Emergency Nursing Role of nurses..

1. Verify that the scene is safe and

secure
- “fast”, “quick”, “rapid” 2. Be an astute observer
- time is of essence 3. Information gathered must be
communicated
4. Record other pertinent
Emergency- any sudden illness or injury which is
information of the patient
perceived by the significant others and/or patient as 5. Provide explanation for omissions of
requiring immediate medical attention care (for purposes of law suits).
6. Record detailed triage notes
Emergency Nursing Triage notes:
How the patient was brought
 care given to situations needing immediate to the hospital (ambulatory,
medical interventions brought by private vehicle,
 care of individuals of all ages with conscious)
perceived or actual physical or emotional Interventions initiated by
alterations of health that are undiagnosed EMT-Basics
or that require further interventions Medications given by the
 It is episodic (at any time, not constant), EMT-Paramedics (advanced
primary (immediate, NO restorative or cardiac life support)
rehabilitative) and usually acute (patients  EMT-Intermediate
are wheeled out after care is given) (performs basic life
support and some
Scope of Emergency Nursing interventions in
advanced cardiac life
A- Ssessment support)
D- iagnosis
T- reatment 3. Patient and Family Education
E- valuation (for as long as the patient is Principle 3…’patient and family education is the
stable) responsibility of every ER nurse’
Role of nurses…
Principle of Emergency Medical Treatment 1. Provide effective, individualized
instruction re: home care
1. Communicating in Crisis 2. Identify learning needs
Principle 1…’patients need to know that their 3. Establish realistic goals
feelings are accepted and acknowledged by the 4. Allow for learning time
ER personnel 5. Evaluate the results
Role of nurses… 6. Document the instruction
1. Give verbal and nonverbal
2. Inform patients (what and why is Other Basic Principles in Emergency care
it to be done)
Physician’s responsibility- (1) 1. Provide for basic survival needs and
obtain informed consent, (2) comfort
explains any invasive procedures 2. Help survivors achieve restful and
to patient restorative sleep
3. Be aware of one’s own feelings 3. Provide privacy
4. Provide non-intrusive ordinary social
(self-assessment)
4. Talk with patients contact
5. Encourage patients to discuss 5. Address immediate physical problem
6. Assist in locating and verifying the
opinions (e.g. delivery of care)
6. Help patients verbalize personal safety of separated loved ones
frustrations and friends
7. Offer realistic hope 7. Help survivors take practical steps to
8. Be honest resume ordinary day to day life

2. Patient Assessment, Reporting and

Documentation Basic Legal Issues
Principle 2… ‘rapid, accurate initial patient
assessment and precise reporting and A. Consent (permission to care) to treatment
documentation, whether in the pre-hospital or 1. Expressed (verbal or/and writing)-freely
hospital settings are keys to effective patient and voluntary given
care’ 2. Implied-presumed consent
 3.Involuntary-patient refuses care and an desires regarding their
individual gives consent (e.g. SO) medical treatment in
4. Informed-given provided that proper circumstances in which
explanation has been done they are no longer able
3 Essential components of Informed to express informed
Consent: consent.
 The physician must c. Do not resuscitate order (DNR)
 Describe the procedure - Legal document signed
to be performed by the patient and his
 Explain the alternatives
physician, which states
available to the
that the patient has
procedure
terminal illness and
 Detail the risks of the
does not wish to prolong
procedure
When does an informed consent become valid? life through
 Legal age – 18 resuscitative efforts
 Mentally stable - Also called an advance
 Information communicated in the directive
language known to the consente

What are good Samaritan laws?

Emergency Doctrine (implied consent) - Laws which are passed in order to
encourage lay persons or all persons
- Implies that the client would have present in emergency situations without
consented to treatment if able, because fear of liability with regard to care given
the alternative would have been death or - E.g Broken ribs caused by inappropriate
disability performance of CPR by a nursing
- Provides and exemption to obtaining student=good Samaritan laws cannot be
informed consent before a procedure is to invoked
be done - E.g patient has incurred bruises (as long
as it is NOT a major
Consent Dilemmas complications=good Samaritan law can
be invoked)
1. Minors - Effect of help should not be graver than
Emancipated minors (economically the condition of the patient
independent, married)
2. Refusal to consent based on religious Patient Transfer Issues
Emergency Medical Treatment and Active
conviction
Labor Act (EMTALA)
General rule-patient can refuse care on
 (Before) Consolidated Omnibus
the ground of religious convictions
Budget Reconciliation Act (COBRA)
Exceptions- (1) social circumstances, (2)
 Laws governing patient with
court order e.g child who needs blood
regarding to dumping or transferring
transfusion of whom both parents are
to one hospital to another because of
Jehova’s witness, the court must have
inability to pay
the final say EMTALA Highlights
3. Refusal of treatment leaving against medical 1. All individuals
advice 2. To determine the existence of an
emergency medical condition, there
Patient self-determination Act (1991) must be: threat to life or limb, or
- Provides hospitalized patients with the ability to
severe pain, or active labor
decide regarding their wishes for termination or - Duty to provide AMS
continuation of life support (Appropriate Medical screening)-
E.g. whether patient is on an
a. Durable Power of Attorney
emergency situation
Attorney-in-fact (could be SO)
3. Hospitalized with specialized
- Things to be done are
capabilities must accept transfers if
the ones specified in
with capacity to treat
the document signed
4. Transfers require:
by a conscious patient  consent of patient
b. Living wills  accepting physician
- a written  accepting facility
statement/document  appropriate vehicle
detailing the patient’s  appropriate equipment
  qualified personnel
 records must accompany the
patient
Principle of Confidentiality
not entitled to spread/share
information to persons not
directly involve to the care of
patient
Exemptions:
- Public interest is at stake
- Criminal cases
- Consent of patient to reveal
information
- Sued for damages (content
of patient’s chart is the very
thing in issue)
* Case of support is not a
criminal case.
More of legal issues…
Documentation
Reportable conditions –report crimes to
appropriate agencies, conditions
mandated by laws, doctors and nurses
has equal responsibility
Note: report the condition even if you
don’t have consent from the doctor
Discharge instructions- written and oral
Physical evidence and chain of custody
- Bullets
- Blood specimens/blood samples
Note: patient should not be force to
undergo blood examinations (forcing
would mean assault); exemptions—
principle of confidentiality
Organ donation-brain death has been
pronounced by the doctor; signed a
legal consent
Roles in Emergency Nursing
1. Triage Nurse
2. Telephone Advice Nurse
3. Poison Control Specialist
4. Transport Nurses
5. Trauma Nurse Coordinator
6. Pediatric ED Nurse
7. Case Manager
8. EMS Liason
9. Nurse Practitioner
10. Clinical Nurse Specialist
General Responsibilities of Emergency Nurses
1. Works in an area staffed and equipped for
the reception and treatment of persons
with conditions requiring immediate
medical care, serious illness and trauma
2. Efficiently do A-P-I-E
Responsibility During Death and Dying
1. Provide ample opportunity to the patient and
family to be together
2. Allow presence of family members during
resuscitation
3. Provides religious support
4. Communicate honestly about the patient’s
condition
5. Encourage viewing the body in instances of
sudden death or trauma
6. Because preservation of legal evidence is often
important in sudden death, SO are advised
beforehand of the various tubes and devices
present.
7. Determine client’s wishes re: organ donation
8. May provide a follow-up telephone call to SO not
present re: their questions or concerns
9. Make referrals to support groups
Disaster Nursing
Disaster- any situation, natural or manmade
that produces an immediate patient load
greater than the normal ED can handle
Mass Casualty Incident
- Any time an incident or disease occurs
that leaves many people ill or injured
- Can be caused by natural ( i.e.
earthquakes, floods) or accidental or
intentional disasters (terrorist attacks,
sarin gas release)
Classification of MCI
1. Level I- involves more than 100
patients
2. Level II- involves greater than 50 but
not more than 100 patients
3. Level III- greater than 25 but not
more than 50
4. Level IV-greater than 10 but not more
than 25
5. Level V-an incident involving no more
than 10 patients
6. MCI (contamination)
- an MCI of any level, which includes
or has the potential for biological,
chemical or radiological
contamination
Note:
Common on all levels:
-Having a great impact on
the emergency department and going
beyond the capacity to treat
Categories of Disaster:
1. Class A (all require response by hospital
disaster team); bigger impact
- Natural disasters: earthquakes, floods,
tornadoes
- External disasters/medical emergencies:
chemical exposure, epidemic of disease,
nuclear fall-out
2. Class B
- Internal disasters/medical emergencies
that may require response by hospital
disaster team or specially created crisis
team
 - Death of key personnel (pope, president), Internal: within personnel
large scale poisoning, death of religious External: one hospital facility
personnel to another
3. Class C 3. Resources-staff
- Internal disasters/non-medical Disaster team must know
emergencies how to contact the resource
- May require response by hospital disaster staff
team or specially created crisis team 4. Security/ Safety –ensure the
- Bomb threats, strikes, criminal activity scene is safe
(rape, kidnapping, shooting) 5. Coordination with Public Agencies
6. Documentation
7. Public relations- officials
Phases /Stages of Disaster 8. Critical Incident Stress Debriefing
1. Pre-impact/preparedness - NOT a form of
- Occurs prior to the onset of the disaster psychotherapy
- Not all type of disasters has the pre- - Done to mitigate
impact phase (lessen) the
2. Impact/response occurrences of PTSD
- Disaster occurs, continuing to - Group process
immediately following disaster (brief or involving persons who
lasing to few hours) are victims/ survivors
- Inventory and rescue period
of an overwhelming
- Assessment of the extent of the losses,
event or trauma
planning on how to use the resources left
including those who
and how to rescue the victims
may have been
3. Post-impact/recovery
- Majority of rescue operations impacted by the
- Remedy and recovery period trauma
- Lengthy phase and may last for years - Aims to prevent the
1. Honeymoon phase-feelings of subsequent
euphoria development of PTSD
2. Disillusionment-anger, - Provides avenue for
disappointment the patient to express
3. Reconstruction phase-acceptance of feelings, coping
loss, coping stress, rebuilding mechanisms, lessons
learned
DISASTER PLAN
Disaster Management Principles
 A predefined set of instructions
1. Prevent occurrence
for a community’s emergency
2. Minimize casualties
responders 3. Prevent further casualties
 Features of a good disaster plan 4. Rescue the injured
1. Written 5. Provide first aid
2. Well-publicized 6. Evaluate the injury
3. Realistic 7. Provide definitive care
4. Rehearsed 8. Facilitate reconstruction and recovery
The responsibility of nursing care
vary (depends on situation or
Key components of Disaster Plan
1. Patient care available resources)
System on how to receive May include triage, patient care,
and distribute patients equipment, directing others,
whether incoming/evacuated recording, transportation
patients
What are the psychological and emotional
Triage procedure
responses to emergency and disaster?
Provides care for the
 Immediate reactions (anxiety, frustration,
greatest number (NOT
anger, physical symptoms)
applicable in non-disaster  Delayed reactions (feelings of loss, grief and
triage) guilt, flashbacks, nightmares)
Avoid treating ambulatory
patients as dependent Nursing Interventions:
patients A. For immediate stress reaction
Pre-assignment with regard 1. 5 minutes break at least every hour
to responsibillity 2. Monitor for shaking, trembling, loss
2. Communication of coordination
 3. Provide rest area
4. Rotate frontline personnel
B. For delayed reaction
1. 2 mandatory debriefing sessions
2. Encourage liberal leave policy
3. Begin stress management class
Triage System
- “trier” to sort
Triage Nursing
- care given to patients to ensure that those
requiring immediate attention for life
threatening emergencies receive it
- first used during Napoleonic war
Primary goal of an effective triage:
- RAPID identification of patients with urgent,
life threatening conditions
Complementary goals of an effective
triage:
1. Prioritizing care needs for all patients
2. Regulating patient flow through ED
3. Determining the most appropriate area for
treatment- the ED or an outside primary care
area
Note:
 The triage models in disaster
those patients who are severely injured and are
unlikely to survive despite medical attention
would receive the lowest priority triage.
(greatest good for the greatest number)
 The triage model in emergency nursing
Priority is those patients who are in severe
condition
Triage Models
Triage tags – refers to color coding, identification to
each injured patient; for priority, save time
A. Non-disaster Triage models
-i.e. models for individual triage: traffic
director; spot check; comprehensive
Purpose: to provide best care for each individual
patient.
A.1. Models for individual triage
a.1.1. Traffic director
 categories: emergent (life-threatening
and major illness) & non-urgent
(treatment can be delayed)
 sometimes done by unlicensed person
 assessment consist of chief complaints
 disadvantage: emergent patients are
disregards due to mixed with
nonemergent patients
 sort to acute care or waiting room
 no further evaluation by triage (re-
triage)
 when used
1. low daily census
2. no waiting period for patients to
see licensed health care
professional
a.1.2. Spot Check
 categories: emergent (life
threatening), urgent (major illness),
delayed (patient may be treated or
treatment may be delayed for more
than 20 hours)
 assessment by RN or MD
 no planned reevaluation
 when used
1. high patient census
2. waiting period is anticipated
a.1.3. Comprehensive Triage
 categories: life-saving (multiple
trauma; assessment is continuous);
stable but urgent (sickle-cell,
fractures; every 15 min); stable but
non-urgent (small laceration; every
30 min); stable, may wait indefinitely
for care (abrasion, impetigo; every
60 min)
 assessment done by RN
 patients who remain in the waiting
room are re-assessed every 15-
60min depending on severity of
illness or injury
 when used
1. high patient census
2. treatment space limited
B. Multi-casualty/Disaster Triage Model
Purposes: to provide the most effective care for the
greatest number of patients
Sample models for Multi-casualty/disaster triage model
b.1.1. Simple
 categories: immediate care
(multiple traumas, inhalation
injuries); delayed care (extremity
fractures, minor burns)
b.1.2. Military
 5 level triage system
Categories
1. Immediate (I)
 triage tag: red
 life-threatening injuries that
probably survivable with
immediate treatment
 i.e. tension pneumothorax,
respiratory distress, airway
injuries, shock
2. Delayed (II)
 triage tag: yellow
  treatment may be postponed
without loss of life
 i.e. minor extremity fractures,
lacerations with hemorrhages
controlled
3. Minimal
 triage tag: green
 little or no professional care
required
 ambulatory, can self-treat or
seek alternative medical
attention independently
 i.e. minor lacerations, abrasions
4. Expectant (0)
 triage tag: black
 have lethal injuries and will die
despite treatment
 i.e. devastating head injuries,
destruction of all vital organs
5. No apparent injuries
 triage tag: white
b.1.3. Disaster ((4 level triage))
* Categories
1. Emergent
 triage tag: red
 critical life threatening; patient is
expected to live; shock; airway
problems
2. urgent
 triage tag: yellow
 major illness/injuries should be
treated within 20min – 2 hours;
i.e. open fractures, chest wounds
3. non-urgent
 triage tag: green
 minor injuries, usually
ambulatory; are maybe delayed
for more than 2 hours; i.e.,
closed fractures, sprains
4. Dead or with impending death –
 Triage tag: black
 slim to no chance of survival;
shouldn’t take priority over
salvageable patient; i.e., massive
trauma, extensive 3rd degree
burns
Other Triage Models
1.) START ((simple triage and rapid
treatment))
 can be performed by lightly trained
lay & emergency personnel in
emergencies
 physiologic parameters: RPM
R – respiration
P – pulse
M – mental
Categories:
1. Priority (0)
 tagged as black; patients not
breathing and have no pulse
 evacuation: leave where they fell
 attempt to open airway to assess
respiration and pulse
2. Priority (1) – immediate
 tagged as red; patients who have
 R - > 30 cpm
 P – absent radial pulse
 M – altered
 used in evacuation: by MEDEVAC
or ambulance
3. Priority (2) delayed
 tagged as yellow
 R < 30 cpm
 P – have radial pulses present
 M – alert
 evacuation: delayed until all
immediate persons have been
transported
4. Priority (3) – minor
 tagged as green
 walking wounded
 evacuation: not evacuated until all
immediate & delayed persons have
been evacuated
2.) Advanced triage-similar to
military
- implemented by skilled nurses
* Categories:
1. Expectant (black)
 severely injured with life threatening
medical crisis unlikely to survive
given with care available
 should be taken to a holding area
and given pain killers
 cardiac arrest; septic shock
 not used in ER
 Advance cardiac life support
2. Immediate (red)
 immediate surgery, “cannot wait” but
likely to survive (i.e. tension
pneumothorax)
3. Observation (yellow)
 stable for the moment but requires
watching and frequent re-triage (i.e.
laceration with controlled
hemorrhage)
4. Wait (green)
 walking wounded
 required doctors care in several
hours or days but not immediately,
maybe told to go home and come
back home within the next day
 i.e. broken bones without compound
fractures, soft tissue injuries
 5. Dismiss (white) e. Hypovolemic
 walking wounded with minor injury, f. Other cardiac causes
do not require doctor’s care
 i.e. small cuts, scrapes
a. Metabolic causes
a.1. hypoglycemia
s/s: unconsciousness,
STEPS IN TRIAGE tachydysrhythmias, seizures,
1. Primary survey aspiration, weakness
 consist of ABC mgt: 50% dextrose
 consist of ABCD proposed by ENA a.2. hyperkalemia
s/s: ECG (prolonged Q-T interval;
A – Airway peaked T wave; wide QRS complexes
B – Breathing mgt: calcium chloride; sodium
C – Circulation bicarbonate
D – Disability (neurologic assessment status)
E – Exposure or environment (coldness or hotness) P – atrial contraction
QRS – ventricles contract to pump out blood
AVPU (a very practical use) ST – time when the ventricles end of
contraction and beginning of the T wave
A – alert T – time of repolarization
V – voice
P – pain (response) b. Drug- Induced
U – unconscious/unresponsive b.1. TCA’s (e.g. amitryptyline)
s/s: tachydsyrhythmias
2. Secondary survey mgt: sodium bicarbonate – alkylating
 follows primary survey and is very brief agent
 use SAMPLE (S – signs and symptoms; b.2. Narcotics
A – allergies; M – medications; P – s/s: bradydysrhythmias; heart
pertinent past history; L – last oral blocks
intake, E – events leading to problem) mgt: naloxone (Narcan)
- AMPLE b.3. Propanolol
- a crash plan s/s: cardiac: bradydysrhythmias;
respiratory: bronchospasm; metab:
A – airway/breathing hypoglycemia
C – cardiovascular mgt: for bradydysrhythmias: Isuprel,
R – respiratory Atropine
A – abdominal for bronchospasm: aminophylline
S – spinal for hypoglycemia: 50%dextrose
H – head & EENT
P – pelvis c. Pulmonary
L – legs c.1. asthma
A – arteries (pulses) s/s: severe bronchospasm,
N – nerves tachydysrhythmias
mgt: endotracheal intubation and
- head to toe assessment : 90 seconds ventilatory support
* Focused Assessment
- diagnostic procedures c.2 pulmonary embolus
1. ECG s/s: pleuritic chest pain, SOB,
2. lab studies tachydsyrhythmias
3. radiology mgt: good ventilatory support

c.3. Tension pneumothorax

CARDIOPULMONARY s/s: distended neck veins, tracheal
deviation, asymmetric chest

ARREST expansion
mgt: needle thoracotomy, chest tube

- with patients heart, circulation, and respiration d. Neurogenic

suddenly cease d.1. increased ICP from any causes
Causes: s/s: dilated pupils, decerebrate-
a. Metabolic decorticate posturing, dysrhythmias
a.1. hypoglycemia mgt: steroids, diuretic agents,
a.2. hyperkalemia surgery
i.e Mannitol: MIO monitoring; soluset
b. Drug-induced used, risk for cardiopulmonary edema
c. Pulmonary
d. Neurologic
 e. Hypovolemia
e.1 anything that causes volume loss of Deliver 1 shock using AED. Cannot perform
blood defibrillation.
s/s: tachycardia, decreasing bp, cool C-L-E-A-R.
clammy skin -Nobody is touching the patient. Repeat CPR for 5
mgt: IV fluids, PASG (Pneumatic -No metallic objects. cycles until ACLS
anti-shock garment), shock position -Not on wet ground. arrives.
PASG is contraindicated in the ff:
 Cardiopulmonary edema Repeat CPR for 5 cycles
 Severe chest injuries even
patient is in shock  Shockable –refers to dysrhythmias which can
 Pregnant woman: do not be subjected to defibrillation (electrical activity
cuff abdomen of the heart is present
f. Other cardiac causes  BLS can operate automated external
defibrillator
f.1 Pericardial tamponade
 Ventricular tachycardia> 100 bpm
s/s: distended neck veins, decrease BP,
bradydysrhythmias, widening pulse pressure
mgt: IV fluids, atropine, Isuprel, thoracotomy
Nitroglycerine patches-dilates the vessel to encourage
blood to stay in the venous system
-less cardiac rate
Chain of survival Use gloved hand in detaching the plastic to prevent
headache.
1. Early access
2. Early CPR
3. Early defibrillation It will burst due to the electrical
4. Early advance care activity being delivered

Position of patches:
Basic Life support  Anterolateral position-most common
 Anterior and posterior
Survey the scene
(Scene is safe, crowd controlled)

Introduce self

Activate the EMS (Emergency Medical Services)

-Call the ambulance

Check for consciousness

L-ook
L-isten
F-eel

Hey, hey are you ok?

Give 2 initial breaths. Continue on LLF.

Check pulse. Brachial-infant; carotid-adult

If pulse and respiration is absent, do 30 cycles of chest

compressions: 2 breaths

Wait for the automated external defibrillator

AED

Check if shockable Check if not

shockable

Ventricular tachycardia, Asystole also called

ventricular defibrillation ventricular stand still,
pulseless electrical
activity (no blood to be
pumped)
 CPR (5 cycles)
Wait AED

Advanced Cardiac Life Support (ACLS) CPR (5 cycles)

If
AED (1 shock)

AED (1 shock) shockable CPR (5 Cycles)

CPR (5 Cycles) Administer the ff

antiarrhythmic drugs
Administer  Amiodarone
 Epinephrine (1 mg/IV)  Lidocaine
 Vasopressin (40 IU IV)  Magnesium
- If epinephrine is
not the choice

If shockable

 Administer
1 shock
(AED)

 Repeat CPR
Pulseless-no respiration for 5 cycles

 Give CPR for 5 cycles

Deliver oxygen If not shockable  Administration of the ff:

If shockable 1. Epinephrine (1
mg/IV) 3-5 minutes
AED 2. Vasopressin 40
Monitor using ECG 12 -lead
IU/IV
3. Atropine 1 mg/IV in
3 doses

If not shockable

 Give CPR for 5 cycles

 Administration of the ff:

1. Epinephrine (1
mg/IV) 3-5 minutes
2. Vasopressin 40
IU/IV
3. Atropine 1 mg/IV in
3 doses
Difference between BLS and ACLS (adrenalin)  Sympathomimetic drugs
- administration of drugs 5. Isoproterenol
0-4 min brain damage not likely (Isuprel)  Sympathomimetic drugs
4-6 min brain damage is probable 6. Lidocaine
6-10 min irreversible brain damage is possible (xylocaine)  Category 1B
More than 10 min irreversible brain damage is certain 7. Procainamide antidysrhythmias
(pronestyl)  Category 1A
8. Sodium Bicarbonate antidysrhythmias
Contraindication in Defibrillation  Electrolyte , alkylating
9. Verapamil (Calan, agent in metabolic
1. Less than 1 year old (infant’s heart is normal, isoptin) acidosis
therefore the electrical activity is normal)—  Calcium channel
respiratory problems brought about by Foreign blocker, category 4
A Body Obstruction and drowning are common antidysrhythmias
causes among this age
2. If electrical activity is normal, no defibrillation
should be given. Commonly Used Parental Vasoactive
3. Patients with severe traumatic chest injuries
4. Hypothermic-no to defibrillation, warm the
Drug
patient first before applying defibrillation

Drugs Classifications
Cardioversion
 Synchronous electrical countershock timed to 1. Esmolol  Antidysrhythmias,
coincide with the QRS (brevibloc) ACE inhibitors
 Not delivered on the T (repolarization) wave 2. Calcium chloride  Electrolytes
(compromised delivery of energy) 3. Diazoxide  Antihypertensive drug
(hyperstat)
Differences: 4. Diltiazem  Calcium channel
(cardizem) blocker
5. Dobutamine  Sympathomimetic
Cardioversion Defibrillation
(dobutrex) drugs
6. Dopamine  Sympathomimetic
-set in synchronous -set in
(Intropin, drugs
mode unsynchronous Dopastat)
-sedate patient if mode
conscious -patient is
-hemodynamically hemodynamically Other Drugs in Cardiac Emergencies
unstable stable
Drugs Classifications

1. Enalapril  ACE inhibitor

Nursing Responsibility for Cardioversion:
(Vasotec)
1. Monitor V/S, LOC and cardiac rhythm
2. Labetalol  Alpha-adrenergic
frequently until patient is hemodynamically
(Normodyne) blocker
stable and returns to pre-orientation LOC
3. Nitroglycerine  Vasodilator
(Tridil)
Complications of Cardioversion:
4. Nitroprusside  Vasodilator;
 Asystole
(Nipride) antihypertensives
 PVC’s (Premature ventricular contractions)
5. Norepinephrine  Vasopressor;
 Ventricular tachycardia
(levophed) adrenergic
 Ventricular fibrillation
6. Propanolol  Beta blockers
 Return to atrial fibrillation or atrial flutter
(Inderal)

Drugs Commonly Used in Cardiopulmonary

Resuscitation Morphine sulfate: emergency drug of MI

-reduces the preload thus decreasing the

Drugs Classifications
myocardial oxygen demand; relieves pain
1. Adenosine  Antiarrhythmias
Phases of MI:
(Adenocard)
2. Atropine  Anticholinergic;
A. Ischemic phase- myocardial repolarization is
parasympathomimetic
altered and delayed causing the T wave to
3. Bretylium (bretylol)
invert
 Category 3
B. Injury phase-causes ST segment changes
antidysrhythmias
-ST segment rises at least 1 mm
4. Epinephrine measuring 0.08 seconds. If the myocardial
 injury is on the endocardial surface, the ST
segment is depressed 1 mm or more at least
0.08 seconds
C. Infarction-abnormal Q wave is 0.04 seconds or
longer
(Smeltzer & Bare, 2004, p. 726)
shock
-state of inadequate perfusion and oxygenation to vital
organs and tissues throughout the body
Vital Organs Affected by shock:
 Brain
 Heart
 Kidneys
 Liver
4 Stages of Shock:
1. Initial –cellular level
- increase anaerobic metabolism;
decrease aerobic metabolism
- Increase lactic acid production= pain
- Decrease cardiac output
2. Compensatory
a. Renin-angiotension system
b. Sympathetic
- Release epinephrine (vasoconstriction)
c. Release of ADH (posterior pituitary gland)
d. Intracellular fluid shifts
3. Progressive
4. Refractory (Irreversible)
Types of Shock:
1. Hypovolemic shock
-caused by a decrease in circulating volume
greater than 15 %
-s/s: initial stage: pain, tachycardia, skin dry
and slightly moist, ABG’s normal
Compensatory stage: anxious,
hypotension, cool, clammy skin, may
have metabolic acidosis
Progressive: confused, restless, agitated,
profound hypotension, cardiac
dysrhythmias, skin pale, no purposeful
movement
Irreversible: severe hypotension,
tachypnea with shallow depth, profound
metabolic acidosis, comatose
2. Cardiogenic
- Caused by abnormal cardiac functioning or
pump failure
- s/s: restless, agitated, hypotension,
tachycardia with weak thread pulse, decreased
pulse pressure, skin cool and moist, JVD
3. Obstructive
-results from the inability of the ventricles of
the heart to fill or empty appropriately because
of an obstruction in the blood flow from the
heart
-s/s: anxiety, hypotension, JVD, pallor,
diminished or absent breath sounds, tracheal
deviation
4. Distributive
a. Anaphylactic shock-results from an
overwhelming immune response to the
presence of an allergen or antigen
s/s: marked restlessness, difficulty
swallowing or severe itching, hypotension
tachycardia
b. Septic shock-associated with endotoxic
release of gram negative bacteria in the
blood stream
s/s: decreased BP, or normal BP with
widened pulse pressure, tachycardia,
hyperventilation, positive cultures
c. Neurogenic shock-occurs as a result of
decreased sympathetic control of
vasomotor responses
s/s: hypotension, bradycardia followed by
tachycardia, pallor, decreased to absent
urinary output.
Emergency Care Steps For Shock:
1. Maintain an open airway and assess respirate
2. If with adequate breathing: apply high
concentration oxygen by nonrebreather mask.
3. Assist ventilation or perform CPR if necessary
4. Control bleeding
5. Apply and inflate the PASG
6. If with possibility of spine injury: elevate the legs
8-12 inches
7. Splint any suspected bone injuries or joint injuries
en route to the hospital. If in shock, place the body
on a spine board.
8. Prevent loss of body heat
9. Transport patient immediately.
10. If patient is conscious, speak calmly, and
reassuringly throughout the assessment, care and
transport
General Treatment Measures of Shock:
1. Follow ABC guidelines
2. Supine position with spinal alignment
maintained
3. Airway should be secured, protected and
supplemental oxygen should be initiated
through the appropriate delivery device
dependent on the client’s overall assessment.
4. Initiate an IV access
5. Initiate continuous cardiac and Sa O2
monitoring and prepare doe frequent, repetitive
vital sign assessments
6. Maintain stabilization of all deformities and
prevent hypothermia
7. Place an indwelling cath
8. Administer sympathomimetic drugs as ordered