EMERGENCY ROOM OBSERVATIONAL EXPERIENCE

Define

Triage Is a French word meaning "to sort". The process is based on the premise that patients
who have a threat to life, vision, or limb should be treated before other patients. When patients
call the ED with health-related questions, triage is conducted over the telephone. The ED uses a
system of words, color coding, or numbers for determining triage decisions.

Emergent you have an Emergency Medical Condition such as difficulty breathing, suspected
heart attack, uncontrolled bleeding, unconsciousness or severe burns; try to use a contracting
hospital emergency room to maximize your benefits.

Urgent An urgent care situation is an unexpected illness or injury that needs prompt medical
attention, but is not an immediate threat to your health. Examples include headaches, back or
joint pain, flu symptoms, or earaches. These are times when care is necessary but not critical.
Medical conditions that are not an emergency should be treated in your family physician¶s office
or at a contracting urgent care center. Talk to your physician about what to do if you or a family
member experiences a non-life threatening situation that needs prompt attention. They may be
able to give you instructions over the phone. Physicians are available 24 hours a day to help you
get the care you and your family need. Their office will instruct you on how to reach them

Non-Urgent some examples of this type of care is for illnesses and injuries that are not true
emergencies such as sprains, cuts, colds and flu - even most lacerations and fractures.

EMS system emergency medical services is widely regarded as including the full spectrum of
emergency care from recognition of the emergency, telephone access of the system, provision of
prehospital care, through definitive care in the hospital. It often also includes medical response to
disasters, planning for and provision of medical coverage at mass gatherings, and interfacility
transfers of patients. However, for the purposes of this document, the definition of EMS is
limited to the more traditional, colloquial meaning: prehospital health care for patients with real
or perceived emergencies from the time point of emergency telephone access until arrival and
transfer of care to the hospital.

Inhalation injury refers to a direct insult at the alveolar level secondary to the inhalation of
chemical fumes or smoke. The result is interstitial edema that prevents the diffusion of oxygen
from the alveoli into the circulatory system. The patient with smoke inhalation may not exhibit
physical manifestations of injury during the first 24 hours after sustaining a major burn.
Fiberoptic bronchoscopy can be used as an early diagnostic tool for suspected inhalation injury.
Another diagnostic indicator may be a history of prolonged exposure to smoke or fumes;
therefore the nurse must be especially sensitive to signs of respiratory distress such as increased

c

 







!"


 "#$$ " %$$&$$  $'('( "



)
"#$$ "   $%""$ "

"#$$  $$*c)++ %%

agitation or change in the rate or character of respirations. Sputum that contains carbon may be
present.

Kinds

O aoxious chemicals
O smoke
O carbon monoxide

Assessment data The client may exhibit rapid, shallow respirations, coughing, singled nasal or
facial hair, smoky breath, carbonaceous sputum, productive cough with black, gray or bloody
sputum, irritation of upper airways or burning pain in throat or chest, difficulty swallowing,
restlessness, anxiety, altered mental status, including confusion, coma, decreased oxygen
saturation, arrhythmias

Tetanus Toxoid- is an immunization vaccine against tetanus.

Indications- for booster injection only for persons 7 years of age or older against tetanus.

Dosage-a booster dose of 0.5 mL of Tetanus Toxoid should be given every 10 years to maintain

adequate immunity.

Route of administration site: - Intramuscular and sometimes subcutaneous.

Define and state the treatment for each

Heat Cramps 1are severe cramps in large muscle groups fatigued by heavy work. Cramps are
brief, intense and tend to occur during rest after exercise or heavy labor. aausea, tachycardia,
pallor weakness, and profuse diaphoresis are often present. The condition is seen most often in
healthy, acclimated athletes with inadequate fluid intake. Treatment: the patient should avoid
strenuous activity for at least 12 hours after the development of heat cramps. Education should
emphasize salt replacement during strenuous exercise in hot humid environments. Commercially
prepared electrolyte solutions are recommended.

Heat Stroke 1the most serious form of heat stress, results from failure of the central
thermoregulatory mechanisms and is considered a medical emergency. Increased sweating,
vasodilation, and increased respiratory rate. Treatment: focuses on stabilizing the patient's
ABCs and rapidly reducing the core temperature. Administration of 100% O2 compensates for
the patients hyper metabolic state.
c

 







!"


 "#$$ " %$$&$$  $'('( "



)
"#$$ "   $%""$ "

"#$$  $$*c)++ %%

Heat Syncope is another stage in the same process as heat stroke, occurs under similar
conditions as heat stroke and is not distinguished from the latter by some authorities. The basic
symptom of heat syncope is a body temperature above 40°C (104°F) with fainting, or without
mental confusion, which does occur in heat stroke. Heat syncope is caused by mild overheating
with inadequate water or salt. In young persons, it is far more common than true sunstroke.
Treatment: the basic treatment for heat syncope is like that for fainting: the patient is
positioned in a seating or supine position with legs raised. Water and oral rehydration salt are
administered slowly, and the patient is moved to a cooler area.

Heat Exhaustion1 prolonged exposure to heat over hours or days leads to heat exhaustion, a
clinical syndrome characterized by fatigue, lightheadedness, nausea, vomiting, diarrhea, and
feelings of impending doom. Tachypnea, hypotension, tachycardia, elevated body temperature,
dilated pupils, mild confusion, ashen color, and profuse diaphoresis are also present.
Hypotension and mild to severe temperature elevation are due to dehydration. Heat exhaustion
usually occurs in individuals engaged in strenuous activity in hot, humid weather, but it also
occurs in sedentary individuals. Treatment: begins with placement of the patient in a cool area
and removal of constrictive clothing. The patient is monitored for airway, breathing and
circulation, including cardiac arrhythmias. Oral fluid and electrolyte replacement is initiated
unless the patient is nauseated. Salt tablets are not recommended because of potential gastric
irritation and hypernatremia. A 0.9 % normal saline solution is initiated intravenously when oral
solutions are not tolerated.

Hypothermia 1 defined as a core temperature less than 95o F (35o C) occurs when heat produced
by the body cannot compensate for heat lost to the environment. From 55% to 60% of all body
heat is lost as radiant energy, with the greatest lost from the head, thorax, and lungs. The elderly
are more prone to hypothermia resulting from decreased body fat, diminished energy reserves,
decreased basal metabolic rate, decreased shivering response, decreased sensory perception and
chronic medical conditions. Treatment: focuses on managing and maintaining ABCs,
rewarming the patient, correcting dehydration and acidosis, and treating cardiac arrhythmias.
Passive or active external rewarming involves moving the patient to a warm, dry place, removing
damp clothing, and placing warm blankets on the patient.

Frostbite1 can be described as "true tissue freezing" which results in the formation of ice
crystals in the tissues and cells. Peripheral vasoconstriction is the initial response to cold stress
and results in a decrease in blood flow and vascular stasis. As cellular temperature decrease and
ice crystals form in the intercellular spaces, intracellular sodium and chloride increase, the cell
membrane is destroyed, and organelles are damaged. Treatment: after rewarming, the
extremity should be elevated to lessen edema. Significant edema may begin within 3 hours, with
blistering in 6 hours to days. Intravenous analgesia is always required in severe frostbite because

c

 







!"


 "#$$ " %$$&$$  $'('( "



)
"#$$ "   $%""$ "

"#$$  $$*c)++ %%

of the pain associated with tissue thawing. Tetanus toxoid should be given for prophylaxis.

Drowning 1 is death from suffocation after submersion in water or other fluid medium.
Treatment: of submersion injuries focuses on correcting hypoxia, acid-base imbalances, and
fluid imbalances; supporting basic physiologic functions; and rewarming when hypothermia is
present. Initial evaluation involves assessment of airway, cervical spine, breathing and
circulation.

Salt water1 hypertonic salt water draws protein-rich fluid from the vascular space into the
alveoli, impairing aveolar ventilation and resulting in hypoxia. Treatment: of submersion
injuries focuses on correcting hypoxia, acid-base imbalances, and fluid imbalances; supporting
basic physiologic functions; and rewarming when hypothermia is present. Initial evaluation
involves assessment of airway, cervical spine, breathing and circulation. Teaching focuses on
water safety and minimizing the risks of drowning.

Free water1 hypotonic fresh water is rapidly absorbed into the circulatory system through the
alveoli. Fresh water may be contaminated with chlorine, mud, and algae causing the breakdown
of lung surfactant, fluid seepage, and pulmonary edema. Treatment: of submersion injuries
focuses on correcting hypoxia, acid-base imbalances, and fluid imbalances; supporting basic
physiologic functions; and rewarming when hypothermia is present. Initial evaluation involves
assessment of airway, cervical spine, breathing and circulation.

Snakebite1 is of particular importance when the snakes are venomous. Treatment: focuses on
preventing the spread of venom. Rings, watches, and restrictive clothing should be removed and
then the affected limb should be immobilized at the level of the heart. Ice and tourniquet's are
not recommended. ED management involves vascular access with a large-bore catheter and
administration of crystalloids to maintain blood pressure. Antivenin treatment is used in mild to
moderate reactions the amount used is based on timing, type and severity.

Dog tick 3One of the most frequently encountered ticks is the American dog tick, also sometimes
known as the wood tick. The larvae and nymphs feed on small warm-blooded animals such as
mice and birds. The adult American dog tick will feed on humans and medium to large mammals
such as raccoons and dogs. Treatment: involves removal of the attached tick is essential for
effective treatment. Forceps may be used to safely remove the tick by grasping at the point of
entry and pulling upward in a steady motion. Covering the tick with alcohol, mineral oil,
petroleum jelly, or ether causes the tick to release from the skin.

Lyme Disease1 is caused by a bite from a tick. Symptoms appear within 4 to 20 days of a bite
from the È
 tick and results from exposure to the spirochete 


  that is found
c

 







!"


 "#$$ " %$$&$$  $'('( "



)
"#$$ "   $%""$ "

"#$$  $$*c)++ %%

on the tick. The initial stage is characterized by nonspecific flulike symptoms and a
characteristic bull's eye rash Treatment: involves removal of the attached tick is essential for
effective treatment. Forceps may be used to safely remove the tick by grasping at the point of
entry and pulling upward in a steady motion. Covering the tick with alcohol, mineral oil,
petroleum jelly, or ether causes the tick to release from the skin.

Cat bite cause deep puncture wounds that can involve tendons and joint capsules. Cat bites
result in a greater incidence of infection than dog bites because of the organism, Pasteurella that
is carried in the mouths of the healthiest cats. Treatment: initial treatment includes cleaning
with copious irrigation, debridement, tetanus prophylaxis, and analgesic as needed. Prophylactic
antibiotics are used for animal bites at risk for infection such as wounds over joints, those greater
than 6 to 12 hours old.

Ingestion of

Caustic agent 4Caustic chemicals produce tissue injury by altering the ionized state and
structure of molecules and disrupting covalent bonds. In aqueous solutions, the hydrogen ion
(H+) produces the principle toxic effects for the majority of acids, whereas the hydroxide ion
(OH-) produces such effects for alkaline substances. Treatment: Airway control is primary.
Gastric emptying and decontamination is essential but do not administer emetics because of risks
of re-exposure of the vulnerable mucosa to the caustic agent. This may result in further injury or
perforation. Gastric lavage by traditional methods using large-bore orogastric Ewald tubes are
contraindicated in both acidic and alkaline ingestions because of risk of esophageal perforation
and tracheal aspiration of stomach contents. 1The most effective intervention for management of
poisonings is administration of activated charcoal orally or via a gastric tube. Toxins adhere to
charcoal and are excreted through the GI tract rather than absorbed into the portal circulation.
Adults receive 50 to 100 g of charcoal. Large-volume liquid acid ingestions may benefit from
nasogastric tube (aGT) suction if performed rapidly after ingestion.

Alkaline lye 4Alkaline ingestions cause tissue injury by liquefactive necrosis, a process that
involves saponification of fats and solubilization of proteins. Cell death occurs from
emulsification and disruption of cellular membranes. The hydroxide ion of the alkaline agent
reacts with tissue collagen and causes it to swell and shorten. Small vessel thrombosis and heat
production occurs.

Questions asked by poison control when assessing an overdose includes:

Patient¶s age, weight, and condition
What was ingested and how much?
c

 







!"


 "#$$ " %$$&$$  $'('( "



)
"#$$ "   $%""$ "

"#$$  $$*c)++ %%

Length of time since substance was ingested.
Have you used drugs other than those required for medical purposes?
Do you abuse more than one drug at a time?
Are you always able to stop using drugs when you want to?
Have you had ³blackouts´ or ³flashbacks´ as a result of drug use?
Do you feel bad about your drug abuse?
Does your spouse (or parents) ever complain about you involvement with drugs?
Have you neglected your family because of your use of drugs?
Have you engaged in illegal activities in order to obtain drugs?
Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
Have you had medical problems as a result of your drug use (e.g./ memory loss, hepatitis,
convulsions, bleeding, etc.)?

Classical Treatments for an overdose.

-Assessment of the patient's airway and breathing to make sure that the trachea, the passage to
the lungs, is not blocked. A tube may be inserted through the mouth and into the trachea to help
the patient breath.

- Assessment of the patient's heart rate, blood pressure, body temperature, and other physical
signs. These might indicate the effects of the drug.

- Blood and urine sample collection. Laboratories will test these for the presence of the suspected
overdose drug and any other drugs or alcohol that might be present.

- Elimination of the drug that has not yet been absorbed. Vomiting may be induced using ipecac
syrup or other substances that cause vomiting. Ipecac syrup should not be given to patients who
overdosed with tricyclic, antidepressants, theophylline, or any drug that causes a significant
change in mental status. If a patient vomits while unconscious, there is a serious risk of choking.
Activated charcoal is also sometimes given to absorb the remaining drugs.

- Gastric lavage, or "pumping" the stomach. For this procedure a flexible tube is inserted through
the nose, down the throat, and into the stomach. The contents of the stomach are then suctioned
out through the tube. A solution of saline is injected into the tube to rinse out the stomach. This
solution is then also suctioned out.

- Medication to stimulate urination or defecation. This may flush any remaining drug out of the
body faster.

- Intravenous fluids. An intravenous line may be put into the arm or back of the hand. Fluids,
either sterile saline or dextrose can be administered through this line. Increasing fluids can help
to flush the drug out of the system and reestablish balance of fluids, acids/bases, and minerals in
the body.

c

 







!"


 "#$$ " %$$&$$  $'('( "



)
"#$$ "   $%""$ "

"#$$  $$*c)++ %%

- Hemodialysis - to filter some drugs out of the blood.

Identify the guidelines when determining vomiting or not to vomit.

-Vomiting may be induced when the drug has not been absorbed.
-You should never attempt to induce vomiting in someone who cannot sit upright or in someone
who is in an altered level of consciousness. They could choke on the vomit.
-aever induce vomiting if a foreign object has been swallowed without first consulting a
physician

Identify the dosages that constitute an overdose in an adult client with th efollowing drugs
listed below. State the treatment each and aftercare.

Tylenol
Overdose dosage-Toxicity is associated with a single acute ingestion of 150 mg/kg or
approximately 7-10 g in adults.
Treatment- Acetylcysteine (Muncomyst), Antiemetics
Aftercare:
O Advice patients of the potential risk associated with the inappropriate use of
acetaminophen, which commonly is considered an innocuous over-the-counter drug.
O Educate parents of the proper acetaminophen dosing for children and the danger
associated with misusing various acetaminophen preparations
O Patients should always be given clear dose and formulation instructions. They should also
be instructed to carefully examine over-the-counter medications that may contain
acetaminophen in combination formulations.
O Educate patients of the increased potential for renal toxicity associated with concurrent
acetaminophen and aSAID analgesic use, or chronic ethanol use.

Tricycle Antidepressant
Overdose dosage- the lowest reported toxic dose is 6.7 mg per kg body weight
Treatment: - Activated charcoal, Fluid, Serum alkalinization with sodium bicarbonate,
physostigmine.
Aftercare:
O Cardiac monitoring for at least 12-24 hours.
O Clients should be screen for suicidal behaviors.

ASA
Overdose dosage- more than 150mg/kg of aspirin
Treatment: Fluids; activated charcoal to soak up aspirin in the stomach; laxative to cause bowel
movements that help remove aspirin and charcoal from the body; other medicines may be given
through a vein, including potassium salt and sodium bicarbonate, which helps the body remove
aspirin that has already been digested; Hemodialysis- to wash out the blood
After Care:
m Assess for bleeding signs
m Clients should be screen for suicidal behavior.
c

 







!"


 "#$$ " %$$&$$  $'('( "



)
"#$$ "   $%""$ "

"#$$  $$*c)++ %%

Digoxin
Overdose dosage- 10 to 15 mg was the dose resulting in death of half of the patients
Treament: Activated Charcoal, Oxygen Digoxin immune Fab (Digibind)
Aftercare:
-Monitor cardiac for arrhythmias or hyperkalemia.
-Intentional overdose requires psychiatric follow-up

Dilantin
Overdose dosage: toxicity can occur as a result of taking a daily dose of the drug that is too high
or a single (2-5 grams).
Treatment: Oral doses of activated charcoal; fluids through an intravenous line (IV); Careful
monitoring of blood pressure.
Aftercare:
-Monitor for seizure activity
-Advice client not to drive
-Intentional overdose requires psychiatric follow-up.

Valium
Overdose dosage: >10-15 mg per day, dosages should be determined on an individual basis,
depending upon the problem.
Treatment:- Fluids, active charcoal, Flumazenil, and hemodialysis.
Aftercare:
-Monitor CaS activity
-Intentional overdose requires psychiatric follow-up.

Cyanide
Overdose dosage: The lethal dose of potassium or sodium cyanide is 200 to 300 mg and of
hydrocyanic acid is 50 mg.
Treatment: A Cyanide Antidote Kit (CAK) or Hydroxocobalamin (Cyanokit) may be used,
Flushing of the stomach with fluids, active charcoal.
Aftercare:
-Monitor lab, especially oxygen
- Intentional overdose requires psychiatric follow-up.

IRON
Overdose dosage- occurs when amounts of iron50 -100 times greater than the recommended
dietary dose are taken
Treatment: Flush out with fluids, gastric lavage, Deferaxamine (Mesylate)
Aftercare;
-Monitor Blood tests to check iron levels
- Laxatives for constipation

Bleach
Overdose dosage- a small or large amount of bleach can be poisoning to the body.
Treament- flush with water, no antidote, ER
c

 







!"


 "#$$ " %$$&$$  $'('( "



)
"#$$ "   $%""$ "

"#$$  $$*c)++ %%

Aftercare:
-Monitor patient¶s vital signs
- Intentional overdose requires psychiatric follow-up.\

Antifreeze
Overdose dosage: more than 0.1 mL per kg body weight (mL/kg) of pure substance
Treatment: gastric lavage, nasogastric aspiration, ethanol or fomepizole (antidote)
Aftercare:
-Monitor for seizure activity
- Intentional overdose requires psychiatric follow-up.

Agent Bacterial Viral Person-to- Antibiotic Active Passive aursing care

Person Treatment Vaccine Vaccine/Antitoxin
Spread

c

 







!"


 "#$$ " %$$&$$  $'('( "



)
"#$$ "   $%""$ "

"#$$  $$*c)++ %%

Botulism X X induce
vomiting,
enemas,
antitoxin,
mechanical
ventilation,
Penicillin
Anthrax X X X administer
antibiotics,
monitor
vitals
Plague X X X(if Antibiotics
early) effective if
administered
immediately,
streptomycin,
isolation
Hemorrhagic X X ao IM
Fever injections, no
antiplatelet
drugs,
isolation,
Tularemia X X Gentamicin

Small pox X X X X no known

care,
cidofovir
isolation,
vaccine
available
Brucellosis X Rare X antibiotics
Meningitis X X X X antibiotics
for bacterial
type, no
available
treatment for
viral, rest and
fluids, clients
usually
exhibit
symptoms
for 7-10 days
[
 



  
  
 
 


 

Flail Chest- is the inward movement of the thorax during inspiration, with outward movement
during expiration. It usually involves one side of the chest and results from multiple fractures
caused by blunt chest trauma leaving a segment of the chest wall loose.
c

 







!"


 "#$$ " %$$&$$  $'('( "



)
"#$$ "   $%""$ "

"#$$  $$*c)++ %%

Status Epilepticus- is characterized by prolonged seizures lasting more than 5 minutes or
repeated seizures over the course of 30 minutes. It is potential complication of all seizures. The
usual causes are sudden withdrawal from antiepileptic drugs, infection, acute alcohol withdrawal,
head trauma, cerebral edema, and metabolic disturbances.

Status Asthmaticus- is a long-lasting and severe asthma episode that does not respond to
standard treatment. It occurs when asthma symptoms ± difficulty breathing, wheezing and
coughing- fail to improve with emergency medication treatment. Status asthmaticus is caused by
severe bronchospasm, in which the smooth muscles of the bronchi suddenly contract and narrow
the airways. Asthma attacks can be triggered by allergens, such as pollen, smoke, and animal
dander, as well as by physical exertion and cold air. Status asthmaticus is a severe, prolonged,
immobilizing attack of asthma that is unresponsive to normal bronchodilators treatment. Its
symptoms are extreme difficulty with breathing, which cause restlessness and anxiety. Although
coughing and wheezing are common symptoms of asthma, an individual with status asthmaticus
may not cough or wheeze because there is not enough airflow. Advanced symptoms include little
or no breath sounds, inability to speak, bluish tinge to the skin (cyanosis), and heavy sweating.
Status asthmaticus can lead to unconsciousness and cardiopulmonary arrest, which can be fatal.

Radiation Exposure- Radiation is energy that travels in the form of waves or high-speed
particles. It occurs naturally in sunlight and sound waves. Man-made radiation is used in x-rays,
nuclear weapons, nuclear powers, plants and cancer treatment.
If you are exposed to small amount of radiation over a long period of time, it raises the risk of
cancer. It can also cause mutations in genes, which can be passed down to children after the
exposure. A lot of radiation over a short period can cause burns or radiation sickness. Symptoms
of radiation sickness include nausea, weakness, hair loss, skin burns and reduced organ function.
If the exposure is large enough, it can cause premature aging or even death. You may be able to
take medicine to reduce the radioactive material in the body.

c

 







!"


 "#$$ " %$$&$$  $'('( "



)
"#$$ "   $%""$ "

"#$$  $$*c)++ %%