D.
Natural Disasters - refer to such natural
Emergency Nursing~~~~~~~
Scope and Practice of Emergency Nursing
• Emergency management
– refers to urgent and critical care needs;
however, the ED has increasingly been
used for non-urgent problems, and
emergency management has broadened
to include the concept that an emergency
is whatever the patient or family
considers it to be
• The emergency nurse has special training,
education, experience, and expertise in
assessing and identifying health care
problems in crisis situations
Priority Emergency Measures for All Patients:
• Make safety the first priority
• Preplan to ensure security and a safe
environment
• Closely observe patient and family
members in the event that they respond to
stress with physical violence
• Assess the patient and family for
psychological function
• Patient and family-focused interventions
– Relieve anxiety and provide a sense of
security
– Allow family to stay with patient, if
possible, to alleviate anxiety
– Provide explanations and information
– Provide additional interventions
depending upon the stage of crisis
Types of Emergency:
• The types of emergencies indicated and
their definitions, with the exception of
terrorism, were selected in accordance with
the categories for which the Centers for
Disease Control and Prevention (CDC)
provide specific emergency response and
prevention information.
A. Bioterrorism - refers to the deliberate
release of viruses, bacteria, or other
agents used to cause illness or death in
people, animals, or plants. These agents
can be spread through the air, water, or
in food.
B. Chemical emergencies - occur when a
hazardous chemical is released and the
release has the potential for harming
people’s health. Chemical releases can
be unintentional such as an industrial
accident, or intentional such as in the
case of a terrorist attack.
C. Mass Casualties - refer to incidents such
as fires, explosions, mass transit
accidents such as train crashes or
bridge collapses that cause numerous
deaths and injuries.
occurrences as earthquakes, extreme
heat, floods, hurricanes, landslides and
mudslides, tornadoes, tsunamis,
volcanoes, wildfires, and winter
weather.
E. Outbreaks - refer to flu epidemics,
viruses, or other contagious diseases;
also could include food-borne
outbreaks such as salmonella or E. coli.
F. Radiation - emergency could be a
nuclear power plant accident or a
terrorist event such as a dirty bomb or
nuclear attack, which would expose
people to significantly higher levels of
radiation than are typical in daily life,
leading to health problems such as
cancer or even death.
G. Terrorism - refers to a deliberate act of
murder and destruction which disrupts
infrastructure and is directed towards
civilians with the aim of meeting
political ends.
Triage
• Triage sorts patients by hierarchy based
on the severity of health problems and
the immediacy with which these
problems must be treated
• collects data and classifies the illnesses
and injuries to ensure that the patients
most in need of care do not needlessly
wait
• Protocols may be initiated in the triage
area
• ED triage differs from disaster triage in
that patients who are the most critically
ill receive the most resources,
regardless of potential outcome
• “trier”- to sort
• To sort patients in groups based on the
severity of their health problem and the
immediacy with which these problems
must be addressed
Triage in the E.R.
• Berner’s
1. Emergent
• Patients have the highest priority
• With life-threatening condition
2. Urgent
• Patients with serious health problems
• Not life-threatening, MUST be seen in 1
hour
3. Non-urgent
• Episodic illness that can be addressed
within 24 hours
Triage in DISASTER!
• NATO
1. Immediate
2. Delayed
3. Minimal
4. Expectant

Airway Obstruction~~~~~~~
• Acute upper airway obstruction is a life-
threatening medical emergency
Pathophysiology
• Airway may partially or completely occluded
• Partial – can lead to progressive hypoxia,
hypercarbia & resp & cardiac arrest
• Complete – causes permanent brain injury,
death will occur within 3 to 5 minutes
secondary to hypoxia.
– Air movement is absent
– Oxygen saturation rapidly decreases
Causes
• Aspiration of foreign body
• Anaphylaxis
• Viral or bacterial infection
• Trauma
• Inhalation or chemical burns
• Narcotic analgesic (morphine) in elderly
depresses the respiratory center
• Diseases affecting motor coordination
(Parkinson)
• Mental dysfunction (dementia)
• Asphyxiation by food
• In Adult aspiration of a bolus meat :
most common
• Small toy in children
• Peritonsillar abscess
• epiglotitis
Establishing an airway
• Repositioning the head to prevent
hypopharyngeal obstruction
• Abdominal thrusts
– Elevating diaphragm can force
air from the lungs to create artificial
cough intended to expel foreign
object
• Head tilt chin lift manuever
• Jaw thrust maneuver
• Oral airway/ intubation
Inserting an oropharyngeal airway
• Measure the oral airway alongside the head.
The airway should reach from lip to ear.
• Extend the patient’s head by placing one hand
under the bony chin. With the other hand, tilt
the head back ward by applying pressure to
the forehead while simultaneously lifting the
chin forward.
• Open patient mouth
• Insert oral airway, rotate the tip 180 degree
to displace the tongue

Clinical Manifestation
• Cannot speak, breath, or cough.
• The patient may clutch the neck
between thumb and fingers.
• Choking
• Apprehensive appearance
• Inspiratory & expiratory stridor
• Labored breathing
• Suprasternal & intercostal retraction
• Flaring nostrils
• Increase anxiety, restlessness and
confusion.
• Cyanosis
Indication
• LOC as hypoxia worsen
• To establish an airway for a patient who
cannot be adequately ventilated.
Assessment and Diagnostic Findings • To bypass an upper airway obstruction.
• Inspection • To prevent aspiration
• Laryngoscopy • T o permit connection to ambubag or
• X-rays mechanical ventilator
• bronchoscopy • To facilitate removal of
tracheobronchial secretions
Management
• Partial: encourage the patient to cough LARYNGEAL OBSTRUCTION:
forcefull
• Edema of the larynx is a serious fatal
• Complete: After removal of obstruction condition. Swelling of the laryngeal mucous
if no pulse (CPR) membrane, may close off the opening tightly
leading to suffocation.

ETIOLOGY:
• Rarely occurs in patients with acute
laryngitis, occasionally with urticaria & more
frequently in patients with severe
inflammations of the throat as in scarlet
fever. It is am occasional cause of death in
severe anaphylaxis (angioneuritic edema).
• Foreign bodies frequently are aspirated into
the pharynx, the larynx or trachea & cause a
two-fold problem, FIRST, they obstruct the
air passageways & cause difficulty in
breathing w/c may lead to asphyxia.
SECOND, the FB may later be drawn farther
down, entering the bronchi or a bronchial
branch and causing symptoms of irritation,
croupy cough, expectoration of blood or
mucus or labored breathing.
MEDICAL MANAGEMENT:
• When allergy is the etiology,
administering SQ epinephrine or a
corticosteroid and applying an ice pack to
the neck is done.
Hemorrhage~~~~~~~~~~~~
• is extreme blood loss. A patient is this
situation is apprehensive, restless and
thirsty, the skin is cold, moist and pale, PR
increases, temperature falls and respirations
are rapid and deep (air hunger)
• if hemorrhage is not treated CO decreases,
BP and Hgb/Hct decreases
CLASSIFICATION OF HEMORRHAGE: see tables
Management
• FLUID REPLACEMENT
– Isotonic electrolyte solution such as
lactated ringers, normal saline
• BT
– Colloid and blood component
– Packed RBC when there is massive
blood loss
– Additional platelets clotting factors
are given when large amts of blood are
needed, because packed RBC lacks
clotting factor
Control of external hge:
• Direct firm pressure
• If extremity immobilized to control blood
loss
• Tourniquet is applied to an extremity only as
a last resort, when the bleeding cannot be
controlled in any other way and immediate
surgery is not feasible.
Hypovolemic Shock
• Hypotension can result from blood loss,
hypoventilation, position changes, pooling of
blood in the extremities or side effects of
medications and anesthetics
• Most Common Cause: loss of circulating
volume thru blood and plasma loss.
• If the amount of blood loss exceeds 500mL,
replacement is usually indicated
• Shock can result from hypovolemia. This is
described as inadequate cellular
oxygenation accompanied by the inability to
excrete waste products of metabolism
Types of SHOCK:
• Hypovolemic shock: characterized by a fall
in venous pressure, a rise in peripheral
resistance and tachycardia, pale, cool
diaphoretic skin, poor capillary refill, poor
urine output
• Earliest Sign: Tachycardia
• Can be avoided by the timely
administration of IVF, blood products and
medications that elevate blood pressure
• INTERVENTION: volume replacement is the
primary intervention for shock, with
administration of cardiotonic drugs, proper
patient positioning, vital sign monitoring
Blood By-product
• Whole Blood
• 1 unit=450ml(+50ml)
• Deficient in platelet & clotting
factor V, VIII, XI
• Rarely use
• Packed RBC
• 1unit= 300ml(+50ml)
• No platelet or clotting factor
• Can mixed with NS to infuse
faster
• Platelet
• Replace platelet 1unit=50ml
usually 6 to 9 units or one single
donor unit (250-300ml) are infused
• Fresh Frozen Plasma
• Replaces clotting factor
• 1unit=200-250ml
• No RBC/WBC/Platelet
• Cryoprecipitate
• Replaces fibrinogen & some
clotting factor
• 1unit= 10 to 15ml
CHANGES OCCUR IN STORAGE OF
WHOLE BLOOD
- Dec Ca, inc K, dec 2,3 DPG, inc H(dec
pH), dec clotting factor V,VII,XI, dec
PMN’s
Neurogenic Shock: a less common cause of
shock in the surgical patient, occurs as a result
of decreased arterial resistance caused by spinal
anesthesia
• Inadequate tissue perfusion due to loss
of sympathetic vasoconstrictive reflexes
 • There is fall of BP

Cardiogenic Shock: Unlikely to occur in a

surgical patient except if the patient has severe
pre-existing cardiovascular disease or
experienced AMI during surgery.
• S/SX: dyspnea, Rales, gallop rhythm

Anaphylactic Shock: Inadequate tissue

perfusion due to increased vascular
permeability; vasodilatation, smooth muscle
constriction, as a result of exposure to an
allergen in a previously sensitized patient
• S/SX: urticaria/angioedema, laryngeal
edema

Septic Shock: Decreased vascular resistance,

decreased intravascular volume, causing
increased capillary permeability, microvascular
pooling and cardiac dysfunction
• Causes: Gram-negative microbes (E.
coli, B. fragilis)
• S/SX: fever, hyperventilation,
hyperglycemia, leukocytosis
CLASSIC SIGNS OF SHOCK:
• pallor
• cool moist skin
• rapid breathing
• cyanosis- circumoral
• rapid, weak, thready pulse
• decreasing pulse pressure
• low BP and concentrated urine
Management
• Patent airway
• Fluid replacement ( rapid rate)
– IV infused at rapid rate until
systolic blood prssure or CVP increases
to satisfactory level
– Lactated Ringer’s : bec it
approximate plasma electrolyte
composition osmolality
• CVP
– Serve as guide for fluid
replacement
• Blood component
• Indwelling urinary catheter
– To record urinary output every
hour
– Urine output indicates
adequacy of kidney perfusion
WOUND~~~~~~~~~~~~~
3 Phases of wound healing:
• Inflammatory: Vasoconstriction, increased
capillary permeability, Migration of cells
• Proliferative: Macrophage migration,
Fibroblast proliferation, epithelial maturation,
Collagen formation
• Maturation phase: at 3 weeks the
wound is said to be essentially healed
MECHANISMS OF WOUND HEALING:
First- Intention Healing (Primary Wound
Healing)
• wounds made aseptically with
minimum tissue destruction
• Granulation tissue is not visible and scar
formation is minimal
• Inflammatory phase lasts only for 1
week
• Post-operatively this type of wound is
covered with dry sterile dressing
• Closure of the wound allows for the
best result.
• If a cyanoacrylate tissue adhesive is
used a dressing is contraindicated
Second-Intention Healing (Secondary Healing)
• Granulation occurs in infected wounds
in which edges have not been
approximated. There is large tissue
defect that must be filled
• GRANULATION TISSUE: a proliferation
of fibroblasts and vascular endothelial
cells formed 3-4 days after
surgery/injury. Characterized by often
edematous pinkish, and soft in
appearance. Histologic features:
Angiogenesis and fibroblast proliferation
• Healing is complete when the epithelial
cells/ skin cells grow over these
granulations. Skin contraction may result
• When the post-operative wound is
allowed to heal by this mechanism, it is
usually packed with saline moistened
 sterile dressings and covered with a dry
sterile dressing
• Some wound are too large necessitating
skin grafts
Third- Intention Healing (Tertiary closure/
Delayed primary closure):
• Used for deep wounds that have either
not been sutured early or that
breakdown and are re-sutured later,
thus bringing together 2 apposing
granulation surfaces
• This results in a deeper, wider scar.
• Wounds that are heavily contaminated
and are likely to develop an infection if
closed may be left open for 3-5 days.
• The wounds are packed post-
operatively with moist gauze and
covered with dry sterile dressing
FACTORS AFFECTING WOUND HEALING:
– age of patient
– handling of tissue
– hemorrhage and hypovolemia
– Edema
– Inadequate dressing technique
– Nutritional deficits
– Foreign body
– O2 deficit
– Drainage accumulation
– Medications
– Patient over activity
– Systemic disorders( hypoxia, acidosis, Renal
and hepatic failure)
– Immunocompromised state
– Wound stressor
TRAUMA--------------------------
• or injury has been defined as damage to
the body caused by an exchange with
environmental energy that is beyond the
body's resilience.
• most common cause of death for
individuals between the ages of 1 and 44
years, and the third most common cause of
death for all ages.
INITIAL EVALUATION AND RESUSCITATION OF
THE INJURED PATIENT
• Treatment of trauma patients often begins in
the field by emergency medical services
(EMS) personnel and completed by
rehabilitation specialists.
• The initial treatment of seriously injured
patients consists of a primary survey,
resuscitation, secondary survey,
diagnostic evaluation, and definitive care
• The ATLS course refers to this as the primary
survey or the ABCs-Airway, with cervical
spine protection, Breathing, and Circulation.
– Any life-threatening problem identified
in the initial survey must be treated
before advancing.
Primary Survey
• A = airway
• B = Breathing
• C = Circulation
Airway Management
•Ensuring an adequate airway is the first
priority in the primary survey.
•Efforts to restore cardiovascular integrity will
be futile if the oxygen content of the blood is
inadequate.
•All blunt-trauma patients require cervical
spine immobilization until injury is ruled out.
This can be
accomplished with a hard (Philadelphia) collar
or sandbags on both sides of the head taped
to the backboard.
•Patients who are conscious and have a normal
voice do not require further evaluation or
early attention to their airway.
•Exceptions to this principle include patients
with penetrating injuries to the neck and an
expanding hematoma, evidence of chemical
or thermal injury to the mouth, nares, or
hypopharynx, extensive subcutaneous air in
the neck, complex maxillofacial trauma, or
airway bleeding.
•These patients initially may have a
satisfactory airway, but it may become
obstructed if soft tissue swelling or edema
progresses. In these cases, elective intubation
should be performed before evidence of
airway compromise is apparent.
•Patients who have an abnormal voice or
altered mental status require further airway
evaluation.
•Direct laryngoscopic inspection often reveals
blood, vomit, the tongue, foreign objects, or
soft tissue swelling as sources of airway
obstruction. Suctioning can offer immediate
relief in many patients.
•Altered mental status is the most common
indication for intubation because of the
patient's inability to protect the airway.
•Options for airway access include
nasotracheal, orotracheal, or operative
intervention.
•If intubation have failed because of extensive
facial injuries require a surgical airway
Cricothyroidotomy
 Breathing
•Once a secure airway is obtained, adequate
oxygenation and ventilation must be assured.
•All injured patients should receive
supplemental oxygen
therapy and be monitored by pulse oximetry.
• The following conditions may constitute an
immediate threat to life because of
inadequate ventilation:
•(1) tension pneumothorax, (2) open
pneumothorax, or (3) flail chest/pulmonary
contusion.
•These diagnoses can be made with a
combination of physical examination and
chest x-ray.
Tension pneumothorax
• Respiratory distress in combination
with any of the following physical
signs:tracheal deviation away from the
affected side; lack of or decreased breath
sounds on the affected side; distended neck
veins or systemic hypotension; or
subcutaneous emphysema on the affected
side.
• Immediate tube thoracostomy is
indicated
• In tension pneumothorax the collapsed
lung pressure becomes positive, depressing
the ipsilateral hemidiaphragm and forcing the
mediastinal structures into the contralateral
chest. The contralateral lung is then
compressed, and the heart is rotated about
the superior and inferior venae cavae,
decreasing venous return and cardiac output
while distending the neck veins.
Open pneumothorax
• or sucking chest wound occurs with full-
thickness loss of the chest wall, permitting a
free communication between the pleural
space and the atmosphere.
• Proper treatment in the field involves
placing an occlusive
dressing over the wound, which is taped on
three sides. The occlusive dressing permits
effective ventilation on inspiration while the
untaped side allows accumulated air to
escape from the pleural space, preventing a
tension pneumothorax. Definitive treatment
requires wound closure and tube
thoracostomy.
Flail chest
• Flail chest occurs when four or more
ribs are fractured in at least two locations.
Paradoxical movement of this free-floating
segment of chest wall may be sufficient to
compromise ventilation
Flail Chest:
 Circulation •Classic signs and symptoms of shock are
• With a secure airway and adequate ventilation tachycardia, hypotension, tachypnea, mental
established, circulatory status is determined. A status changes, diaphoresis, and pallor.
rough first approximation of the patient's •Normalization of vital signs, clearing of the
cardiovascular status is obtained by palpating sensorium, evidence of good peripheral
peripheral pulses. perfusion (warm fingers and toes
• A systolic blood pressure of 60 mmHg is with normal capillary refill) are presumed to
required for the carotid pulse to be palpable, 70 have adequate perfusion.
mmHg for the femoral pulse and 80 mmHg for •Urine output is a quantitative and relatively
the radial pulse. At this point in the patient's reliable indicator of organ perfusion.
treatment, hypotension is assumed to be Adequate urine output is 0.5 mL/kg/h in an
caused by hemorrhage. Blood pressure and adult, 1 mL/kg/h in a child, and 2 mL/kg/h in
pulse should be measured at least every15 min. an infant less than 1 year of age.
• External control of hemorrhage should be
obtained before restoring circulating volume. Persistent Hypotension
• Manual compression and splints frequently
•CVP determines right ventricular preload; in
control extremity hemorrhage as effectively as
otherwise healthy trauma patients, its
tourniquets and with less tissue damage. Blind
measurement yields objective information
clamping should be avoided because of the risk
regarding the patient's overall volume status.
to adjacent structures, particularly nerves.
•A hypotensive patient with flat neck veins and
• Digital control of hemorrhage for penetrating
a CVP less than 5 cmH2O is hypovolemic and
injuries of the head, neck, thoracic outlet, groin,
is likely to have ongoing hemorrhage.
and extremities should be done with a gloved
• A hypotensive patient with distended
finger placed through the wound directly on the
neck veins or a CVP more than 15 cmH2O is
bleeding vessel applying only enough pressure
likely to be in cardiogenic shock. The CVP may
to control active bleeding.
be falsely elevated if the patient is agitated
•Scalp lacerations through the galea
and straining.
aponeurotica tend to bleed profusely; these
• In trauma patients the differential diagnosis
can be temporarily controlled with Rainey
of cardiogenic shock is indicated by: (1)
clips or a full-thickness large nylon continuous
tension pneumothorax, (2) pericardial
stitch.
tamponade, (3)
•Intravenous access for fluid resuscitation is
myocardial contusion or infarction, and (4)
begun with two peripheral catheters, 16-
air embolism.
gauge or larger in an adult.
• Tension pneumothorax is the most frequent
•Blood should be drawn simultaneously and
cause of cardiac failure.
sent for typing and hematocrit measurement.
• Traumatic pericardial tamponade is most
•For patients requiring vigorous fluid
often associated with penetrating injury to
resuscitation, saphenous vein cutdowns at
the heart. As blood leaks out of the injured
the ankle or percutaneous femoral vein
heart, it accumulates in the
catheter introducers are preferred.
pericardial sac.
•Venous access in the lower extremities
• The classic findings of Beck's triad
provides effective volume resuscitation in
(hypotension, distended neck veins, and
cases of abdominal venous injury.
muffled heart sounds)

Secondary Survey
• When the conditions that constitute an
immediate threat to life have been attended
to or excluded, the patient is examined in a
systematic fashion to identify occult injuries.
• Special attention should be given to the
patient's
back, axillae, and perineum because injuries
in these areas are easily overlooked.
• Patients should undergo digital rectal
Initial Fluid Resuscitation
examination to evaluate sphincter tone and
•Initial fluid resuscitation is a 1-L intravenous
to look for blood,perforation, or a high-riding
bolus of normal saline,
prostate.
lactated Ringer's solution, or other isotonic
• A Foley catheter should be inserted to
crystalloid in an adult, or 20
decompress the bladder, obtain a urine
mL/kg of body weight lactated Ringer's
specimen, and monitor urine output.
solution in a child.
• A nasogastric tube should be inserted to
•fluid resuscitation is to reestablish tissue
decrease the
perfusion.
risk of gastric aspiration and allow inspection
 of the contents for blood suggestive of occult
gastroduodenal injury.
Regional Assessment and
Special Diagnostic Tests
• Head
– A score based on the Glasgow
Coma
Scale (GCS) should be determined for all
injured patients. It is calculated by adding
the scores of the best motor response, best
verbal response, and eye opening. Scores
range from 3 (the lowest) to 15 (normal).
Scores of 13 to 15 indicate mild head injury,
9 to 12, moderate injury, and less than 9, a
severe injury.
– The GSC is useful for triage and
prognosis.
•presence of lateralizing findings are
important, e.g., a unilateral dilated pupil
unreactive to light, asymmetric movement of
the extremities either spontaneously or in
response to noxious stimuli, or a unilateral
Babinski's reflex suggest a treatable
intracranial mass lesion or major structural
damage.
•Otorrhea, rhinorrhea, “raccoon eyes,” and
Battle's sign (ecchymosis behind the ear) can
be seen with basilar skull fractures.
•head and face should be systematically
palpated for fractures.
•Cerebral pathologic lesions from blunt
trauma include hematomas, contusions,
hemorrhage into ventricular and
subarachnoid spaces
•CT scan, plain skull films
• Neck
– Attention should be focused on signs
and symptoms of an occult cervical spine
injury. Because of the devastating
consequences of quadriplegia
Zone of the Neck
• Zone I is between the clavicles and the
cricoid cartilage, and is also referred to
as the thoracic outlet.
• Zone II is between the cricoid cartilage
and the angle of the mandible.
• Zone III is above the angle of mandible.
• Chest
– Blunt trauma to the chest may involve
the chest wall, thoracic spine, heart, lungs,
thoracic aorta and great vessels, and the
esophagus.
– Most of these injuries are assessable by
physical examination and chest x-ray.
– most threatening occult injury in
trauma surgery is a tear of the descending
thoracic aorta.
• Abdomen
– most authorities agree that the
presence of abdominal rigidity or gross
abdominal distention in a patient with
truncal trauma is an indication for prompt
surgical exploration.
• Diagnostic peritoneal lavage (DPL)
remains the most sensitive
test available for determining the presence
of intraabdominal injury
• For stab wounds to the abdomen, its
sensitivity for detecting intraabdominal
injury exceeds 95 percent.
• The results of DPL are
– grossly positive if more than 10
mL of free blood can be aspirated after
insertion of the catheter.
– If less than 10 mL is withdrawn,
1 L of normal saline solution is instilled and
the patient is gently rocked from side to side
and up and down.
• Pelvis
– plain x-rays reveal gross
abnormalities, but CT scanning may be
necessary to assess the pelvis for stability.
Sharp spicules of bone can lacerate the
rectum or vagina.
– The finding of gross blood on
digital examination strongly suggests injury to
these organs.
– The bladder can be lacerated by
sharp fracture fragments, or, if the bladder is
full, a direct blow to the hypogastrium can
generate sufficient intravesicular pressure to
cause rupture.
– Gross blood on urinalysis
 – Urethral injuries are suspected •Assessment
by the findings of blood at the meatus, scrotal – Obtain history
or perineal hematomas, and a high-riding – Perform abdominal assessment and
prostate on rectal examination. assess other body systems for injuries
that frequently accompany
•Extremities abdominal injuries
– Injury of the extremities from •Assess for referred pain that may indicate
any cause requires plain x-ray films to spleen, liver, or intraperitoneal injury
evaluate fractures. •Perform laboratory studies, CT scan,
Transfusion abdominal ultrasound (FAST), and
• packed red blood cells (pRBC), fresh- diagnostic peritoneal lavage
frozen plasma •Assess stab wound via sonography
(FFP), and platelet packs. Not all trauma •Ensure airway, breathing, and circulation
patients requiring transfusions receive •Immobilize cervical spine
all three components. •Continually monitor the patient
• Most trauma patients receive between •Document all wounds
1 and 5 units of pRBC and no other •If viscera are protruding, cover with a
components, but major trauma centers sterile, moist saline dressing
have the capability of transfusing •Hold oral fluids
tremendous quantities of blood •NG to aspirate stomach contents
components. •Provide tetanus and antibiotic prophylaxis
•Provide rapid transport to surgery if
•Intra Abdominal Injuries indicated
• Category
• Penetrating: GSW, SW
• Blunt Trauma: VA, Fall, blow,
explotion Priorities of Care for the Patient With Multiple
Trauma
Penetrating •Use a team approach
•Injury to hollow organs •Determine the extent of injuries and
•Small bowel establish priorities of treatment
•Liver the most common solid organ affected • Assume cervical spine injury
•GSW velocity is a factor, high velocity create • Assign highest priority to injuries
extensive tissue damage interfering with vital physiologic
•All GSW that crosses the peritoneum may function
require surgical exploration
Blunt
•Usually associated with extra abdominal
injury to the chest, head, or extremities
•Difficult to detect
•The incidence of delayed trauma related
complication is greater than penetrating
injuries
•Common organ injured liver, kidney, spleen,
blood vessels
•May cause massive blood loss into the
peritoneal cavity
Assessment
•Inspection: bruises, abrasions, abdominal
distention
•Auscultation: bowel sound
•Palpation: involuntary guarding,
tenderness, pain, muscle rigidity or rebound
tenderness,
•shock

Management of Patients With

Intra-Abdominal Injuries
•Blunt trauma or penetrating injuries
•Abdominal trauma can cause massive life-
threatening blood loss into abdominal
cavity

Priorities in the Management of the Patient
With Multiple Injuries
TRAUMA to the GIT:
- Penetrating trauma: most commonly
injured organ is the LIVER
- Blunt trauma: the most commonly
affected organ is the SPLEEN , others
kidneys, blood vessels
- DX: diagnostic peritoneal lavage, HX, PE,
abdominal xray, CT scan, - DPL after
instillation of I liter saline, >100,000 cubic
meter/of RBC, > 500/cubic meter of WBC,
presence of the food, fecal matter. Presence
of bile,feces or food
Crush Injury
• Run over a moving vehicle, compressed by
machine, crushed between 2 cars, crushed
under collapse building
• Shock
• Paralysis of body part involve
• Erythema, blister
• Renal dysfxn due to hypotension
• pulseless extremity is detected
• Management
• ABC
•Observed acute renal isufficiency ( may
damage the kidney)
•Slint to control bleeding
• Monitor lactic acid if less than
2.5mmol/L indication for
successful resuscitation
• Elevate extremity to relieve
swelling and pressure
• Fasciotomy to restore neurovascular
function
• Pain medication
• Stat surgery for wound debridement
and fracture repair
• Hyperbaric oxygen for
hyperoxygenation of injured tissues
Fracture~~~~~~~~~~~~~~~~
Types
• Close fx
– Intact skin over fx or hematoma
• Open fx
– Wound overlying fx
– High risk for infection
• Simple fx
– One fx line, 2 bone fragment
• Comminuted
– more than 2 bone fragment
– fragmentation
• Transverse
– fx line perpendicular to long
bone
• Oblique
– Fx line creates an oblique angle
with long axis of bone
• Spiral
– Severe oblique fx w/c plane
rotates along the long bone axis
caused by a twisting injury
• Pathologic
– Fx through abn bone, ex
osteoporotic bone, tumor laden
• Greenstick
– incomplete fx in w/c cortex on
only side is disrupted
Assessment
• Handle body part gently and as little as
possible
• Clothing is cut off to visualize the
affected body part
• Assessment is conducted for pain over
or near a bone, swelling, and exudates
Assess echymosis, tenderness,
crepitation
Management
• ABC
• Evaluate neurologic or abdominal
injuries before extremity is treated, unless
• Pulseless: repositioning to proper
alignment is required
• Fractured hip/ femur are pulseless –
Hare traction is use
– A portable in line traction
device to assist alignment
• If ineffective in restoring pulse stat OR
for arteriography and possible arterial
repair
• Splints is applied before the px is moved
• Splinting immobilizes the joint at a site
distal and proximal to the fracture, relieves
pain, restores or improves circulation,
prevents further tissue injury, and prevents
a closed fx from becoming an open one
• To splint an extremity one hand is placed
distal to the fx and some traction is applied
while the other hand is placed beneath the
fx for support.
• The splints should extend beyond the joints
adjacent to the fracture
• Upper extremities must be splinted in a
functional position
 • Open fracture moist sterile dressing is
applied
• After splinting re assess the vascular status
• Check nail bed cyanosis, color, temperature,
pulse
Environmental Emergencies
—Heat Stroke
• Aute medical Emergency, A failure of heat
regulating mechanisms
• Occur during heat wavws
• Elderly, very young, px w/ chronic
debilitating diseases, on tranquilizer, etc are
at risk
• In healthy individual occurs during sports or
work activities
• Most heat related deaths occur in elderly
because systems are unable to compensate
for stress imposed by heat
• Types
• Exertional: occurs in healthy
individuals during exertion in extreme
heat and humidity
• Hyperthermia: the result of
inadequate heat loss
• Elderly, very young, ill, or debilitated—and
persons on some medications—are at high
risk
• Can cause death
• Manifestations: CNS dysfunction, elevated
temperature, hot dry skin, anhydrosis,
tachypnea, hypotension, and tachycardia
Management of Patients With Heat Stroke
• Use ABCs and reduce temperature to 39° C
as quickly as possible
• Cooling methods
– Cool sheets, towels, or
sponging with cool water
– Apply ice to neck, groin, chest,
and axillae
– Cooling blankets
– Iced lavage of the stomach or
colon
– Immersion in cold water bath
• Monitor temperature, VS, ECG, CVP, LOC,
urine output
• Use IVs to replace fluid losses
– Hyperthermia may recur in 3 to
4 hours; avoid hypothermia
Environmental Emergencies
—Frostbite
• Trauma from freezing temperature and
actual freezing of fluid in the intracellular
and intercellular spaces
• Causes vascular damage
• Body parts frequently affected feet,
hands, nose, ears
• Ranging frm 1st degree erythema, to
4th degree full depth tissue destruction
• Manifestations: hard, cold, and
insensitive to touch; may appear white or
mottled; and may turn red and painful as
rewarmed
• The extent of injury is not always
initially known
• Controlled but rapid rewarming; 37° to
40° C circulating bath for 30- to 40-minute
intervals
• Administer analgesics for pain
• Do not massage or handle; if feet are
involved, do not allow patient to walk
Environmental Emergencies—Hypothermia
• Internal core temperate is 35° C or less
• Elderly, infants, persons with
concurrent illness, the homeless, and
trauma victims are at risk
• Alcohol ingestion increases
susceptibility
• Hypothermia may be seen with
frostbite; treatment of hypothermia takes
precedence
• Physiologic changes in all organ systems
• Monitor continuously
Management of Patients With Hypothermia
• Use ABCs, remove wet clothing, and
rewarm
• Rewarming
– Active core rewarming
• Cardiopulmonary bypass, warm
fluid administration, warm
humidified oxygen, and warm
peritoneal lavage
– Passive external rewarming
• Warm blankets and over-the-
bed heaters
• Cold blood returning from the
extremities has high levels of lactic acid and
can cause potential cardiac dysrhythmias
and electrolyte disturbances
Poisoning and Drug
overdose
Management of Patients With Poisoning
• Poison is any substance that when
ingested, inhaled, absorbed, applied to the
skin, or produced within the body in
relativity small amounts injures the body by
its chemical action
• Treatment goals:
– Remove or inactivate the
poison before it is absorbed
 – Provide supportive care in
maintaining vital organ systems
– Administer specific antidotes
– Implement treatment to hasten
the elimination of the poison
General Guidelines
• Maintain adequate ABC support. In
large tricyclic antidepressant overdose
intubate
• Comatose, stupor, drowsy px: give 50ml
ampule of 50% dextrose followed by
naloxone 2mg IV
• Perform gastric lavage in most adult px
with suspected oral ingestion
• Consider possible suicide attempts or
intentional poisoning in overdoses.
• All female px w/ intentional ingestion
should ideally have a pregnancy test (check
LMP) following informed consent
• Suicide precautions should be instituted
as needed, always have a 24hr possible
watcher, no access to sharp object, keep
balcony window lock, never leave
medication at bed side
Assessment of Patients With Ingested
Poisons
• Use ABCs
• Monitor VS, LOC, ECG, and UO
• Assess laboratory specimens
• Determine what, when, and how much
substance was ingested
• Assess signs and symptoms of poisoning
and tissue damage
• Assess health history
• Determine age and weight
Principles of decontamination
• 1. External Decontamination
– Remove clothes
– Wash skin w/ soap n water
– Keep warm; use blankets
• 2. Gastric lavage
– Contraindication strong acid,
alkali, petroleum distilates
– Airway must be protected w et
unless px is awake, alert has gag
– Place px in trendelenburg n left
lateral decubitus position
Acid ingestion
– Position head to one side to
minimize aspiration
– If w DOB ventilator n O2 is
indicated
– Perform gastric lavage unless
overdose was parenteral or distant
time
– Lavage may be usefull w/in 2hrs
of drug ingestion
• 3. activated charcoal
– Single dose, after emesis unless
contraindicated such as if oral
Alkali Ingestion
antidote will be use or if endoscopy
is planned
– Dose Adult; 50-100grams (1g/kg
body wt) in 200ml tap water in a
thick slurry, instill slurry by lavage
tube or have px ingest slurry
– Multiple dose 0.5gr/kg/bw q 4-
6hrs for metamphetamine,
phenothiazines, digoxin,
theophylline, phenobarbital,
organophosphate bec these subs
has enterohepatic recirculation
kinetics
– activated charcoal may cause
constipation or fecal impaction
– Not effective for alkali, cyanide,
mineral acid, ferous sulfate,
petroleum ingestion
• 4 cathartics (sodium sulfate)
– Contraindicated in infants, acid
n alkali ingestion, px who receive an
oral antidote, adynamic ileus,
severe diarrhea, abdominal trauma,
surgery, suspected intestinal
obstruction, severe electrolyte loss
or dehydration
– Magnesium sulfate cathartics
are contraindicated in renal failure
– Sodium sulfate contraindicated
in hypertension n heart failure
– Dose: 15 to 30grams
( 250mg/kg) in 100ml water given
30 minutes after the activated
charcoal. May repeat procedure if
still w/o bowel movements w/in 1
hr
• 5. force diuresis
– Attempted in treatment ctr that
can monitor hydration n electrolyte
status
– Forced diuresis
• Maintain urinary flow rate of 5-
7ml/kg/hr by infusing normal
saline and intermitent boluses of
furosemide 20mg IV doses
• Alternative: manitol 20-100mg
IV max 300mg
• Monitor electrolyte
• Diet NPO
• Monitor BP, HR, and abdomen for
guarding n tenderness
• Check for pneumothorax n
pneumoperitoneum
• Provide airway control, ventilation,
circulatory support fluid resuscitation, wash
oral cavity copiously w/ cold water
• Induction of emesis, lavage or charcoal
contraindicated ngt should not be perform
in most px.
 • NPO
• Monitor BP, HR, abd. For guarding n
tenderness
• Check for perforation,
pneumoperitoneum
• Immediately rinse oral cavity w/ cold
water protect airway n administer O2 n
fluid, antibiotic if w/ esophageal is present
• Esophagoscopy n gastroscopy shld not
be performed immediately if w/ drooling
stridor, odinophagia
• Hydrocortisone dose IV recommended
for deep burn
• Emesis, neutralizing agents, gastric
lavage, cathartics charcoal contraindicated
Amphetamine/ metamphetamine
• CBC c APC, PT, PTT, RBS, BUN,
creatinine, na, k, urine amphetamine level,
UA, ABG
• Activated charcoal, cathartics, emesis
has no role
• Further elimination with
– Mannitol 20% 50-100ml q 6hrs
– Acidification of urine w/ vi c at
1 grm q 6hr
• Watch out for complication
– Seizure: diazepam 5-10mg IV up
to 20mg followed by loading dose
of phenytoin 18mg/kg in nss IV
– Psychosis or agitation:
chlorpromazine or haloperidol,
diazepam IV
– Hypertensive crisis: alpha or
beta blocking agent
– Arrythmias: propranolol,
lidocaine
Anticoagulant overdose
• CBC c APC, PT, PTT, creatinine
• Heparine
– Protamine sulfate 1mg IV for q
50-100units of heparin infused in
the preceeding 2 hrs, dilute in 25-
50ml IV fluids over 10min
• Warfarin
– Gastric lavage n activated
charcoal if recently ingested
– Vit k 5-10mg IV or sq q 8-12 hrs
– Fresh frozen plasma 2-6units
for severe bleeding
Diazepam overdose
• I n o BP n respiration, pulse oximeter,
aspiration n seizure precautions, monitor
• Cbc, rbs,abg
• Support bp n respiration
• Place ngt, gastric lavage protect airway
w/ et
• Instill 50-100g charcoal, followed
repeated doses of 20-25gm via ngt q 4-6hr
• Cathartics
• Flumazenil 200mcg iv q 5-15min until px
wakes up or tot of 1mg is reached
• Flumazenil may ptt withdrawal seizure
on chronic user of diazepam
• Watch out for hypotension, cns, respi
depression, withdrawal syndrome(seizure,
agitation, restlessness, insomia
• Digoxin/ digitalis overdose
• IV, NGT, do gastric lavage
• DC digitalis preparation, correct
hypokalemia, hypomagnesemia or
hypercalcemia.
• Administer charcoal slurry q 4-6hrs &
cathartics
• Symptomatic sinus depression & low-
degree AV block; atropine 0.5mg IV q 15
maximum of 3mg
Ethanol toxicity
• I & O, NGT followed gastric lavage
• Maintain adequate airway, ventilation,
circulation, O2
• Thiamine 100mg IV or IM q 8hrs,
followed by Glucose 25-50g IV
• Seizures:
– Diazepam or Phenytoin IV
Hydrocarbon/ kerosene
• Adequate airway protection, respiratory
support
• Treatment not required in the absence
of symptoms.
• Gastric emptying: gastric lavage
• Skin decontamination: remove clothing
& wash affected skin with soap & water,
once defecated wash perianal area to
prevent chemical burns
Isoniazid overdose
• I&O, foley catheter, D5NM 1 L x 8hrs
• NGT, lavage till clean, activated charcoal
• Antidote: pyridoxine HCl (VitB6) 1
gm/10ml given per gram basis
• Seizures: diazepam 5mg IV for active
seizure
• Metabolic acidosis: Na bicarbonate IV
Narcotic overdose
• NGT gastric lavage
• Maintain airway, ventilation &
circulation
• Naloxone 2mg q 5min initially IV, IM,
SQ, endotracheally or continuous IV untill
px sensorium & respiratory patterns
improves
• Activated charcoal if (+) bowel sounds &
cathartics
• Complication: seizure, pulmonary
edema, hypotension
Organophosphate poisoning
• NPO, I&O, foley catheter
 • Decontamination:
– External: have the px rinse
gently w/ alkaline soap or baking
soda (10gm in 100ml water) change
clothes
– Internal: NGT do gastric lavage
w/ activated charcoal 100gm in
200-500ml water
• Activated charcoal 1 gm/kg PO then Na
sulfate 15-30grams in water after 30min
repeat after 1hr if still no bowel movement
• Antidote: atropine sulfate 0.01-0.05
mg/kg IV q 5min
– Maintain Dry mucosa,
HR>60bpm (target HR 100),
hypoactive BS, pupils >4mm
– Toxicity: >39 deg C temp,
absence of sweating, psychosis,
restlessness
• Seizure: diazepam 5mg IV
• Arrythmia: Calcium chanel or phenytoin
Management Patients With Carbon
Monoxide Poisoning
• Inhaled carbon monoxide binds to
hemoglobin as carboxyhemoglobin, which
does not transport oxygen
• Manifestations: CNS symptoms
predominate
– Skin color is not a reliable sign
and pulse oximetry is not valid
• Treatment
– Get to fresh air immediately
– Perform CPR as necessary
– Administer oxygen: 100% or
oxygen under hyperbaric pressure
• Monitor patient continuously
Management of Patients With
Chemical Burns
• Severity of the injury depends upon the
mechanism of action of the substance, the
penetrating strength and concentration,
and the amount of skin exposed to the
agent
• Immediately flush the skin with running
water from a shower, hose, or faucet
– Lye or white phosphorus must
be brushed off the skin dry
• Protect health care personnel from the
substance
• Determine the substance
• Some substances may require
prolonged flushing/irrigation
• Follow-up care includes reexamination
of the area at 24 hours, 72 hours, and 7
days
Management of Patients With
Food Poisoning
• A sudden illness due to the ingestion of
contaminated food or drink
• Food poisoning, such as botulism or fish
poisoning, may result in respiratory
paralysis and death
• ABCs and supportive measures
• Determination of food poisoning: see
Chart 71-12
• Treat fluid and electrolyte imbalances
• Control nausea and vomiting
• Provide clear liquid diet and
progression of diet after nausea and
vomiting subside
Management of Patients With
Substance Abuse
• Acute alcohol intoxication: a
multisystem toxin
– Alcohol poisoning may result in
death
– Maintain airway and observe
for CNS depression and
hypotension
– Rule out other potential causes
of the behaviors before it is
assumed the patient is intoxicated
– Use a nonjudgmental, calm
manner
– Patient may need sedation if
noisy or belligerent
– Examine for withdrawal
delirium, injuries, and evidence of
other disorders
• Commonly abused substances: see
Table 71-1
Crisis Intervention—Rape
Victims~~~~~~~~~~
• How the patient is received and treated
in the ED is important to his or her
psychological well-being
• Crisis intervention begins as soon as the
patient enters the facility; the patient
should be seen immediately
• Goals are to provide support, reduce
emotional trauma, and gather evidence for
possible legal proceedings
• Patient reaction; rape trauma syndrome
• History taking and documentation
• Physical examination and collection of
forensic evidence
• Role of the sexual assault nurse
examiner (SANE)
Psychiatric Emergencies~~~
• Overactive, underactive, violent, and
depressed or suicidal patients
• Management
 – Maintain the safety of all
persons and gain control of the
situation
– Determine if the patient is at
risk for injuring himself or others
– Maintain the person’s self-
esteem while providing care
– Determine if the person has a
psychiatric history or is currently
under care to contact the therapist
• Crisis intervention
• Interventions specific to each of the
conditions

BURN~~~~~~~~~~~~~
• 2nd leading cause of death in children
– 1st degree
• Only epidermis,painful,
erythematous, blisters
not present
– 2nd degree
• Epidermis & partial
thickness of the dermis,
painful, with blisters
– 3rd degree
• Epidermis, dermis,
nerves, painless, white,
charred
• Diagnosis
– ABC
– Vigilant for shock, inhalation
injury, carbon monoxide
poisoning
– Evaluate BSA %
• Treatment
– Supportive measures,
tetanus,, stress ulcer
prophylaxis, IV narcotic
analgesia
– 2nd & 3rd degree
• Fluid repletion using
Parkland formula
• Parkland Formula
• Fluid for the 1st 24hrs.=4x pt’s wt in kg.
x %BSA.
• Give 50% of fluids over
the 1st 8hrs, &
remaining 50% over the
following 16 hrs.
– Topical silver sulfadiazine,
mafenide