

Secondary Survey  Obtains vital signs  Places Patient on 02 at appropriate rate 54

 Initiates IV line  Performs targeted history, OPQRST, SAMPLE Treatment  Administers 325mg Aspirin  Administers Nitro 0.4mg SL then Q 5 minutes X2, (if B/P > 100 Systolic & pain not relieved) Contraindications  Hypotension  Suspected increased intracranial pressure  Viagra or Levitra within past 24 hours & Cialis within past 96 hours 3. Diabetic Emergency and Altered Mental status

A. Diabetes Mellitus 1. A metabolic disorder in which the body cannot metabolize glucose. 2. Usually due to the lack of insulin or inadequate insulin production B. Insulin 1. Allows glucose to pass from the blood stream into cell. 2. Produced in the pancreas 3. Production stimulated by increased blood sugar C. Glucose 1. Major source of energy for the body 2. All cells need it to function 3. As important to the brain as oxygen D. Normal blood sugar = 80–120mg/dl E. Hypoglycemia (insulin shock) 1. Low blood sugar (<70mg/dl) F. Hyperglycemia [diabetic ketoacidosis (DKA)] 1. High blood sugar (>200mg/dl) G. Precipitating factors 1. Heredity 2. Obesity 3. Pregnancy 4. Viral infections H. Long term effects on the body 1. Blindness 2. Heart disease 3. Kidney failure 4. Nerve disorders 5. Circulatory disorders


I. Type I (Insulin dependent – IDDM) 1. No insulin produced 2. Can significantly shorten life span if not managed 3. Effects on the body are usually more severe than with type II 4. Treated with daily insulin shots J. Type II (Non-insulin dependent – NIDDM) 1. Usually appears later in life 2. Patient produces inadequate insulin or insulin doesn‟t function correctly 3. Treated with diet/exercise and/or oral medications 4. Can progress to type I diabetes II. Diabetic Medical Emergencies A. DKA (Diabetic ketoacidosis) 1. Decreased insulin which results in increased blood sugar 2. Slow in onset 3. Mimics dehydration

Pathophysiology of Hyperglycemia (DKA)
Decreased insulin and/or increased blood sugar

Increased sugar in the urine

Starving cells

Water is pulled into urine

Fat and protein breakdown

Increased urine output

Production of ketones and other acids/byproducts Irritability


Diabetic coma



4. Common causes a. Infection – raises metabolism b. Stress – raises metabolism c. Exercise/diet changes d. Pregnancy e. Some drugs (prescription or street) 5. Pertinent questions (may have to ask family members) a. Do you take insulin or control your diabetes with diet/oral meds? b. Have you taken your insulin/oral meds today? c. Have your meds been changed lately? d. When did you last eat, and how much? e. Have you been unusually stressed? (heat, cold, sickness, physical or emotional stress) f. When did you last take your blood sugar reading and what was it? 6. Signs/symptoms a. Altered LOC b. Skin warm/dry c. Tachycardia d. Kussmaul respirations – Rapid/deep respirations in an attempt to blow off acids (CO2) e. Blood pressure normal or low (dehydration) f. Smell of acetone on the breath (fruity odor) – acids g. ABD pain h. Polydipsia – Thirsty i. Polyphagia – Hungry j. Polyuria – Increased urine output 7. Treatment a. ABC‟s, High flow O2 b. Position as per blood pressure c. Rapid transport d. ALS support e. If unsure treat as hypoglycemia B. Hypoglycemia (Insulin shock) 1. Increased insulin which leads to low blood sugar 2. Rapid onset 3. Mimics shock 4. True medical emergency 5. Can be seen in non-diabetic patients


Pathophysiology of Hypoglycemia
Increased insulin

Decreased blood sugar

Starved brain (brain damage)

Sugar stores used up



6. Common causes a. Too much insulin b. Normal insulin/not enough food c. Starvation d. Alcohol e. Hypothermia f. Exercise g. Tumors of the pancreas h. Liver problems i. ASA overdose 7. Pertinent questions (same as for DKA) a. Do you take insulin or control your diabetes with diet/oral meds? b. Have you taken your insulin/oral meds today? c. Have your meds been changed lately? d. When did you last eat, and how much? e. Have you been unusually stressed? (heat, cold, sickness, physical or emotional stress) f. When did you last take your blood sugar reading and what was it? 8. Signs/symptoms a. Altered LOC (combatitive) b. Skin pale/cool/diaphoretic c. Tachycardia d. Rapid/shallow respirations e. Blood pressure usually normal f. Seizures g. Stroke like symptoms h. Rapid onset

9. Treatment a. ABC‟s, High flow O2 b. Oral glucose between cheek and gum c. DO NOT place anything into mouth of patient if they can‟t protect their own airway d. Position of comfort e. Rapid transport f. ALS support

Major Differences in presentation
Onset Skin vitals (most obvious) Respirations

Hypoglycemia Rapid (minutes) Diaphoretic Rapid shallow

Hyperglycemia Slow (days) Dry Rapid deep (kussmaul)

III. Medication A. Oral Glucose 1. Medication Name a. Generic - Glucose, Oral b. Trade - Glutose, Insta-glucose 2. Indications - patients with altered mental status with a known history of diabetes controlled by medication. 3. Contraindications a. Unresponsive. b. Unable to swallow. 4. Medication form - Gel, in toothpaste type tubes 5. Dosage - one tube 6. Administration a. Obtain order from medical direction either on-line or off-line. b. Assure signs and symptoms of altered mental status with a known history of diabetes. c. Assure patient is conscious and can swallow and protect their airway. d. Administer glucose. (1) Between cheek and gum. (2) Place on tongue depressor between cheek and gum. e. Perform ongoing assessment. 7. Actions - increases blood sugar 8. Side effects - none when given properly. May be aspirated by the patient without a gag reflex 9. Re-assessment strategies - if patient loses consciousness or seizes, remove tongue depressor from mouth.


IV. Altered Mental Status A. Causes of Altered Mental Status 1. Hypoglycemia 2. Poisoning (Including Alcohol & Drugs) 3. Infection 4. Head Trauma 5. Hypoxia B. Emergency Care of Altered Mental Status 1. Secure airway 2. Ventilate and suction as needed 3. Transport 4. Evaluate potential causes 5. Treat patient as trauma patient if injury cannot be ruled out V. Seizures A. Definition - Sudden change in sensation, behavior, or movement caused by irregular electrical activity of the brain B. Causes of Seizure 1. Toxin (Including drugs and alcohol) 2. Brain tumor 3. Congenital brain defects 4. Trauma 5. Infection/Fever a. #1 cause in pediatric patients 6 months to 3 years old 6. Epilepsy 7. Stroke 8. Hypoglycemia 9. Eclampsia (complication of pregnancy) 10. Hypoxia 11. Unknown C. Information to Obtain 1. What was the patient doing before seizure? 2. What movements were exhibited? 3. Loss of bladder or bowel control? 4. What did the patient do after seizure? 5. Length of episode? D. Emergency care during seizure 1. Place patient on floor 2. Position patient on side 3. Loosen restrictive clothing 4. Remove harmful objects 5. Protect patient from injury; do not hold patient still or place anything in mouth. 6. After seizure subsides:

a. protect airway with positioning and suction b. If cyanotic, ventilate with oxygen c. Treat injuries d. Transport E. Status Epilepticus 1. Definition - A life-threatening condition in which the patient has two or more convulsive seizures without regaining consciousness 2. Emergency Care a. Secure the airway b. Ventilate with 100% oxygen c. Request ALS d. Transport immediately VI. Cerebrovascular Accident (CVA) – Stroke A. Pathophysiology 1. Death or injury of brain tissue that is deprived of oxygen. 2. Caused by a blockage (ischemic) or bleeding (hemorrhagic) of a blood vessel in the brain. B. Signs and Symptoms 1. Intoxicated appearance, slurred speech, unconsciousness 2. Severe headache, vision changes 3. One-sided weakness on body 4. Confusion 5. Loss of bowel and/or bladder control 6. Unequal pupils 7. High blood pressure C. Transient Ischemic Attack (TIA) 1. Sometimes called a “mini stroke” 2. Signs and symptoms of a stroke 3. Often resolved before EMS arrival 4. Symptoms resolve without treatment in less than 24 hours 5. Significant risk of having a “full” stroke D. Treatment of stroke patient 1. Prompt transport is critical 2. Identify potential stroke patients and notify the hospital 3. Maintain airway, administer oxygen E. Cincinnati Prehospital Stroke Schedule 1. Facial drooping 2. Arm drift 3. Slurred speech VII. Dizziness and Syncope A. Syncope is a brief loss of consciousness B. It can occur at any age, more common in the elderly C. It may be an indicator of a more serious medical problem D. Causes of Syncope 1. Hypovolemia

a. Trauma b. Dehydration 2. Metabolic a. Hypoglycemia b. Stroke c. Seizure 3. Environmental / Toxicological a. Drugs and Alcohol b. Carbon Monoxide c. Panic / Anxiety 4. Cardiovascular a. Fast or slow heart rates b. Electrical system disturbance c. Vagus nerve stimulation E. Assessment of dizziness and syncope 1. Obtain a SAMPLE history 2. Ask about onset time, activities 3. Length of episode 4. Any previous episodes 5. Any medications for this condition 6. Any nausea / vomiting / bowel changes F. Treatment of dizziness and syncope 1. Administer high-concentration oxygen 2. Loosen restrictive clothing 3. Lay patient flat and elevate legs (if no suspected spinal injury) 4. Treat any associated injuries 5. Request ALS and transport
4. Anaphylactic Reaction It is also called severe allergic reaction; anaphylaxis; anaphylactic shock. It is an acute systemic hypersensitivity reaction that occurs within seconds or minutes of exposure to various foreign substances, such as medications and other agents such as, insects or foods. Repeated administration of parenteral or oral therapeutic agents may also precipitate an anaphylactic reaction. Anaphylactic reactions range from mild to severe. It can also be sudden or massive. It is a lifethreatening situation. If untreated anaphylaxis can be fatal within 5-30 minutes about 60% - 80% of anaphylactic deaths are caused by inability to breathe because swollen airway passages obstruct airflow to the lungs. Another main cause results when blood vessels dilate so blood is deficient in the body.

Signs and Symptoms: *Respiratory signs:  Nasal congestion  Sneezing, coughing or wheezing  Dyspnea  Cyanosis 62

 

Chest tightness Tightness or swelling of the throat

*Skin manifestations:  Severe itching, burning, rash or hives on the skin  Swelling of face, tongue and / or mouth *Cardivascular and Neurologic manifestations:  Tachycardia or bradycardia  Pallor  Imperceptible pulse  Decreasing BP  Dizziness  Convulsions  Unconsciousness  Circulatory failure that may lead to death * Gastrointestinal problems:    Nausea and vomiting Colicky abdominal pains Diarrhea

Management: 1. Do not mistake anaphylaxis for other reactions such as, hyperventilation, anxiety attacks, alcohol intoxication and hypoglycemia. 2. Check ABCs. 3. Maintaining patent airway and ventilation is essential. 4. Seek medical attention immediately. 5. Early endotracheal tube intubation is essential to avoid loss of airway. 6. Oropharyngeal suctioning may be necessary to remove excessive secretions. 7. First aid for seizures may be necessary. 8. Resuscitative measures are used, especially for patients with stridor and progressive pulmonary edema. 9. If glottal edema occurs, a cricothyroidotomy is used to provide airway. 10. Simultaneously, with airway management, epinephrine is administered as prescribed to provide rapid relief of hypersensitivity reaction. 11. Keeping the conscious victim sitting in an upright position may also help breathing.


5. Poisoning, Substance Abuse and Drug Overdose POISONING A poison is any substance that when ingested, inhaled, absorbed, applied on the skin or produced within the body in relatively small amounts injures the body by its chemical action. Poisoning from inhalation, and ingestion of toxic materials, both unintentional or by design, constitutes a major health hazard and an emergency situation. a. INGESTED (SWALLOWED) POISONS: Swallowed poison usually remains in the stomach only a short time and the stomach absorbs only small amounts. Much absorption takes place after the poison passes into the small intestine. Swallowed poisons may be corrosive. Corrosive poisons include alkaline and acid agents that can cause tissue destruction after coming in contact with mucous membranes.   Alkaline Products: lye, drain cleaners, toilet bowl cleaners, bleach, nonphosphate detergents, oven cleaners, button batteries. Acid Products: toilet bowl cleaners, pool cleaners, metal cleaners, rust removers, battery acid.

Signs and Symptoms:       Abdominal pain and cramping Nausea and vomiting Diarrhea Burns, odor, strains around and in mouth Drowsiness or unconsciousness Poison containers nearby

Management: 1. Determine the critical information which includes:    Who? Age and size of the victim. What was swallowed? How much was swallowed? When was it swallowed?

2. Control of the airway, ventilation and oxygenation are essential. 3. If a corrosive or caustic material was swallowed, immediately dilute with water or milk.


4. Call a poison control center immediately. 5. Keep victim on the left side. This places the end of the stomach straight up. This position delays stomach emptying into the small intestine. With the pyloric valve straight up it delays the stomach emptying by as much as 2 hours. The side position also protects the lungs. 6. If instructed and available, give activated charcoal. Powdered activated charcoal acts like sponge and binds and keeps the poison within the digestive system, and thus prevents absorption of the poison into the blood. 7. Save poison containers, plants and vomit to help medical personnel to identify the poison.

Precautions: DO NOT:  Give water or milk to dilute other types of poisons unless instructed by a medical source. Reasons include the fact that fluids may dissolve a dry poison more rapidly and may fill up the stomach, which forces stomach contents into the small intestine faster, where poisons are absorbed faster. Induce vomiting unless a poison control center or physician advises it. Inducing vomiting removes 30% 50% of the poison from the stomach, which means that 50 % - 70% of the poison remains in the stomach. If instructed by the physician to induce vomiting, use Syrup of Ipecac. * Reasons for not using syrup of ipecac are as follows:     Waiting for vomiting to begin may take 20-30 minutes, during which time some poison may pass into the small intestine. Any additional treatment must be delayed until vomiting stops. Any vomitus could be inhaled.

Induce vomiting under these conditions:  Seizures  Unconscious or drowsy  Late stage of pregnancy  History of heart disease or likely to suffer heart attack  Corrosive or caustic  Petroleum product  Strychnine (rat poison)  Less than 6 months old   Use salt waters to induces vomiting because it is unreliable and dangerous and death have resulted Force the victim to gag or tickle the back of the throat by sticking a finger or spoon handle down the victim‟s throat. This is usually ineffective in causing vomiting and any vomit produce is not very large. 65

   

Give liquid dishwashing detergent, raw eggs or mustard water. Use ipecac and activated charcoal at the same time. Charcoal will bind the ipecac and may prevent vomiting. Follow a container label‟s first aid procedures or recommendations without getting confirmation from a poison control center. Think that there is a “universal antidote”. There is no product effective in treating most or all poisons.

b. INHALED POISONS: Carbon Monoxide Poisoning Carbon monoxide poisoning may occur as a result of industrial or household incidents or attempted suicide. It is implicated in more deaths than any other toxin except alcohol. Carbon monoxide exerts its toxic effect by binding to circulating Hgb and thereby reducing oxygen carrying capacity of the blood. Signs and Symptoms:           Critical need for oxygen Appears intoxicated Headache Ringing of the ears Angina Muscular weakness Palpitations Dizziness Mental confusion which can progress to coma Skin color which can range from pink or cherry red to cyanotic

Management: 1. Carry the patient to fresh air immediately; open all doors and windows. 2. Loosen all tight clothing.Initiate CPR if required. 3. Administer oxygen 4. Prevent chilling; wrap the patient in blankets. 5. Keep the patient as quiet as possible. 6. Do not give alcohol in any form.


c. SKIN CONTAMINATION POISONING: Chemical Burns A chemical burn occurs when a caustic or corrosive substance touches the skin. First aid is the same for all chemical burns, except a few special burns, which require additional treatment to neutralize the chemical. The chemical continues to burn as long as it stays in contact with the skin. Alkali burns are more serious than acid burns because they penetrate deeper and remain active longer. Dry powder chemicals should be brushed from the skin before flushing since water activate a dry chemical and cause more damage to the skin than when it is dry. Management: 1. Immediately flush the chemical with large amount of water. If available, use hose or shower. 2. Remove the victim‟s contaminated clothing while flushing with water. 3. Flush for 15-20 minutes or even longer. Let the victim wash with a mild soap before a final rinse. 4. Cover the burned area with a dry, sterile dressing or, for large areas, a clean sheet. 5. If the chemical is in the eye, flood it for at least 15-20 minutes using low pressure. 6. Seek medical attention immediately for all chemical burns. d. FOOD POISONING It is a sudden, explosive illness that may occur after ingestion of contaminated food or drink. Botulism is a serious form of food poisoning that requires continual surveillance. Signs and Symptoms  Abdominal pain and cramps  Nausea and vomiting  Diarrhea  Headache  General malaise  Fever  Pale in color Management: 1. Determine the source and type of food poisoning. 2. Refer to the nearest hospital immediately, if possible. 3. Maintain proper hydration to prevent dehydration and correct the fluids and electrolytes imbalance. 4. Render measures to control vomiting. 5. Antiemetics may be given as prescribed, either parentherally or orally, depending on the capability of the patient. 6. For mild nausea, the patient makes take sips of weak tea, carbonated drinks or tap water. 7. After nausea and vomiting subsides, clear liquids are usually prescribed for 12-24 hours, and the diet gradually progresses to low residue, bland diet


SUBSTANCE ABUSE Substance abuse is the misuse of specific substance to alter mood or behavior; drug and alcohol abuse are two examples of substance abuse. A. Alcoholism Refer to the continued excessive or compulsive consumption of alcoholic beverages.

Blood alcohol level is the amount of alcohol in the blood at any one time.

.04% allowable blood alcohol level for drivers for the age 21 and 0% for those under the age of 21. Most laws designate blood alcohol level of 100mg/100ml (0.10%) as the legal limit for intoxication. EFFECTS OF BLOOD ALCHOL LEVELS MON AVERAGE SIZED NON-TOLERANT ADULT



50 – 70 mg

Pleasant, relaxed state, mild sedation, loosing inhibition

100 – 200 mg

Overt signs of intoxication, loosening of tongue, clumsiness, beginning emotional changes

200 – 400 mg

Severe intoxication, difficulty of speaking, stumbling emotional liability

400 – 500 mg

Stupor coma

Over 500 mg

Usually FATAL!

Health problems related to drinking    lower testosterone shrinking gonads, erectile dysfunction,


                

interference with reproductive fertility, Weak bones, Memory disorders, Difficulty with balance and walking, Liver disease (including cirrhosis and hepatitis) Weakness of muscles (including the heart) High blood pressure, Disturbances of heart rhythm, Anemia Clotting disorders, Weak immunity to infections, Inflammation and irritation of the entire Gastrointestinal system, Acute and chronic problems with the pancreas Low blood sugar High blood fat content Poor nutrition.

Major Categories of Symptoms A. Immediate (acute) effects of alcohol use 1. 2. 3. 4. 5. 6. Difficulty walking, poor balance, slurring of speech, poor coordination Impairment of peripheral vision Breathing and heart rates will be slowed, Vomiting Pneumonia Coma and death.

B. Effects of long-term (chronic) alcoholism 1. Nervous system
   

Alcoholic blackout, sleep disturbances, Numbness and tingling of arms and legs. Low thiamine (a form of vitamin B complex)

2. Gastrointestinal system
        

Loosening of the muscular ring that prevents the stomach's contents from re-entering the esophagus. Pain and bleeding. Decreased desire to eat. Uncontrollable bleeding (hemorrhage) Diarrhea Inflammation of the pancreas (pancreatitis Liver enlarge Cirrhosis Hepatitis 69

3. Blood    4. Heart.         Drop in blood Increase blood pressure. Heart disease Increase in heart size, Weakening of the heart muscle, Abnormal heart rhythms, Risk of blood clots forming within the chambers of the heart Increased risk of stroke Red blood cells become abnormally large. White blood cells (important for fighting infections) decrease in number Platelets and blood clotting

5. Reproductive system.   Negative effect on fertility in both men and women, by decreasing testicle and ovary size, and interfering with both sperm and egg production. Fetal alcohol syndrome

Alcohol withdrawal Symptoms Mild withdrawal symptoms 1. 2. 3. 4. 5. 6. 7. Nausea, Ache, Diarrhea, Difficulty sleeping, Excessive sweating, Anxiety, Trembling.

Severe withdrawal Symptoms 1. 2. 3. 4. 5. 6. 7. 8. Hallucinations (in which a patient sees, hears, or feels something that is not real), Seizures, Unbearable craving for more alcohol, Confusion, Fever, Fast heart rate, High blood pressure Delirium (a fluctuating level of consciousness).  Delirium tremens usually begins about three to five days after the patient's last drink and may last a number of days. Withdrawal usually progresses from the more mild symptoms to the more severe ones. 70

Treatment 1. Mild withdrawal, monitored carefully to make sure that more severe symptoms do not develop, may not require medication.. 2. Patients suffering more severe effects of withdrawal may need to be given sedative medications, benzodiazepines like Valium or Librium. 3. Thiamin must be given 4. Suicide precaution 5. Haloperidol or droperidol may be given 6. Phenytoin (Dilantin) or other anti-seizure medication may be prescribed 7. V/S monitoring q 30 min.

DRUG OVDERDOSE Drug overdose – an accident or a purposeful use of a drug, large enough to cause severe adverse reaction Initial Evaluation to the patient 1. Obtaining a complete and reliable history 2. Thorough physical examination 3. Laboratory test Most Abused Drugs and Its Effect: * NARCOTICS  COCAINE – CNS stimulant, produces euphoria and many other psychiatric manifestations  HEROIN - acute intoxication  OPIUM - pinpoint pupils, decreased BP  MORPHINE - marked respiratory depression  FENTANYL – stupor to coma * BARBITURATES  PHENOBARBITAL - acute intoxication  SECOBARBITAL – respiratory depression  AMOBARBITAL - depressed deep tendon reflex, decreasing mental alertness, poor motor coordination, coma that may lead to death * AMPHETAMINE TYPE DRUGS  AMPHETAMINE - nausea, vomiting, anorexia


 DEXTROAMPHETAMINE-palpitations, tachycardia Focus Area for the Management of the Patient Experiencing an Overdose A. Supportive Care B. Prevention of Absorption C. Enhancement of excretion D. Administration of an antidote

A. Supportive Care – this includes frequent monitoring of vital signs with particular focus on the temperature.

B. Prevention of Absorption  Induce Emesis – in the alert patient.  The drug of choice is IPECAC. It is a dried root or rhizome of Cephaelis ipecacuanha and C. acuminata. Plants found in Brazil and Central America.  Ipecac induces emesis by acting locally in the stomach, as well as delayed action in which stimulation of the chemoreceptor trigger zone of the CNS occurs.  Gastric Lavage – is the aspiration of stomach content and washing of the stomach with sterile water or saline solution.

Indication: 1. Lost of gag reflex 2. Comatose patient 3. Seizing Contraindication: 1. After acid or alkaline ingestion 2. Ingestions of hydrocarbons or petroleum distillates 3. Ingestion of strong corrosive agents Solutions Use Activated Charcoal – is a residue of destructive distillation of burned organic materials such as wood, pulp paper, bone and saw dust .. Etc. It is a fine black powder with a gritty consistency that is tasteless and odorless. It is mixed with 60 to 90 ml water to make it slurry mixture. Between 30 to 100g for an adult and is induced via NG or lavage tube.



It can be administered orally if the patient I alert and cooperative. Recommended dose is 50 to 100mg mixed in 8oz of water

Cathartics – an agent that promotes bowel evacuation by Stimulating peristalsis, increasing the fluidity of Intestinal contents, lubricating the intestinal wall Cathartic Agents 1. Sorbitol – the fastest and most potent osmotic agent 2. Magnesium sulfate (Epsom salt)3. Magnesium citrate slower acting and magnesium level needs to be monitored This is avoided in patient with salt intake restriction and in those with history of heart failure 4. Sodium sulfate (Glauber‟s solution) 5. Disodium phosphate (fleet enema) C. Enhancement of Excretion 1. Forced diuresis – requires diuretics 2. Alteration of urine ph – involves the concept of ion trapping. 3. Hemodialysis- blood is sent through a dialyzer. 4. Hemoperfusion – requires the blood to be delivered through a cartridge that contains an absorbent such as active charcoal. The blood is then returned to venous circulation. D.Antidotes General or supportive antidote are not true antidotes but assist in treating overdose symptoms and include activated charcoal and sodium bicarbonate  

First Line Initial Treatment 1. 2. 3. 4. 5. 6. 7. 8. Assess responsiveness Establish an airway Provide Oxygen Check pulse. If no pulse, initiate CPR Initiate Cardiac monitoring Establish IV access (gauge 20 or 18 for an adult) Provide fluid replacement Determine substance taken; give appropriate reversal agent


i. HEAT STROKE Heat stroke is defined typically as hyperthermia exceeding 41°C, it is a medical emergency. Even with immediate treatment, it can be life-threatening or result in serious, long-term complications. After calling 911 or other emergency medical services. Heatstroke occurs when the body fails to regulate its own temperature and body temperature continues to rise, often to 105° (40.6°) or higher. Signs of rapidly progressing heatstroke include:  Unconsciousness for longer than a few seconds.  Convulsion (seizure).  Signs of moderate to severe difficulty breathing.  A rectal temperature over 104° (40°) after exposure to a hot environment.  Confusion, severe restlessness, or anxiety.  Fast heart rate.  Severe vomiting and diarrhea. Types of Heat Stroke Exertional heat stroke

A. 1.

- Occurs in young individuals who engage in strenuous physical activity for a prolonged period of time in a hot environment.   EHS is characterized by hyperthermia, diaphoresis, and an altered sensorium, which may manifest suddenly during extreme physical exertion in a hot environment. A number of symptoms (eg, abdominal and muscular cramping, nausea, vomiting, diarrhea, headache, dizziness, dyspnea, weakness) commonly precede the heat stroke and may remain unrecognized. Syncope and loss of consciousness also are observed commonly before the development of EHS. EHS commonly is observed in young, healthy individuals (eg, athletes, firefighters, military personnel) who, while engaging in strenuous physical activity, overwhelm their thermoregulatory system and become hyperthermic. Because their ability to sweat remains intact, patients with EHS are able to cool down after cessation of physical activity and may present for medical attention with temperatures well below 41°C. Risk factors that increase the likelihood of heat-related illnesses include a preceding viral infection, dehydration, fatigue, obesity, lack of sleep, poor physical fitness, and unacclimatization. While unacclimatization is a risk factor for heat stroke, EHS also can occur in acclimatized individuals who are subjected to moderately intense exercise. EHS also may occur because of increased motor activity due to drug use, such as cocaine and amphetamines, and as a complication of status epilepticus.


B. Classic non exertional heat stroke Commonly affects sedentary elderly individuals, persons who are chronically ill and very young persons. Classic NEHS occurs during environmental heat waves and is more common in areas that have not experienced a heat wave in many years.  Classic NEHS is characterized by hyperthermia, anhidrosis, and an altered sensorium, which develop suddenly after a period of prolonged elevations in ambient temperatures (ie, heat waves). Core body temperatures greater than 41°C are diagnostic, although heat stroke may occur with lower core body temperatures. Numerous CNS symptoms, ranging from minor irritability to delusions, irrational behavior, hallucinations, and coma have been described. Anhidrosis due to cessation of sweating is a late occurrence in heat stroke and may not be present when patients are examined. Other CNS symptoms include hallucinations, seizures, cranial nerve abnormalities, cerebellar dysfunction, and opisthotonos. Patients with NEHS initially may exhibit a hyperdynamic circulatory state, but, in severe cases, hypodynamic states may be noted. Classic heat stroke most commonly occurs during episodes of prolonged elevations in ambient temperatures. It affects people who are unable to control their environment and water intake (eg, infants, elderly persons, individuals who are chronically ill), people with reduced cardiovascular reserve (eg, elderly persons, patients with chronic cardiovascular illnesses), and people with impaired sweating (eg, patients with skin disease, patients ingesting anticholinergic and psychiatric drugs). In addition, infants have an immature thermoregulatory system, and elderly persons have impaired perception of changes in body and ambient temperatures and a decreased capacity to sweat.

    

Both types of heat stroke are associated with a high morbidity and mortality, especially when therapy is delayed. Prevention of heat stroke 1. A variety of human factors should be taken into account, such as acclimatization, general health and salt intake, peculiarities of religious devotion and liability to neglect, regulations intended to promote public health. 2. Athletes or pilgrims should be informed of the work load and the level of heat stress they may encounter, and of the risks of heat stroke. 3. A period of acclimatization is recommended before vigorous physical activity and/or severe exposure is risked. 4. The level of activity should be matched to the ambient temperature, and physical exertion should be avoided or at least minimized during the hottest hours of the day. 5. 6. The opportunity for voluntary ingestion of water may be limited, thus delaying restitution from thermal dehydration, electrolytes should also be replaced in case of profuse sweating. Proper clothing is also an important measure. Clothes made of fabrics which are both water-absorbent and permeable to air and water vapor facilitates heat dissipation.


Management a. Emergency Care 1. Immersion in cool or iced water with skin massage is a classic technique for cooling heat stroke patients. Both have demonstrated effectiveness in lowering body temperature. Ice water probably produces the most rapid rate of cooling. However, ice water is an uncomfortable environment in which to work and, in the field, is very difficult to obtain. Circulating cooling blankets (unlikely to be available in the field situation) will also lower body temperature. Although cooling blankets have the advantage of maintaining a dry working environment, their limited contact surface provides slower cooling than immersion or surface wetting techniques. Their best use is probably maintaining normal body temperature in the period after resusitation and rapid cooling where temperature instability is characteristic. 2. Invasive cooling techniques have been tried including ice water lavage or enemas and peritoneal lavage with cool fluids. These techniques do not provide faster cooling and have the additional disadvantages of potential complications and substantial inappropriate fluid loads. These techniques are not recommended. 3. Heat stroke patients usually do not require aggressive fluid resuscitation. Fluid requirements of 1 to 1.5 liters in the first few hours are typical. Over-replacement carries the risk of congestive heart failure, cerebral edema and pulmonary edema. Since heat stroke patients are frequently hypoglycemic, the initial fluid should include dextrose. Hypotensive patients who do not respond to saline should receive inotropic support. Isoproterenol has been reported anecdotally to be helpful. Careful titrated use of dopamine or dobutamine is also reasonable and has the potential added advantage of improving renal perfusion. 4. Airway control is essential. Vomiting is common and endotracheal intubation should be used in any patient with a reduced level of consciousness. Supplemental oxygen should be provided when available.

5. Patients are frequently agitated, combative or seizing. Valium is effective for control and can be administered iv, endotracheally or rectally. The sedated heat stroke patient should be intubated. Nasogastric intubation to control vomiting should be done as soon as practicable. 6. 7. Hyperkalemia is the most life threatening early clinical problem. Measurement of plasma [K] is an early priority. Acute renal injury is common in exertional heat stroke. Urinary catheterization to monitor urine output and obtain urine for [Na] should be done early. The oliguric patient with a casts, pigmenturia or red cells and urine [Na] greater than 30 meq/l (before diuretics) has a high likelihood of acute renal failure. Early management of suspected acute renal failure should include assuring adequate renal perfusion and mannitol (12.5-25 grams iv).

b. Continuing Care After cooling and hemodynamic stabilization, continuing care is supportive and is directed at the complications of heat stroke as they appear. 1. Patients with heat stroke frequently have impaired temperature regulation for several days with alternate periods of hyperthermia and hypothermia. Constant monitoring is essential and clinically significant


deviations in temperature may require either cooling or warming measures. It is important to remember that changes in temperature may be due to reasons OTHER than hypothalamic instability, such as infection. 2. The effects of rhabdomyolysis that require management are renal injury due to myoglobinuria and hyperuricemia, hyperkalemia, hypocalcemia and compartment syndromes due to muscle swelling. Assurance of adequate renal perfusion and urine flow will moderate the nephrotoxic effects of myoglobin and uric acid. Hyperkalemia can be managed by kayexalate or dialysis. The hypocalcemia does not usually require treatment. Increasing tenderness or tension in a muscle compartment may represent increasing intracompartmental pressures. Direct measurement of intramuscular pressure or fasciotomy should be considered at this point. Pain and paresthesia may not signal the compartment syndrome until permanent damage has occurred.

ii. FROSBITE Is the medical condition whereby damage is caused to skin and other tissues due to extreme cold. Frostbite is most likely to happen in body parts farthest from the heart, and those with a lot of surface area exposed to cold. Frostbite occurs when the skin and body tissues are exposed to cold temperature for a prolonged period of time. Hands, feet, noses, and ears are most likely to be affected. Symptoms   The first symptoms are a "pins and needles" sensation followed by numbness. There may be an early throbbing or aching, but later on the affected part becomes insensate (feels like a "block of wood"). Frostbitten skin is hard, pale, cold, and has no feeling. When skin has thawed out, it becomes red and painful (early frostbite). With more severe frostbite, the skin may appear white and numb (tissue has started to freeze). Very severe frostbite may cause blisters, gangrene (blackened, dead tissue), and damage to deep structures such as tendons, muscles, nerves, and bone.

Classification of Frosbite  First Degree – hyperemia of involved area and edema formation   Second Degree – large fluid fikled blister develop with partial thickness Third Degree – appear a small blister that contain fluid and an affected body part that is cool, numb, blue or redFourth Degree – no blister or edema, the parts numb, cold and bloodloss

Types of Frosbite   Superficial Mild (frostnip) – induced tissue injury may produce initial pain numbness and pallor to affected area Deep – characterized by degree of tissue freezing

First Aid Treatment 1. Shelter the victim from the cold and move the victim to a warmer place. Remove any constricting jewelry and wet clothing. Look for signs of hypothermia (lowered body temperature) and treat accordingly.


2. If immediate medical help is available, it is usually best to wrap the affected areas in sterile dressings (remember to separate affected fingers and toes) and transport the victim to an emergency department for further care. 3. If immediate care is not available, re-warming first aid may be given. Immerse the affected areas in warm (never HOT) water -- or repeatedly apply warm cloths to affected ears, nose, or cheeks -- for 20 to 30 minutes. The recommended water temperature is 104 to 108 degrees Fahrenheit. Keep circulating the water to aid the warming process. Severe burning pain, swelling, and color changes may occur during warming. Warming is complete when the skin is soft and sensation returns. 4. Apply dry, sterile dressing to the frostbitten areas. Put dressings between frostbitten fingers or toes to keep them separated. 5. Move thawed areas as little as possible. 6. Re-freezing of thawed extremities can cause more severe damage. Prevent re-freezing by wrapping the thawed areas and keeping the victim warm. If re-freezing cannot be guaranteed, it may be better to delay the initial re-warming process until a warm, safe location is reached. 7. If the frostbite is extensive, give warm drinks to the victim in order to replace lost fluids. Do Not      Preventions 1. Be aware of factors that can contribute to frostbite, such as extreme cold, wet clothes, high winds, and poor circulation. This can be caused by tight clothing or boots, cramped positions, fatigue, certain medications, smoking, alcohol use, or diseases that affect the blood vessels, such as diabetes. 2. Wear suitable clothing in cold temperatures and protect susceptible areas. In cold weather, wear mittens (not gloves); wind-proof, water-resistant, many-layered clothing; two pairs of socks (cotton next to skin, then wool); and a scarf and a hat that cover the ears (to avoid substantial heat loss through the scalp). 3. Before anticipated prolonged exposure to cold, don't drink alcohol or smoke, and get adequate food and rest. 4. If caught in a severe snowstorm, find shelter early or increase physical activity to maintain body warmth. DO NOT thaw out a frostbitten area if it cannot be kept thawed. Refreezing may make tissue damage even worse. DO NOT use direct dry heat (such as a radiator, campfire, heating pad, or hair dryer) to thaw the frostbitten areas. Direct heat can burn the tissues that are already damaged. DO NOT rub or massage the affected area. DO NOT disturb blisters on frostbitten skin. DO NOT smoke or drink alcoholic beverages during recovery as both can interfere with blood circulation


iii. HYPOTHERMIA Hypothermia is a condition in which the core (internal) temperature is 35 C (95 F) or below as a result of exposure to cold. Classification of Hypothermia a. Primary / Accidental hypothermia   b.  Occurs as a result of cold exposure. Environmental exposure or prolonged surgical exposures are the primary cause.

Secondary or deliberate hypothermia Maybe observed in patient with decrease heat production such as hypo-adrenalism, hypothyroidism, abnormal temperature regulation such as brain injuries involving the hypothalamus

Risk Factors of Hypothermia              extreme age trauma especially CNS hypothyroidism hypoadrenalism parkinson‟ s disease multiple sclerosis CVA burns malnourish/ malnutrition sepsis shock trauma vasodilatation induced by alcohol

Physiologic Effect of Hypothermia a. Hypothermia Stage (impending hypothermia) Core temperature - 36 C S/ Sx     b. skin:pale, numb, waxy shivering weakness fatigue Hypothermia Stage (mild hypothermia) Core temperature - 32- 35 C


S/ Sx           uncontrolled, intense shivering movement less coordinated coldness creates pain and discomfort tachycardia vasoconstriction increase BP increase CO increase central venous pressure increase O2 consumption myocardial ischemia, pulmonary edema, CHF

c. Hypothermia Stage (Moderate hypothermia) Core temperature - 28- 32 C S/ Sx                  absence of shivering (stops below 32 C) muscle stiffness mental confusion apathy (absence of emotion) slow, vague, slurred speech slow shallow breathing drowsiness strange behavior no complains of being cold (below 35 C) decrease HR decrease cardiac output increase risk of atrial and ventricular arrythmias “J” or Osborne wave (hypothermia hump) may appear on the ECG decrease RR 50% reduction in O2 consumption impaired insulin action hyperglycemia

d.Hypothermia Stage (Severe hypothermia) Core temperature - 28- 30 C S/ Sx       skin: cold, bluish- gray in color weak lack of coordination decrease LOC to coma absent tendon reflex rigid extremities (may appear dead) 80

     

decrease/ absence of respiration pupils dilated no reactive pupils 29- 30 C loss of cerebral blood flow decrease cardiac output decrease renal blood flow (oliguria)

iv. DROWNING Drowning is a type of asphyxia related to either aspiration of fluids or obstruction of airway caused by the spasm of the larynx while in water. CLASSIFICATIONS OF DROWNING  Near drowning- when the victim recovers spontaneously/ is successfully resuscitated, it may develop from acute laryngospasm immediately after submersion leading to acute airway obstruction and the victim has survived for at least 24 hours after submersion NEAR DROWNING CAN BE:  With aspiration- aspiration is the entry of fluid into the alveoli of the lungs  .W/out aspiration-laryngeal spasm or breath holding prevents water from entering the lungs and death from asphyxia can result.Secondary drowning-delayed onset of respiratory insufficiency from submersion.  Secondary drowning-delayed onset of respiratory insufficiency from submersion.

CAUSES            Not knowing how to swim Leg or stomach cramps Loss of consciousness Playing in the water too deep or to rough for one‟s ability to swim Exhaustion Use of alcohol or other drugs Accidents(falling through the ice while fishing, skating, snowmobiling during winter, surfing accident) Not wearing life preservers Decompression illness or air embolism associated with scuba diving Venomous sting by aquatic animals Sudden acute illness like epilepsy, myocardial infarction, stroke

SIGNS AND SYMPTOMS       Mild dyspnea Deathlike appearance w/ blue/gray in color Apnea / tachypnea Hypotension Hypothermia Cold skin Dilated pupil( fish eye) 81

 Vomiting  Severe drowning may suffer from pulmonary edema, respiratory failure, shock, anoxic encephalopathy, brain edema, cardiac arrest MANAGEMENT         Assess airway, breathing, circulation Clean the airway if there is obstruction Control the airway with chin lift or jaw thrust method. Protect the c spine trauma is suspected Begin mouth to mouth or mask ventilation if breathing is present. Begin CPR if no heart rate is palpable Remove the wet clothing and wrap in blanket For hypothermia, wrap in a dry warm blanket and initiate rewarming Transport immediately to a hospital

v. DECOMPRESSION SICKNESS (DCS) It is also called the bends. It occurs in patients who have engaged in diving, high altitude flying or flying commercial aircraft within 24 hours diving. Although, DCS occurs in number of divers worldwide, its effects are still hazardous. DCS results from nitrogen bubbles trapped in the body. They may occur in joint or muscle spaces, resulting in musculoskeletal pain, numbness or hypoesthesia. Nitrogen bubbles can become air emboli in the bloodstream and thereby produce stroke (brain), paralysis (spine), death (heart). Taking a rapid history about the events preceding the symptoms is essential. Recompression is necessary as soon as possible, which may necessitate a low0altitude flight to the nearest hyperbaric chamber. Assessment:       Detailed rapid history may show any of the ff. : Evidence of rapid ascent Loss of air in the tank Recent alcohol intake Loss of rest A flight home within 24 hours diving

Signs and Symptoms:  Joint or extremity pain  Numbness  Hypesthesia (reduced sensitivity to touch)  Loss of ROM  Neurologic symptoms, mimicking a stroke or spinal cord injury could indicate air embolus.  Cardiopulmonary arrest can also occur in severe cases. * Because of hypoxia, these patients seldom survive. * Onset of cardiopulmonary arrest can occur while the patient is still in the water.*any neurologic symptoms can be assessed rapidly. * All patients with DCS need rapid transfer to a hyperbaric chamber Management: 1. Establish patent airway and ventilation. 2. Provide safety to patient.


3. Wet clothing of the patient must be removed. 4. Must be kept warm to prevent hypothermia. 5. If air embolus is suspected, lower the head of the bed. 6. Administer 100% oxygen on board during transport. 7. Start an IV line with lactated Ringer‟s or NSS. 8. Transfer to the closest hyperbaric chamber capable of treating DCS. 9. Obtain chest X-ray to identify aspiration. 10. If aspiration is suspected, antibiotics may be prescribed. vi. INJECTED POISONS a. STING BITES (insects): Stinging insects may include the honeybees, bumblebees, yellow jacket, hornet and fire ant. For the severely allergic person, a single sting may be fatal within minutes. Most people who have such reactions have no history of them. Massive multiple stings are rare. Although stings in any area of the body can trigger anaphylaxis, stings of the head and neck are especially serious. The most dangerous single stings in nonallergic individuals are those inside the throat, which results from being stung after swallowing an insect that has dropped into a softdrink can, on to food, or from inhaling one that zooms into the victim‟s open mouth. Though not an allergic reaction, the swelling in the airway can cause airway obstruction. One of the difficulties in dealing with stings is the lack of uniformity in victims‟ responses. One sting is not necessarily equivalent to another even with the same species, because the amount of venom injected varies from sting to sting. Those who have had a reaction to an insect sting should be instructed I self-treatment so they can protect themselves from severe reactions.

Signs and Symptoms:              Generalized urticariaItching Momentary pain Redness around the sting site Localized swelling of lips or tongue Wheezing Abdominal cramps Diarrhea Cyanosis Seizures Malaise Unconsciousness Inability to breath due to swelling of airway passage. Anxiety due to laryngeal edema to severe bronchospasm


Management: 1. Keeping a check on the ABCs for severe cases. 2. Look at the sting site for a stinger embedded in the skin. If the stinger is still embedded, remove it because it will continue to inject venom for 2-3 minutes unless removed. Scrape the stinger and venom sac with a long finger nail, credit card, scissor edge or knife blade. 3. Do not pull the stinger with tweezers of fingers because you may squeeze more venom into the victim from the venom sac. 4. Wash the sting site with soap and water. 5. Apply an ice pack for 15-20 minutes over the sting site to slow absorption of the venom and relieve pain. 6. To further relieve pain and itching, Acetaminophen is usually adequate. A steroid cream, such as Hydrocortisone, may help combat local swelling and itching. An antihistamine may prevent some local symptoms if given early. 7. Observe victims for at least 30 minutes for signs of an allergic reaction

Patient Education and Home Care:  Avoid places where stinging insects congregate, such as camps, picnic sites, flower beds, ripe fruit orchards, and garbage.  Avoid perfumes, scented soaps, and bright colors which attract bees.  Keep car windows closed.  Spray garbage cans with quick-acting insecticides.  Secure a professional exterminator to dispose wasp and hornet nests or beehives in the home area.  Remain motionless if an insect is buzzing around.  Motion, especially running, increases the likelihood to. b. SNAKE BITES: Venomous snakes are about the leading causes of death in most of the Western Countries. The greater number of bites occurs through the daylight hours into early evening in summer months. The rattlesnake, copperhead, water moccasin and coral snake are the 4 most poisonous species of snakes. The first three are known as pit vipers. They have the 3 common characteristics:  Triangular, flat head wider than its neck  Elliptical pupils  Heat-sensitive “pit” located between each eye and nostril The coral snake is small and very colorful, with a series of bright red, yellow and black bands around its body. Every other band is yellow. A black snout also marks the coral snake. It is the most venomous snake but rarely bites people. It has short fangs and tends to hang on and “chew” its venom into the victim rather than to strike and release like a pit viper. 84

Signs and Symptoms: Pit Viper Snakebites:  Severe burning pain at the bite site.  Two small puncture wounds about ½ inch apart (some cases may have only one fang mark)  Swelling happens within 5 minutes and can involve an entire extremity.  Discoloration and blood-filled blister may develop within 6-10 hours.  In severe cases: nausea, vomiting, sweating and weakness.

Management: Pit Viper Snakebites: 1. Get the victim away from the snake. 2. Keep the victim quiet. If possible, carry the victim or walk very slowly to help. 3. Gently wash the bitten area with soap and water. 4. If you are more than a few hours from a medical facility, you should apply immediate suction, there are readily available suctions for use over the counter. 5. Seek medical attention quickly. This is the most important thing to do for the victim. 6. Do not use ice to the bite site, it does not inactivate the venom and poses a frostbite hazard. 7. Do not cut and suck method, because there is a danger of damaging underlying structures. 8. Do not do mouth suction, your mouth is filled with bacteria and a wound infection can result in the snakebite victim. 9. Do not use tourniquet Coral Snakebites: 1. Keep victim calm. 2. Gently clean bite site with soap and water. 3. Seek medical attention immediately for antivenin. 4. Do not apply a constriction band or cut the victim‟s skin.


Unit VII Emergency Management of Special Population
1. VIOLENCE, ABUSE AND NEGLECT Domestic violence - is physical, sexual, economical, or psychological abuse directed towards one‟s spouse, partner or other family members with In the house hold. Physical violence – is the intentional use of physical force with the potential for causing injury, harm, disability or death ( e.g. hitting, shoving, biting, restraints, kicking or use of weapons) Indirect physical violence – Including destruction of objects, striking or throwing objects near the victim Psychological/ Emotional violence     violence to the victims caused by acts, threat of acts controlling what the victim can and cannot do, withholding information from the victim

Economic abuse     Is when the abuser has the complete control over the victim‟s money and other economic resources. Putting the victim on a strict allowance Withholding money at will and forcing the victim to beg for the money It is common for the victim to receive less money as the abuse continues

Sexual Violence and Incest  Use of physical force to compel a person to engage in sexual act against their will whether or not the act is completed.  Attempted or completed sex act involving a person who is unable to understand the nature or condition of the act  Unable to decline participation  Unable to communicate unwillingness to engage in the sexual act Example:     Underage immaturity Illness Disability The influence of alcohol or drugs

Clinical Manifestations 1. Physical injuries  Unexplained bruises  Lacerations


 Abrasions  Head injuries  Fractures 2. Health problem related to stress (e.g. anxiety, insomnia or gastrointestinal symptoms 3. Patient usually do not identify their abuser / Denial 4. Multiple injuries that are in various stages of healing Assessment and Diagnostic Findings Nurse in EDs are in ideal position to provide early detection/ interventions for victim of domestic violence. This requires: 1. Awareness of the signs of possible abuse, maltreatment and neglect 2. The Nurse must be skilled in interviewing techniques that are likely to elicit accurate information  Asking question in private - away from others 3. Careful documentation of descriptions of event and drawing or photos of injuries. Manifestations that Need Crucial Assessment 1. General appearance and interactions with significant others. 2. Examination of the entire surface area of the body 3. Mental status examination SEXUAL ASSAULT The legal definition of rape is carnal knowledge of a female by force or the threat of force against her will. Considered an act of violence, however, rape not only affects females. It happens to males, especially young males. The manner in which the victim is received and treated in the ER is important to his or her future psychological wellbeing. Crisis intervention should begin when the patient enters the health care facility.

THE SEXUAL ASSAULT NURSE EXAMINER The role allows for specific training in forensic evidence collection, history taking, documentation and ways to approach the victim and family. Specialized training also includes photography and the use of colposcopy. Coloposcopy increases the assessment by examining for microtrauma through magnification. Evidence is collected through photography, videography and specimens. Another useful tool to SANE is the light-staining microscope, which enables the examiner to identify motile and nonmotile sperm and infection. Signs and Symptoms: The victim‟s reaction to rape has been termed as rape trauma syndrome and is seen as an acute stress reaction to a life threatening situation.


ACUTE DISORGANIZATIONAL PHASE  Shock  Disbelief  Fear  Guilt  Humiliation  Anger  Other emotions and feeling which are masked or hidden and the victim appears composed PHASE OF DENIAL AND UNWILLINGNESS       Unwillingness to talk about the incident Heightened anxiety Fear Flashbacks Sleep disturbances Hyper alertness

PHASE OF REORGANIZATION  Incident is put into perspective  Some victims do not fully recovered and develop chronic stress disorders  Phobia Management: 1. Give sympathetic support, to reduce the emotional trauma of the victim and to gather available evidence for possible legal proceedings. 2. The victim‟s privacy and sensitivity must be respected. 3. Support and caring of the victim is crucial. 4. The victim should be reassured that anxiety is natural and asked if a support person can be called Physical Examination  A written witnessed informed consent must be obtained from the patient or guardian for examination, for taking photographs and for release of findings to police  A history is obtained only if the patient has not already talked to a police officer, social worker for crisis intervention for crisis intervention worker. The patient should not be asked to repeat the history  The patient is asked if she or he is bathe, douched, brushed teeth, changed cloths, urinated or defected since it may alter the interpretation of subsequent findings  The time of admission, examination, date and time of alleged rape and the victim‟s emotional state and general appearance are documented


 The patient is examined for injuries External evidence of trauma Dried semen stains on the victim‟s body or cloths Broken fingernails and body tissues and foreign material under nails Oral examination including a specimen of saliva and prescribed culture of gum and tooth areas

SPECIMEN COLLECTION  Vaginal aspirate, examine for presence or absence of motile and nonmotile sperm.  Secretions from the vaginal pool for acid phosphatase, blood group antigen of semen and precipitin test against human sperm and blood.  Separate smear from the oral, vaginal and anal areas.  Culture of body orifices for gonorrhea  Blood serum for syphilis and HIV testing.  Pregnancy test  Any foreign material which is placed in a clean envelops.  Pubic hair samples obtain by combing or trimming

2. OBSTETRIC EMERGENCIES Supine Hypotensive Syndrome  Near birth, weight of uterus, fetus, placenta, & amniotic fluid can be as much as 20-24 pounds  If mother is supine weight can compress inferior vena cava, reducing venous return to the heart, reducing cardiac output. (amount of blood pumped by the heart in 1 minute) Signs and Symptoms/ Treatment       Vertigo Possible syncope Drop in blood pressure Assess A,B,C‟s All third trimester patients should be transported on their left side Place a pillow or blanket behind their back to ensure proper positioning


Miscarriage/Spontaneous Abortion Fetus & placenta delivered before the 28th week of pregnancy Induced Abortion  Deliberate actions taken to stop pregnancy  Therapeutic abortion  Done as a legal medical procedure Criminal abortion    Illegal attempt to stop abortion Use drugs, chemicals, poisons, to induce labor Insert objects into the vagina to disrupt pregnancy

Signs & Symptoms  Cramping abdominal pain  Bleeding moderate to severe, bright or dark red  Passage of tissue or blood clots
NOTE: Ask about starting date of LMP. If more than 24 weeks, prepare OB kit

Self-Induced/Non-Medical Abortions  Pain is much greater  Bleeding usually more severe  May be high fever from infection Emergency Care  Monitor vitals  Sanitary napkin over vagina  Treat for shock  Immediate transport  Replace and save blood soaked pads  Save all tissue  If poison was ingested contact med-control  Provide emotional support Note: Use the term miscarriage when speaking with family or where bystanders can hear you. Most people associate spontaneous abortion with self-induced abortion. General Care Predelivery Emergencies        Airway Ensure adequate circulation Treat for shock Control bleeding Never place anything into vagina Provide same care as for any other patient Transport left lateral recumbent


On Scene Delivery         Patients first delivery? How long has patient been pregnant? Any bleeding or discharge? Any contractions or pain present? What is the frequency and duration of contractions? Is the patient crowning? Feel the urge to push? Is uterus hard upon palpation?

3 Cases When Delivery Must be Assisted 1. No suitable transportation 2. Hospital or physician can‟t be reached due to bad weather 3. Natural disaster, or if delivery is imminent Signs & Symptoms of Probable Delivery      Delivery     Do not touch vaginal area except to deliver & in the presence of your partner Don‟t allow the patient to use the bathroom Do not hold the mother‟s legs together Use sterile OB kit Crowning has occurred Contractions closer than 2 minutes apart, intense, last 30 to 90 seconds Patient has the urge to push Patient‟s abdomen is hard If birth does not occur within 10 minutes, contact medical control for permission to transport

Things to Remember     Stay calm Explain that you are trained to help Ensure mothers comfort, modesty, & peace of mind Be able to recognize your limitations

Emergency Care 1. 2. 3. 4. 5. Position patient Create sterile field around vaginal opening Monitor patient for vomiting Continually assess for crowning Place glove fingers on bony part of infant's skull when it crowns 91

6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.

Puncture amniotic sac if not already broke Determine position of umbilical cord Suction infant‟s airway As torso is born support with 2 hands Grasp feet as they are born Clean and suction mouth and nose Dry, wrap, and position infant On back, level with vagina until cord is cut Assign care of infant to partner and you continue care of mother Clamp, tie, & cut cord as pulsation ceases 1st clamp 6 to 7 inches from infant 2nd clamp 3 inches from first Deliver placenta Usually delivers within 10 to 20 minutes Do not delay transport for delivery of placenta Place placenta in towel and plastic bag Place 1 or 2 sanitary napkins over vaginal opening Record time of delivery and transport 500cc normal blood loss Excessive blood loss appears Massage the uterus

3. PSYCHIATRIC EMERGENCIES A psychiatric emergency is an urgent, serious disturbance of behavior, affect, or thought that makes the patient unable to cope with life situations and interpersonal relationships. A patient presenting with a psychiatric emergency may display overactive or violent, underactive or depressed, or suicidal behaviors. The most important concern of the ED personnel is determining whether the patient is at risk for injuring self or others. The aim is to try to maintain the patient‟s self -esteem while providing care. Determining whether the patient is currently under psychiatric treatment is important so that contact can be made with the therapist or physician who works with the patient. A. OVERACTIVE PATIENT

Patients who display disturbed, uncooperative, and paranoid behavior and those who feel anxious and panicky may be prone to assaultive and destructive impulses and abnormal social behavior. Intense nervousness, depression, and crying are evident in some patients. Disturbed and noisy behavior may be exacerbated or compounded by alcohol or drug intoxication. MANAGEMENT: A reliable source is needed to identify events leading to the crisis, and a history is obtained. Past mental illnesses, use of alcohol or drugs, crises interpersonal relationships, or intrapshychic conflicts are explored. Because abnormal thought and behavior may be manifestations of an underlying physical disorder, such as hypoglycemia, stoke, epilepsy, head injury, or drug or alcohol toxicity, a physical assessment is performed when possible. The immediate goal is to gain control of the situation. If the patient is potentially violent, security or local police should be nearby. Restraints are used as a last resort and as prescribed. Approaching the patient with a calm, confident, and firm manner is therapeutic and has a calming effect.


Helpful interventions include the following:        

Introduce yourself by name Tell the patient, “I am here to help you.” Repeat the patient‟s name from time to time. Speak in one-thought sentences and be consistent. Give the patient space and time to slow down Show interest in, listen to, and encourage the patient to talk about personal thoughts and feeling. Offer appropriate an honest explanation. After combativeness, agitation, and fear have decreased.

Restraints are only prescribed by the physician.

B. POSTTRAUMATIC STRESS DISORDER Posttraumatic stress disorder is the development of characteristic symptoms after a psychologically stressful event that is considered outside the range of normal human experience. Symptoms of this disorder include:       Intrusive thoughts and dreams Phobic avoidance reaction Heightened vigilance Exaggerated startle reaction Generalized anxiety Societal withdrawal

ASSESSMENT AND DIAGNOSTIC FINDINGS Assessment include an evaluation of the patient‟s pretrauma history, the trauma itself, and postrauma functioning. PTSD often presents as multiple readmissions to the ED for minor or recurring complaints without evidence of injury. The patient is allowed to discuss the traumatic event and permitted to grieve. MANAGEMENT: 1. Crisis intervention strategies 2. Establish a trusting a sharing relationship 3. Educate the family and the patient about stress management. 4. Support services available in the community C. OVERACTIVE OR DEPRESSED PATIENTS In the ED, depression may be seen as the primary condition bringing the patient to the health care facility, or it may be masked by anxiety and somatic complaints. The depressed person has a mood disturbance. Clinical manifestations may include:  Sadness  Apathy  Feelings of worthlessness  Self-blame  Suicidal thoughts  Desire to escape  Avoidance of simple problems  Anorexia  Decreased interest in sex 93

   

Sleeplessness Ceaseless activity or reduction in activity Motor restlessness Severe anxiety

OTHER MANAGEMENT: 1. A psychotropic agent may be prescribed for emergency management of functional psychosis. (Chlorpromazine, Haldol) 2. Transfer the patient to a psychiatric unit after stabilization or psychiatric outpatient treatment is arranged. D. VIOLENT BEHAVIOR Violent and aggressive behavior, usually episodic, is a means of expressing feelings of anger, fear, or hopelessness about a situation. Usually, the patient has a history of outbursts or rage, temper tantrums, or impulsive behavior. People with a tendency for violence frequently lose control when intoxicated with alcohol or drugs. Family members are the most frequent victims of their aggression. Patients with a propensity for violence include:  Those intoxicated by drug or alcohol.  Those going through drug or alcohol withdrawal.  Those diagnosed with acute paranoid schizophrenic state, acute organic brain syndrome, acute psychosis, paranoid character, borderline personality, or antisocial personality MANAGEMENT: A specially designated room with at least two exits should be used for the interview. No weapons should be in sight, in the room, or carried in with health care personnel. Never leave patient alone to lessen opportunity of self-harm by the patient. Use a calm and non-critical approach while remaining in control of the situation. If the patient carries a weapon, the emergency health care provider should ask the patient to surrender it. Express interest in the patient‟s well-being while attempting to tune in to the patient and remain firm. Allow patient to ventilate anger verbally. The patient should be informed that violent behavior may be frightening others and that violence is not acceptable. 9. Prescription of medication is allowed if the above measures fail. (Haldol, diazepam, chlorpromazine). 10. Patient is referred for further mental health treatment Other MANAGEMENT: 1. 2. 3. 4. 5. 6. 7. Allow patient to talk about personal problems and ventilate personal feelings. Listen in a calm, unhurried manner. Attempt to find out if the patient has a thought about or attempted suicide. Relatives should be notified if the patient is seriously depressed. Patient should never be left alone because suicide is usually committed in solitude. Antidepressant and anti-anxiety may be prescribed. Refer patient for a psychiatric consultation or to a psychiatric facility 1. 2. 3. 4. 5. 6. 7. 8.


E. SUICIDAL PATIENTS Attempted suicide is an act that stems from depression and can be viewed as a cry for help and intervention. Males are at greater risk than females. Others at risk are:  elderly people  young adults  people who are enduring unusual loss or stress  unemployed people  divorced  widowed  living alone  people who show signs of significant depression  those who had a history of attempted suicide attempts  suicide in the family  psychiatric illness Being aware of people at risk and assessing for specific factors that predispose a person to suicide are key management strategies. Specific signs and symptoms of potential suicide include the following:  communication of suicidal intent, such as preoccupation with death or talking of someone else‟s suicide  history of a previous suicide attempt  family history of suicide  loss of a parent at an early age  specific plan for suicide  a means to carry out the plan MANAGEMENT: 1. determine suicide potential 2. discover areas of depression and conflict 3. admission to a psychiatric unit


References Daniel Limmer ,Michael F. O‟keefe. Emergency Care .12 th ed, Pearson Education, Inc., 2011. ISBN-10: 013254380X • ISBN-13: 9780132543804 Dolan, B. and Holt, L. (2000) Accidents and Emergency: Theory Into practice. London, Bailliere Tindall Kathleen sanders Jordan, Emergency Nursing Core Curriculum,5 th ed, Philadelphia, W.B. Saunders company :A division of Harcourt Brace & company,2000. McQuillan, K., Von Rueden, K., Hartsock, R., Flynn, M. and Whalen, E. (2002) Trauma Nursing: From Resuscitation to Rehabilitation (3rd ed) Saunders, Philadelphia. Newberry, L. (2003) Sheehy's Emergency Nursing: Principles and practice (5th ed) Mosby, St Louis Electronic Materials and Web Sites Emergency nursing resources (https://www.ena.org/ienr/enr/Pages/Default.aspx ) . http://enw.org/TOC.htm http://www.ovid.com/site/catalog/Journal/371.jsp?top=2&mid=3&bottom=7&subsection=12 http://www.medi-smart.com/emergency.htm http://allnurses.com/forums/f18/ http://www.lib.flinders.edu.au/resources/sub/healthsci/a-zlist/emergency.html http://www.huntsvillehospital.org/educationandevents/university/pdfs/AHABLSreviewweb.pdf http://www.heart.org/HEARTORG/CPRAndECC/HealthcareTraining/BasicLifeSupportBLS/Basic-Life-SupportBLS_UCM_001281_SubHomePage.jsp http://www.heart.org/HEARTORG/CPRAndECC/Science/Guidelines/Reprint-2010-AHA-Guidelines-for-CPRECC_UCM_317174_Article.jsp


You're Reading a Free Preview

/*********** DO NOT ALTER ANYTHING BELOW THIS LINE ! ************/ var s_code=s.t();if(s_code)document.write(s_code)//-->