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Principle of emergency care Triage (French “trier”) (to sort, to choose) Sort patient into groups based on severity of health problems & immediacy of tx Mgt of priorities Levels of acuity Highest acuity Receive quickest eval, tx, prioritized resource utilization (Xrays, labs, CT scan) Three general approaches to emergency /disaster care Hospital triage Disaster triage Emergency medical services Hospital triage 3–tiered model triage (under usual conditions) Hospital triage: Emergent triage Urgent triage Non urgent triage Emergent triage Seen & treated immediately Poses immediate threat to life/ limb Ex: Critically injured Substernal chest pain (Unstable angina)
strain (tendons. muscles) Simple fxs Simple laceration/ soft tissue injuries Viral / “cold” symptoms .Active bleeding Shock Airway obstruction Urgent triage Immediate threat to life does not exist at the moment Major injuries that require immediate tx Reassessment done by Triage RN if MD not available within 30mins-1 hr Treated within 30mins-1 hr Ex: New onset of pneumonia with no RF Abd pain Renal colic Complex lacerations with no major bleeding Displaced fxs/ dislocations Hx seizure prior to ER Temp over 102 F (38 C) Non urgent triage Minor injuries or problems which do not pose threat to life or limb Does not require immediate tx Treated within 2-24hrs w/o up morbidity (clinical deterioration) Ex: Sprains (ligaments).
sprain/ strains. contusions. abrasions “walking wounded” Expectant (class IV / black tag) Expected & allowed to die. high cervical SCI. hemorrhagic shock Urgent (class II/ yellow tag) Needs tx w/in 30-2hrs Open fxs.Skin rashes Mass casualty / Disaster triage Triage under Mass casualty conditions (Disaster Triage) Disaster situation # of casualties exceed resource capabilities Emergent (class I / red tag) Airway compromise. dead Massive head trauma. extensive burns Psychological Reactions 2ndary to disaster Panic Hysteria Depression Emergency medical services Certifications for Emergency Nursing BCLS / BLS (Basic Cardiac Life Support) Noninvasive assessment & mgt skills for airway maintenance & CPR . large wounds Non urgent (class III/ green tag) Tx delayed >2 hrs Closed fxs.
special resuscitation (AED) Automatic External Defibrillator PALS (Pediatric Advanced Life Support) Neonatal & pedia resuscitation Certified Emergency Nurse (CERN) Validates core emergency nursing knowledge base Emergency medical services EMT( “E” medical technicians) BLS (Basic Life Support) certified Prerequisite to paramedics 200hrs training Paramedics ACLS ( Advanced Cardiac Life Support) certified >1K hrs training ER nurse ER doctor Principles of emergency nursing Principles of emergency nursing Triage Primary survey & resuscitation interventions 2ndary survey & resuscitation interventions Care of the ER patient Disposition Case management Patient / Family health teaching .ACLS (Advanced Cardiac Life Support) Invasive airway mgt skills. pharmacology & electrical tx.
Primary survey Initial assessment Rapid identification + intervention techniques To address most immediate life threats ABC + DE (used in trauma) Disability Exposure Priorities of Primary Survey Airway / cervical spine Breathing Circulation Disability Exposure Primary survey & resuscitation interventions Airway / cervical spine Patent airway Jaw thrust maneuver (cervical spine injury) Neutral neck alignment Check resp status Suction . abnormality . resp effort Chest wall trauma. O2 PRN GCS <8 = ET intubation + mech ventilation Breathing Assess breath sounds.
esp BP. responsive to Pain. responsive to Voice. Unresponsive) or GCS Exposure (trauma) Remove all clothing for accurate assessment Prevent hypothermia Blankets Heat lamps Infusion warm IVF 2ndary survey Done post patient stabilized Immediate threats to life had been addressed Comprehensive head to toe assessment To identify other injuries or med issues Care of ER patient Privacy Dignity Confidentiality of info HIPAA (Health Insurance Portability and Accountability Act 2003) .Prepare for chest compression PRN Primary survey & resuscitation interventions Circulation Monitor VS. pulse Vascular access w/ LARGE bore cath Direct pressure for external bleeding Disability (trauma) Monitor LOC AVPU (Alert.
public info officer Event resolution Deactivating “E” response plan Resume normal operations Debriefing . triage officer. TV flash alerts Hospital “E” preparedness: Personnel roles & responsibilities hosp incident commander. health insurance Patient / Family health teachings Discharge teachings Prevention Health teachings Mass casualty principles Principles of Mass casualty principles Triage System of notification/ activation of “E” preparedness group paging systems.Disposition Admitted to hospital Discharged to home w/ instruction for continued care. elder abuse) Info on community resources Low cost RX plan. ff up Case management Arrange appropriate referral & ff-up Disposition for homeless pts Safe environment for victims of violence (domestic. instant electronic based alert messages. medical command physician.
floor / unit RN.Promote effective coping strategies Review of staff & system performance Modifications for improvement Mass evacuation (hospital) Ambulatory 1st Wheelchair next Bed bound last Unit manager can authorize pt evacuation Common reasons for going to ER Chest pain Abd pain Headache Fever Common “Codes” used in the hospital setting Code blue Members (MD. ICU RN) Code pink Deactivated ONLY by head of security and dept unit manager Code gray Code red Deactivated ONLY by head of security Code black Bioterrorism / Bio Crisis Bomb threat . Resp therapist. Pharmacist.
“E” kit Contents Inside Outside Daily check Defibrillator Plastic lock with security # tag Suction apparatus O2 tank Stat pads Fire extinguisher P-A-S-S method Pull the pin Aim the spout Squeeze the handle .Rapid Response Team Same members as in code blue team Prevent “code blue” Mandated by JCAHO / JCI / The Joint Commission in 2001 Ex: Decreasing O2 sat Decreasing CBG/ FSBS despite interventions Worsening VS “gut feeling” that something wrong with patient but can’t pin point exactly what & why Crash cart “E” cart.
windows Appliances Fire wall door Safety preparedness manual Clinical pathways Mandated by JCAHO Care Pathways. Care Maps mgt tool based on evidence-based practice for specific group of pts with predictable clinical course Different medical emergencies shock cardiopulmonary emergencies neurological/neurosurgical emergencies abdominal emergencies genitourinary emergencies ocular emergencies . Integrated Care Pathways. towels Door .Sweep the fire DO NOT use in BIG fire Monthly inspection by the fire dept / security dept Check expiration date Label Color of foam Fire drill Q 6-12mons Search for fire Wet linens. Critical Pathways.
amphetamines Dehydration Lack of sleep Fatigue Obesity Strenuous exercise Burns ( all degrees) Seizures . ACE inhibitors. anticholinergics.musculoskeletal emergencies poisoning and overdoses environmental/temperature emergencies multiple system trauma Environmental/temperature “E” Heat stroke Heat exhaustion Hypothermia Frostbite High altitude Near drowning Snake bites Heat related illnessess Heat exhaustion Heat stroke Risks : Meds Beta blockers. diuretics.
arm pits.5 C (105 F) >= organ dysfunction>= death Risk factors: . use suncreen SPF >15 If no improvement in 30 mins>= seek medical attention Heat stroke Failure of heat regulatory mechanism Body temp exceeds 40. chest. legs & feet up 12-18 inches Constrictive clothing removed ORS / sports drink (Gatorade) if alert Cold packs ( neck. groin) Abundant blood supply Soak person in cool water Fan while spraying person’s skin Crushed Na tabs dissolved in adeq H20 Prevent GI s/s Prevent sun exposure (10a-4p). abd.Heat exhaustion Syndrome caused by dehydration during heat exposure over hrs-days Precursor to heat stroke Not true medical “E” s/s: Flu like s/s + diaphoresis + GI s/s Temp not significantly up (normal or subnormal) Moist clammy skin Heat exhaustion: Mgt Bedrest in cool place.
hot skin .8 C) Prevent hypothermia No ice immersion >=shivering Keep head . arm pits) Cold water immersion Wet body with tepid H20 + rapid fanning Stop cooling till temp drops to 102 F ( 38. shoulders elevated DO NOT give ASA / antipyretics VS monitoring Hydration Monitor for seizure Seek medical help ASAP Hypothermia Body temp is < 35 C (95 F) as a result to exposure to cold .5) Heat stroke: TX Patent airway Rapid cooling measures Ice packs (neck. groins. Neuro changes Presence of sweat DOES NOT rule presence of heat stroke Very high temp (>40.Strenuous physical activity/ wearing thick clothing in hot humid conditions Chronic exposure to hot humid weather s/s: Dry.
cheeks. ETOH. PVD Early s/s: White waxy areas on nose. ears High altitude illnesses Elevations > 5K ft >= O2 decreased >= hypoxia Acclimatization Compensation to high altitude 3 conditions resulting from high altitude Acute mountain sickness (AMS) High altitude cerebral edema (HACE) High altitude pulmo edema (HAPE) Acclimatization .TX: Monitoring ABC Rewarming Supportive Frost bite Cold-related injury that may or may not be associated with hypothermia Cause : Inadequate insulation against cold Skin exposed to cold Insufficient clothing Risk: Smokers.
O2 Carbonic anhydrase inhibitors (Acetazolamide<Diamox>) Bicarb diuresis>= metabolic acidosis>= up RR Dexamethasone Furosemide Decrease pulmo edema Keep warm .3300 ft Rest O2 Hosp tx: Patent airway.Compensation to high altitude >= up RR rate >= hypocapnia ( decreased C02) >= resp alkalosis >=limits further up in RR >= hypoxia >= pulmo constriction >= up pulmo artery pressure >= excrete excess bicarb (kidneys) (24-48hrs in hi altitude) >=ph to normal >= up RBC (up hgb concentration) High altitude illness : TX First aid: Descent to lower altitude areas 1600 ft.
food s/s: resp s/s. other agents (insect sting. never dive in shallow water No ETOH Enough H20 rescue equipment readily available ANAPHYLACTIC REACTION Acute systemic hypersensitivity reaction within few seconds/ minutes Ex : meds. button batteries) Acid (bowl cleaners. rust removers) TX: Offer 3 glasses of milk / water . fatigue persist for 2 wks (expected) Near drowning Recovery post submersion Leads to death by suffocation from submersion in the liquid medium (water) Prevention: No swimming alone Test H20 depth before diving head 1st. drop BP ( massive vasodilation) TX: patent airway epinephrine SQ injection ffd by antiH2 drug Poisoning Swallowed poisons (corrosive) Alkaline ( detergent.Cold>= up pulmo artery pressure Weakness . bleach. bees).
up HR. heparin. caffeine Up venom absorption Never LEAVE patient.to dilute poison Bring unused poison to hospital for identification Do not induce vomiting just keep on NPO *** if not sure of cause of poisoning = CALL poison Call Center Overdose Ipecac (Ipecacuanha plant) TX: Ipecac to induce vomiting EXCEPT in corrosive substances Gastric lavage Send contents to lab for toxicology test Activated Charcoal administration Snake bites Pit vipers (Crotalidae) most frequent poisonous snake bites (triangular head) Can cause multiple organ failure esp NEURO TX: immobilize injured part below the heart Cleanse cover wound DO NOT USE ice / tourniquet. bring snake to hosp Observe for 6 hrs Shock s/s: cool moist skin. delayed capillary refill . falling BP. corticosteroids during ACUTE stage (6-8 hrs) No ETOH .
inhalation (pulmo) . GI. metal objects. Decontamination team decontaminates the patients who were exposed Bio crisis agents Anthrax ( Bacillus anthracis) Cutaneous (direct contact). protective gear patients who were exposed are separated from others in emergency dept. windows Stay away from high powered voltage plants Bio Crisis: Bioterrorism Decontamination team wears special.TX : ABC Patent airway & maintain breathing Determine cause IVF & blood transfusion using LARGE bore cath Monitoring Lightning injuries Single lightning stroke= >1M volts High voltage= >1K volt Produce injury by: Direct striking Splashing nearby strike area Travel via ground (“step voltage) Prevention : (during thunder storm) Seek shelter No use phone Stay away from H20.
Ciprofloxacin SARS Cause:Coronavirus: N95 mask Bird flu (Avian influenza) Tamiflu Small pox Cause: virus Variola Mgt: Cidofovir Bioterrorism .Tx: Doxycycline .
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