ERDN NOTES

Four Issue in Emergency Nursing

 Consent and Privacy:
o Statement of Privacy Policy
o Invasives
o Transfer
 Protect Personal Identity
 Protect Private Parts
 Protect During Procedures
 Exposure:
o Diseases
o Organisms
o Chemicals (Gases and Radiation)
 Fitted with HEPA-Filtered Mask
 Violence:
o Violent Situations Encountered
o Injuries or Other Emergencies
o Substance Abuse
o Emotions
 Precautions: Handcuff MR. GGSS
 Handcuff is never released
 Mask (protect you from biting/spitting)
 Restraints (last resort)
 Grabbed Items Removed
 Guard Present
 Safety Course – Exit route
 Silent Code
 Gun Fire: Whose safety is your priority?
 SELF
 Holistic Care
5 Steps in Helping Family in Coping with SUDDEN DEATH
 Provide Private Room
 Communicate:
o Reassure
o Avoid Euphemism
o Care
o No Sedation
o Support
 View the Body
 Touch: Let the family touch the body
o Faster acceptance
 Spend Time with the Family
Emergency Department’s most common sentinel event – Unanticipated events
 Errors (Drugs)
 Delays (Care)
o Compassion Fatigue – Burn Out
 Exposure – Suffering and Injury
  Energy – Expended Everyday
o CISM: Critical Incident Stress Management
 Approach to preventing and treating the emotional trauma that can affect
emergency responders.
 Defusing – Immediately
 Debriefing – 1 – 10 Days
 Further Follow Up – Persistent negative symptoms
Emergency Nursing Principles:Care rendered without delay.
 Triage: “Trier” – To Sort: Assessment of patients to know management priorities.
o Emergent: Life Threatening
o Urgent: Serious but not immediately life-threatening
o Non Urgent: Episodic illness
o Types of Triage:
 ESI (Emergency Severity Index)
 Level 1: Patient requires immediate lifesaving intervention
 Level 2: Patient is in a high-risk situation, is disoriented, in severe pain, or vitals
are in danger.
 Level 3: If multiple resources are required to stabilize the patient, but vitals are
not in the danger zone.
 Level 4: If one resources is required to stabilize the patient.
 Level 5: If patient does not require any resources to be stabilized.
 CTAS (Canadian Triage and Acuity Scale)
 ITS (International Triage Scale)
 Chinese 4-Level and 3 District Triage Standard
 MTS (Manchester Triage System)
o Triage ED vs Field:
 Routine Triage: Directs resources to “most critical” (regardless of potential outcome)
 Field Triage: Scarce resources must be used to benefit the “most people” possible
 Utilitarian – Teleology
Disaster Nursing
 Disasters to Mass Casualties
o Terrorism
o Toxic Substance Spills
o Natural Disaster
o Crashers
o Outbreaks
o Warfare
 CDC – Core Competency
o Chain of Command
o Activating Response Plan
o Role
 NATO (North Atlantic Treaty Org) Triage System
o Level:
 Immediate – Red
 Criteria:
o Life Threatening
o Survivable
o Minimal Intervention
  Sucking Chest Wound
 Airway Obstruction
 Shock
 Hemothorax
 Asphyxia
 Long bone open fracture
 Amputation
 Burn 2nd to 3rd degree (15 – 40%)
 Unstable chest/abdominal wound
 Delayed – Yellow
 Criteria:
o Significant Injuries
o No Life or Limb Threat
o Can wait for HOURS
 Stable Abdominal Wounds
 Maxillo-Facial Injuries
 Eye and CNS Injuries
 Vascular Injuries
 GUT Disruption
 Soft Tissue Injuries
 Fracture -> Fixation
 Minimal – Green
 Criteria:
o Minor Injuries
o Removed
o Hours to Days
 Fracture “Upper Extremities”
 Burn Minor
 Injury that are minor
 Psychological and Behavioral problems
 Expectant – Black
 Criteria:
o Extensive Injuries
o Survival Unlikely
o Separated
o Comfort
 High SCI Injury (C3 to C4)
 Unresponsive with Penetrating Head Wound
 Multiple Organ Injury
 Agonal Respiration
 No PR, No BP
 Fixed/Dilated Pupils
 Multiple System Failure
 Burn 2nd to 3rd degree > 60%
 Seizure/Vomiting within 24 hours after radiation
Triage Systems
 Salt Triage:
o Sort
o Assess
o Life Saving Intervention
o Treatment/Transport
 Start Triage: 30 secs – 1 min.
o Simple Triage and Rapid Treatment
 Reverse Triage: Priority: Fewer Damages and Minor Injuries
o Resources Limited
o Return People ASAP (Help Other People)
 Military Triage: Treat and Return more injured soldiers to the battlefield.
o Treatment Codes: T1 , T2, T3, T4 and Dead.
o Priority Codes: P1, P2, P3 and P-Hold
Primary Survey:
 What: Assessment of patient triaged as
 Who: Emergent + Resuscitative Patient
 How: Focus on Life Stabilization
o Airway
 Can’t speak, breathe, lie flat
 Coughing difficulty
 Choking universal distress sign
 Confusion (anxiety, restlessness)
 Cacophony (stridor)
 Cyanosis
 Consciousness Loss
 Partial Obstruction: When patient can breathe and cough spontaneously.
o The victim is encouraged to cough forcibly.
 Complete Airway Obstruction: 3 – 5 mins is all it takes for patient to have
complete brain damage or death.
o Cyanosis
o Stridor
o Increased Dyspnea
o Weak Cough
 Open the Airway:
o Position: Head Tilt-Chin Lift Maneuver (Without Trauma) or Jaw Thrust
Maneuver (With Trauma)
 Protect Cervical Spine
 Look Listen and Feel
o Insertion: Oropharyngeal Airway
 Measure: Lip to Ear
 Position
 Open the Mouth
 Insert: Upwards
 Rotate: 180 Degree
 Alternative: Hold tongue with a tongue blade and insert
directly, no rotation.
 In the case of potential facial trauma or basal skull
fracture, the nasopharyngeal airway should not be used
because it could enter the brain.
o Cricothyroidotomy:
 Opening of Cricothyroid Membrane
 Used when ETT not possible.
 Replaced with Tracheostomy Tube.
o Breathing
 Assess Lungs Using:
 Absent Breath Sounds (Diminished)
 Chest Wound (Open)
 Difficulty Giving Artificial Breaths
 Manage Breathing Problems:
 Drain: Chest Tube
 Occlude: Sucking Wound
 Assist: Airway or Ventilatory
o Circulation
 Shock: Decreased tissue perfusion
 Distributive Shock: Massive Vasodilation
o Anaphylactic, Septic, and Neurogenic
 Obstructive Shock: Heart Filling
o Massive Pulmonary Embolism, Tension Pneumothorax, and Pulmonary
Edema
 Cardiogenic Shock: Heart Pumping
o Heart Failure
 Hypovolemic Shock:
o Dehydration and Hemorrhage
o Assess:
 Delayed CRT
 Oliguria
 Cool Moist Skin
 Hypo-Tachy-Tachy
o Management:
 Drip (Fluid Replacement)
 Large Bore IV Catheters (G14 – G18)
 Blood Sample
 Replacement Fluids (Crystalloids – Fluid and Electrolytes)
 Infusion Rate: Severity of Blood Loss and clinical evidence
of hypovolemia
o BT given via warmer
o Large Amounts of Refrigerated Blood
 Core Cooling
 Coagulopathy
 Cardiac Arrest
 Occlude (Control External Bleeding)
 Pressure
 Immobilize
 Elevate
 o Last Resort: Torniquet – Put “T” on the forehead,
location, and time.
o Definitive: Surgery
 Control Internal Bleeding
 Plasma, Packed RBC, and Platelets
 Pharmacologic
 Supine and Monitor: Modified Trendelenburg
 Surgery
o Disability
 GCS:
 Eye Opening Response: 4
 Verbal Response: 5
 Motor Response: 6
 AVPU:
 Alert
 Verbal Stimuli
 Painful Stimuli
 Unresponsive
o Exposure:
 Undress the patient quickly but gently so that any wounds or areas of injury are
identified.
Secondary Survey
 Data/Details: Complete History Taking
 Discover (head-to-toe): Complete Vital Sign
 Diagnostics (tests)
 Devices (monitoring)
 Debridement and Splint (fractures)
 Dressing (wound management)
o Hair: Leave Them (Clipped if needed)
o Agents:
 PNSS
 Polymer Agent
 Povidone: Should not be allowed to get deep into the wound without thorough rinsing
because it destroys exposed and healthy tissues.
Trauma: Unintentional or Intentional wound or injury inflicted on the body.
 Multiple Trauma: Caused by a single catastrophic event that causes life-threatening injuries to at least
two distinct organs or organ systems.
o Abdominal Penetrating Trauma:
 Dressing – moist warm if evisceration
 Do Not Feed
 Decompress
o Blunt Trauma: Head, Chest, and Abdomen
 ABCDE
 Cervical Collar
 Logroll
 Stretcher
o Crush Injuries: Caught between opposing forces
 ABCDE (Shock, SCI)
  Acute Kidney Injury
 Classic Triad of Rhabdomyolysis: Toxic Syndrome caused by widespread skeletal
muscle injuries – myoglobin – myoglobinuria = AKI
o Dark Urine
o Cramps
o Myalgia
 Diagnostic Test: Serum Creatinine Kinase
 Resuscitation: Fix the Injuries = Decreased Serum Lactic Acid =
Effective Resuscitation
 Acute Tubular Necrolysis
 Quality and Safety Nursing Alert
o Left Shoulder Pain: Splenic Rupture
o Right Shoulder Pain: Lacerated Liver
Non-Fatal Drowning: Survival at least 24 hours after submersion that caused Respiratory Arrest
 “Start” Hypoxemia – Acidosis – Cerebral Hypoxia – Loss of Consciousness – Respiratory Arrest – Passive
Entry of Water
 Risk Factors:
o Age: Below 5 and Above 85
o Alcohol
o Inability to Swim
o Injury
o Temp Low
o Tired
 Common Place: Pools, Lakes, and Bathtub
o Why Emergency:
 Hypoxemia – Oxygenation – Hyperbaric Chamber
 Acidosis – Sodium Bicarbonate
 Hypothermia – Below 35-degree Core Temperature (Thermisor)
 Bladder
 Esophagus
 Rectal
 ARDS
 Freshwater = Surfactant Loss
 Salt Water = Pulmonary Edema
Decompression Sickness: Formation of nitrogen bubbles that occur with rapid changes in atmospheric
pressure.
 Risk Factors:
o Diving (Lake/Ocean Diving)
o High Altitude Flying
o Flying in Aircraft within 24 hours after diving
 WOF:
o Numbness
o Hypesthesia
o Extremity or Joint Pain
o ROM Loss
o Stroke or SCI Like = Air Embolism
 Management:
o ABCDE – O2: Hyperbaric Chamber/IVF: Lactated Ringer
 o Air Embolism: Trendelenburg with Left Lateral
o Altitude Low: < 300 meters
o Antibiotics: Aspiration
Animal & Human Bites:
 Non-Venomous:
o Dog: 80 – 90% Death caused by non-venomous bite.
 Rabies 100% Mortality Rate
o Cat: Pasteurella Infection
o Human: Sexual Assault or Rape
 Snake Bites: 5% Mortality
o US: Crotalidae – Pit Vipers, Water Moccasins, Copperheads, Rattlesnakes
o PH: Russell’s Vipers, Hump-Nosed Pit Vipers and Sea Snakes
 Common Site: Upper Extremities
 Victim: Children
 During: Day
o Management:
 Vasopressors
 IV Fluid
 Anti-Venin: Manufactured from venom of snake to assist immune system response.
 Don’t CHIT:
o Corticosteroids (After Anti-Venin)
o Heparin
o Ice
o Torniquets
 When: 4 – 12 Hours After Bite
 Name: Crotalidae Polyvalent Immune Fab Antivenom (FabAV or CroFab)
 Dose: Severity, Symptoms – More than 10 Vials – Serum Sickness
 After Negative Sensitivity Test: None
 Pre-Med: Antihistamine
 WOF: Serum Sickness
o Prevention:
 Buffer Zone
 Education
 Sticks
 Toilets. Tucked Mosquito Net
 Protective Clothes
 Lighting
 Sleeping Area Separate from Foods
Carbon Monoxide Poisoning
o 200 Times Faster to Bind in Hemoglobin than Oxygen.
 Seems Like: Alcohol Intoxicated
 Skin: Cherry Red
 SpO2: Normal
o Management:
 Fresh Air
 Release Clothing, Render CPR
 Evaluate CarboxyHgb Level
 Set 100% O2 (Until: <5 Level)
  Hypothermia Prevented
o No SAS
 Smoking
 Alcohol
 Stimulus
Skin Contamination Poisoning
 Nursing Consideration:
o Decontamination: Drench Immediately with Running Water
 Protect Patient from Further Injury
 Protect Staff
 Protect Others
 Quality and Safety Nursing Alerts
o Water should not be applied to burns from Lye or White Phosphorus – It
will explode in Patient’s Skin: Decontaminate by brushing off before
drenching.
 Management:
o Plastic Surgery
o Antimicrobial
o Tetanus Prophylaxis
o Debridement
o Antidote
o Wound Care
Environmental Emergencies:
 Heat Induced Illnesses: 39.2 Degree Environment Temperature
o Heat Cramps:
 Cramping
 Continuous Sweating
 Compensates
 Craves Water
o Heat Exhaustion:
 Headache
 Anxiety
 Temp 38.8 down
 Diaphoresis
 Orthostasis
 Gooseflesh
 Management for Exhaustion and Cramps:
o Cool Place
o Oral or IV Fluids
o Oral Electrolyte Solutions
o Lie Supine
o Heat Stroke:
 Severe, 40.6 and above (Core Temperature)
 Stroke Like
 Shock Symptoms
 Sweating Gone
 Management:
o CABDE
 o Cooling – Cooling Bath, Cooling Blankets, Cooling Sheets
o Core Temp: Reach 39 degree in 1 Hour
o Cooling Stopped: 38 degree
Hypothermia
 Core Temp: 35 degrees (95 degree Fahrenheit) and Below
 Management:
o Rewarming:
 Active Internal (Severe)
 Cardiopulmonary Bypass
 Warmed IVF
 O2 Warmed Humidifier
 Warmed Peritoneal Lavage
 Active External (Moderate)
 Forced Air Warming Blanket
 Passive External (Mild)
 Over the bed heaters
o CABDE, Core Body Temp
o Oust Wet Clothes
o Organize Rewarming
o Line: IV/Arterial
 Assess:
o Vital Sign
o CVP
o ECG
o Urine Output
o ABG
o Blood Chem
o Glucose
o Electrolytes
o X-Ray