Emergency Nursing

Erickson R. Bernardo, MAN, RN

NCM 118
Emergency Nursing
• A nursing specialty that
focuses on the care of
patients who require prompt
medical attention to avoid
long-term disability or death.
• Involves the assessment,
diagnosis, and treatment of
perceived, actual or
potential, sudden or urgent,
physical or psychosocial
problems that are primarily
episodic or acute.
Principles of Emergency Nursing
• Establish a patent airway and provide adequate ventilation
• Control hemorrhage, prevent and manage shock
• Maintain and restore effective circulation
• Evaluate the neurological status of the client
• Carry out rapid initial and ongoing physical assessment
• Start cardiac monitoring
• Protect and clean wounds
• Identify significant medical history and allergies
• Document the findings in medical records
Scope of Emergency Nursing
• To provide immediate action to treat the patient
• For crisis intervention
• To treat emergency condition irrespective of age group
• To treat a wide variety of illness or injury situations
Principles of Emergency Management
• Early detection
• Early reporting
• Early response
• Good on scene care
• Care during transport
• Transport to definitive care
General Principles of Emergency Medical Care
• Triage
• Primary Survey
• Secondary Survey
Triage
• Originated from the French word "trier,"
• to describe the processes of sorting and organization
• Utilized in the healthcare community to categorize patients
based on the severity of their injuries and, by extension, the
order in which multiple patients require care and
monitoring.
Triage
• History
• Originated in the military for field
doctors.
• 18th century: documentation shows
field surgeons quickly look over soldiers
and determine if there was anything
they could do for the wounded soldier.
• French military surgeon Baron
Dominique Jean Larrey, the chief
surgeon in Napoleon Bonaparte's
imperial guard, developed a system
based on the need to evaluate and
categorize wounded soldiers quickly
during battle.
Triage
• 1964: First implemented in hospitals when Weinerman et al. published
a systematic interpretation of civilian emergency departments using
triage.
• Three phases:
• prehospital triage
• triage at the scene of the event
• triage upon arrival to the emergency department
• There are various triage systems implemented around the world, but
the universal goal of triage is to supply effective and prioritized care to
patients while optimizing resource usage and timing.
START Triage
• “Simple Triage And Rapid Transport"
• Most widely used triage system in the US for mass casualty
incidents.
• Developed in 1983 by staff at Hoag Hospital and Newport Beach
Fire Department in California for rescuers with basic first-aid skills.
START Triage
• First responders delegate the movement of injured victims to a
designated collection point as directed by using four main categories
based on injury severity:
• BLACK: (Deceased/expectant) injuries incompatible with life or without
spontaneous respiration; should not be moved forward to the collection
point
• RED: (Immediate) severe injuries but high potential for survival with
treatment; taken to collection point first
• YELLOW: (Delayed) serious injuries but not immediately life-threatening
• GREEN: (Walking wounded) minor injuries
START Triage Algorithm
YES MINOR Priority: 3
Walking All Walking Wounded

NO

NO NO DECEASED Priority: 4
Position
Respirations Not breathing;
Airway
lifesaving impossible

YES YES
Judgment of Vital Stability
Vital Abnormal IMMEDIATE Priority: 1 Stable
If you hurry, there is a
Immediate DELAYED Immediate

Signs
possibility of saving life
/1 min /15 sec
Normal Respirations 10-29 3-8
DELAYED Priority: 2 Pulse 50-120 13-40
Can Wait Mental obeys commands
SALT Triage
• Sort, Assess, Life-saving interventions, and
Treatment/transport
• Similar to the START system
• More comprehensive and adds simple life-saving techniques
during the triage phase.
SALT Triage
• SORT:
• sort the walking, waving, and still.
• ask everyone at the scene to walk to a designated casualty collection
point similar to the START method; however, this is followed by asking
to wave an arm or leg if they need help.
• those who cannot move or follow commands should be assessed first.
• ASSESSMENT:
• assessment and life-saving interventions go hand in hand.
• when you assess a victim and find life-threatening injuries, you should
intervene.
SALT Triage
• LIFE-SAVING INTERVENTIONS:
• simple techniques such as controlling major hemorrhage, opening
airways, needle decompression, and auto-injector antidotes should be
performed as long as it is not time intensive.
• once performed, the provider should assign a color-coded tag similar to
the START system and move onto the next patient to ensure the
forward flow of patients.
• TREATMENT AND TRANSPORT:
• once tagged, patients will be moved to the designated casualty
collection point for transport by emergency management services to
receiving facilities.
JumpSTART
• A modification to the START system and takes into account the
difference in “normal” respiratory rates for children.
• Acts to assess pediatric patients better.
• The age cutoff for use is 8 years old.
• If the child’s age is unknown, the rescuer can assess for underarm hair
in males or breast development in females as an indicator of adult
age and exclusion from this cohort.
JumpSTART
• The differences in this algorithm include:
• 5 rescue breaths are to be given to apneic children with a pulse; then,
they are given a black tag.
• Normal RR: > 15 or < 45 cpm
• Neurological assessment is done using the mnemonic AVPU (alert,
responds to verbal stimuli, responds to painful stimuli, and
unresponsive).
• Any patient who has abnormal posturing to painful stimuli or is
unresponsive gets a red tag designation.
Five-Level Emergency Seventy Index (ESI)
• The first question in the ESI triage algorithm for triage nurses asks
whether "the patient requires immediate life-saving interventions" or
simply "is the patient dying?"
• The nurse determines this by looking to see if the patient has a patent
airway, is the patient breathing, and does the patient have a pulse.
Five-Level Emergency Seventy Index (ESI)
• The nurse evaluates the patient, checking pulse, rhythm, rate, and
airway patency.
• Is there concern for inadequate oxygenation?
• Is this person hemodynamically stable?
• Does the patient need any immediate medication or interventions to
replace volume or blood loss?
• Does this patient have pulselessness, apnea, severe respiratory distress,
oxygen saturation below 90, acute mental status changes, or
unresponsiveness?
• If the nurse can accurately diagnose the patient with these criteria
and mark as a Level 1 trauma patient, the patient will need
immediate life-saving therapy.
Five-Level Emergency Seventy Index (ESI)
• Immediate physician involvement in the care of the patient is critical
and is one of the differences between level 1 and level 2 patient
designations.
• Another scale used by nurses in the assessment is if the patient is
meeting criteria for a true level 1 trauma is the AVPU (alert, verbal,
pain, unresponsive) scale.
• The scale is used to evaluate if the patient had a recent or sudden
change in LOC and needs immediate intervention.
• Patients who are only responsive to painful stimuli (P) or unresponsive
(U) are categorized as level 1.
Five-Level Emergency Seventy Index (ESI)
• If the patient is not categorized as a level 1, the nurse then decides if
the patients should wait or not.
• This is determined by three questions;
• Is the patient in a high-risk situation?
• Is the patient confused, lethargic, or disoriented?
• Is the patient in severe pain or distress?
• The clinical experience of the nurse allows for pinpointing the unusual
presentations of diseases that may progress with rapid deterioration.
Five-Level Emergency Seventy Index (ESI)
• Once the level 1 and level 2 questions are ruled as negative, the nurse
needs to ask how many different resources are needed for the
physician to provide adequate care and allow the physician to reach a
disposition decision.
• That decision meaning discharge, admit to the observation unit, or
the hospital floor.
• The experience of the triage nurse is again referenced to make a
clinical judgment on what is done for patients who typically present
with these symptoms.
• The nurse uses experience and the routine practice of the emergency
department to make this decision.
Five-Level Emergency Seventy Index (ESI)
• Before moving on, if the nurse has concluded that the patient will
need many hospital resources during the visit, the nurse will again
evaluate the patient's vital signs and look for unstable vital signs.
• If the patient is outside the normal or acceptable limits and
approaching dangerous vitals, the patient would then be triaged as a
Level 2.
• The dangerous vital signs are adjusted according to age.
• These findings, along with the patient's history and physical, are taken
into consideration whether the triage nurse is concerned for the
patient and decides on a Level 2 or 3/4/5 level triage.
Five-Level Emergency Seventy Index (ESI)
• Differentiating between levels 3,4, and 5 are determined by how
many hospital resources the patient will most likely need.
• If the patient requires two or more hospital resources, the patient is
triaged as a level 3.
• If the patient needs one hospital resource, the patient would be
labeled a 4.
• If the patient does not need any hospital resources, the patient
would be labeled a 5.
Five-Level Emergency Seventy Index (ESI)
• One aspect of ESI that may differ at various institutions is what they
consider an ESI resource.
• Laboratory tests
• Electrocardiograms
• Radiographic imaging
• Parenteral or nebulizer medications
• Consultations
• Simple procedures (laceration repair)
• Complex procedure
Five-Level Emergency Seventy Index (ESI)
• Resources qualified as "not resources"
• History and physical examination (including pelvic exams)
• Peripheral IV access placement
• Oral medications
• Immunizations
• Prescription refills
• Phone calls to outside physicians
• Simple wound care
• Crutches, splints, or slings
Five-Level Emergency Seventy Index (ESI)
• Whether or not some emergency departments (EDs) send certain
tests such as a urinalysis or pregnancy test to the laboratory would
change the ESI level between a 4 and a 5.
• Regardless, ESI is a simple and effective way for nurses to assess
patient needs.
Phases - Prehospital Care
• Goals
• Immediate identification of life-threatening injuries
• Transport (ground or air) to the closest appropriate medical facility
• Priorities
• Airway maintenance
• Recognition and control of external bleeding and shock
• Immobilization of the patient
• Vital components
• Initiation of a peripheral intravenous (IV) line
• Splinting of fractures
• Pain management
Phases - Emergency Department
• ATLS guidelines
• Rapid assessment
• Immediate identification of life-threatening injuries
• Initial resuscitation of trauma patients in the emergency department
• Systematic approach to initial assessment and care of a trauma
patient
• Rapid primary survey
• Resuscitation of vital organ systems
• A more detailed secondary survey
• Initiation of the most appropriate care
Primary Survey
• Initiated on arrival
• Purpose: to identify and treat any life-threatening injuries that, if left
untreated, could potentially cause the patient’s death.
• Airway maintenance with cervical spine protection
• Breathing and ventilation
• Circulation with hemorrhage control
• Disability: Neurologic status
• Exposure or environmental control
Secondary Survey
• Begins when the primary survey is completed, potentially life-
threatening injuries have been identified, and resuscitation
initiated.
• In reality, both primary and secondary surveys may seem to occur
almost simultaneously.
• However, the secondary survey is a more detailed, in-depth physical
examination of the trauma patient.
• During the secondary survey, a head-to-toe approach is used to
thoroughly examine each body region.
Secondary Survey
• E-F-G-H-I
• Exposure to environment
• Full set of vital signs
• Give comfort measures
• History collection
• Inspect the posterior surface
• A-M-P-L-E
• Allergy
• Medication history
• Past health history
• Last meal
• Events/Environment
preceding illness/injury
Phases – Critical Care Phase
• Critical care admissions: direct
transfers from the emergency
department, diagnostic imaging, or
operating room.
• Information the critical care nurse
must obtain can be summarized using
the SBAR communication tool:
• Situation
• Background
• Assessment
• Recommendations
Nursing Care of Clients in
Emergency Situations
Medical Emergencies
• Airway, Breathing, • Disability (D)
Circulation (ABC) • Head Injury*
• Foreign Body Airway • Stroke*
Obstruction (FBAO)
• Inhalation Injury
• Anaphylaxis*
• Trauma
• Thoracic Emergency
• Cardiac Arrest
• External Hemorrhage
1. Foreign Body Airway Obstruction (FBAO)
• Choking:
• blockage or hindrance of respiration
by a foreign body obstruction in the
airway
• Humans possess mechanisms that
protect them from choking, but in
adults with neuromuscular
impairment or children with narrow
airways, these mechanisms may be
insufficient to prevent airway
obstruction.
Foreign Body Airway Obstruction (FBAO)
• A child’s airway is much smaller than that
of an adult.
• A child does not generate the same force
when coughing as an adult, so their efforts
may not be enough to dislodge a foreign
body.
• Additionally, children commonly put
objects in their mouths, starting in infancy
as they discover their environment.
Foreign Body Airway Obstruction (FBAO)
• Round foods are more likely to cause fatal choking in children, with
hotdogs being the most common, followed by candy, nuts, and
grapes.
• Among non-food items, latex balloons are reportedly the leading
cause of fatal choking events among children.
• For adults, autopsy results from 200 choking victims showed meat,
fish, and sausage to be responsible for death in 71% of cases followed
by bread and bread products (12%) and fruits and vegetables (7%).
Assessment
• The approach to a choking patient should begin with an assessment
of the ABCs.
• The clinician should focus on skin color, LOC, and work of breathing,
noting chest wall retractions, nasal flaring, and the use of accessory
muscles.
• A complete airway obstruction will result in respiratory failure if not
recognized and treated early.
Assessment
• Sudden onset of respiratory distress accompanied by coughing,
stridor, wheezing, or gagging warrants emergent action and should
illicit a high suspicion for FBAO.
• The choking patient may show the universal sign for an airway
obstruction by grabbing his or her neck with both hands.
• When the patient is stable, and the clinician can obtain their history,
particular attention should focus on age (either very young or
elderly), intellectual or neuromuscular disability, and precipitating
events such as eating or playing with toys.
Management
• A child with a presumed airway obstruction that is still able to
maintain some degree of ventilation should be allowed to clear the
airway by coughing.
• If the child cannot cough, vocalize, or breathe, emergent steps are
necessary to clear the airway.
• For infants under one year of age, alternating sequences of five back
blows and five chest thrusts are performed until the object clears or
the infant becomes unresponsive.
• Abdominal thrusts should not be performed in infants as their livers
are more prone to injury.
Management
• For a choking child, over one year of age, subdiaphragmatic
abdominal thrusts (i.e., the Heimlich maneuver) should be performed
until clearing the object, or the child becomes unconscious.
• If the infant or child becomes unresponsive, immediately start chest
compressions.
• After 30 compressions, the airway should undergo evaluation, and if a
foreign body is visible, it requires removal, but blind finger sweeps
should not be performed as they may push the foreign body
downwards to the larynx.
• A series of 30 compressions and two breaths should continue until
the object is expelled.
Management
• The treatment for an adult with complete FBAO is similar to that of a
child where a bystander performs the Heimlich maneuver until
expelling the foreign body or CPR if the patient loses consciousness.
• If nobody is present to assist in the Heimlich maneuver, the choking
individual may self-administer thrusts with his or her fist or by
forcibly leaning against a firm object such as the back of a chair.
• For patients who are pregnant or morbidly obese, abdominal thrusts
may not be feasible, and chest thrusts against the patient’s sternum
may be performed.
Complications
• Most feared complication: hypoxia resulting in respiratory arrest,
anoxic brain injury, and death.
• Long term complications: atelectasis, pneumonia, or bronchiectasis,
occasionally requiring lobectomy or segmentectomy.
• It is also not uncommon for the treatment of FBAO to have
deleterious side effects.
• Complications of the Heimlich maneuver include injury to the
abdominal or thoracic viscera and regurgitation of stomach contents.
• For patients requiring bronchoscopy, potential complications include
bleeding, infection, airway perforation, and pneumothorax.
2. Inhalation Injury
• Broad term that includes pulmonary exposure to a wide range of
chemicals in various forms including smoke, gases, vapors, or fumes.
• Inhalation injury from smoke exposure is commonly seen in patients
exposed to fires.
• Smoke inhalation
• one of the most commonly encountered type of inhalation injury
Inhalation Injury
• Occur when a patient's respiratory system is exposed to direct heat
from fire as well as toxic chemicals that are formed from the
decomposition of materials during combustion.
• The composition of smoke varies with each fire depending upon the
materials being burned, the amount of oxygen available to the fire,
and the nature of the fire.
• High-oxygen and high-temperature fires often do not produce large
amounts of smoke.
• Low oxygen fires are often lower temperature fires, and these lower
temperatures often give rise to more toxic chemicals, such as carbon
monoxide.
Inhalation Injury
• Other common toxic compounds created in smoke are ammonia,
carbon dioxide, hydrogen cyanide, aldehydes, sulfur dioxides, and
nitrogen dioxide.
• These different elements give rise to a combination of gases, airborne
solids, and liquid vapors that mix with the ambient air to create
smoke.
• Inhalation of these components, when exposed to smoke, causes
both upper and lower airway injury.
Assessment
• A high index of suspicion is important for all clinicians to have when
evaluating patients for inhalation injury.
• It is important to elucidate whether the exposure was to smoke,
flames, and/or possible chemicals (both industrial and household).
• Duration of exposure, the location of exposure (such as if it was in an
enclosed space), and any LOC are all important as well.
Assessment
• Patients may be unconscious at presentation and interviewing
first responders/rescuers may be required.
• Duration of exposure is often greater for pediatric and elderly
patients as often they will have longer exposure due to
disorientation or mobility issues.
• Children also often hide from smoke or fires thus increasing time
exposed.
• Pediatric patients also have increased minute ventilation with a
higher respiratory rate when compared to adults, thus,
increasing the amount of exposure.
Management
• Limiting exposure and removing the patient from the exposure area,
such as in a house fire or occupational exposure, and maintaining a
secure airway are paramount.
• Airway protection should include considering early and preemptive
intubation for patients with inhalation injury.
• Airway edema may occur suddenly as edema worsens, and often, the
upper airways develop injury and obstruction earliest, prior to the
parenchymal injury.
Management
• Maintain secure airway: Intubation, tracheostomy if necessary
• Obstruction often results in edema, hemorrhage, and mucosal
sloughing, and aggressive pulmonary hygiene can help to manage
these secretions.
• Obstruction may also occur due to airway reactivity, for which
bronchodilators should be used.
• Usage of steroids, in either inhaled or intravenous form, has not been
proven beneficial in clinical studies.
• Early/prophylactic antibiotic usage is not recommended.
• Anticoagulation: Nebulized heparin has shown some promise as a
treatment specifically for smoke inhalation injury.
3. Trauma
• Occurs when an external force of energy impacts the body and causes
structural or physiologic alterations, or injury.
• External forces: radiation, electrical, thermal, chemical, or mechanical
forms of energy.
• Trauma that occurs from high-velocity impact (mechanical energy) is
most common; can produce blunt or penetrating traumatic injuries.
Blunt Trauma
• Seen most often with MVCs, falls, contact sports, or blunt-force
injuries (e.g., trauma caused by a baseball bat).
• Occurs because of the forces sustained during a rapid change in
velocity (deceleration).
• To estimate the amount of force sustained in an MVC, multiply the
person’s weight by the miles per hour (speed) the vehicle was
traveling.
• For example, a woman weighing 130 pounds traveling in a vehicle 60
miles/h that hits a brick wall would sustain 7800 pounds of force within
milliseconds.
Blunt Trauma
• As the body stops suddenly, tissues and internal organs continue to
move forward.
• This sudden change in velocity can cause significant external and
internal injury.
• Blunt injury may be difficult to diagnose, as injuries are not always
obvious or readily apparent.
Penetrating Trauma
• Those that puncture the body and result in damage to internal
structures—occur with stabbings, firearms, or impalement.
• Damage is created along the path of penetration.
• Can be misleading, because the appearance of the external wound
may not accurately reflect the extent of internal injury.
• For instance, bullets can create internal cavitation several times larger
than the diameter of the bullet itself.
• Several factors determine the extent of damage sustained as a result
of penetrating trauma.
Penetrating Trauma
• Severity of a gunshot wound depends on the type of gun,
ammunition used, and the distance and angle from which the gun
was fired.
• Pellets from a shotgun blast expand on impact and cause multiple
injuries to internal structures.
• Handgun bullets usually damage what is directly in the bullet’s path.
• With penetrating stab wounds, factors that determine the extent of
injury include the type and length of object used and the angle of
insertion.
• Stab wounds typically produce less serious injury (but not always), as
most stabbings are typically a low-velocity injury.
4. Thoracic Emergency
• Involve trauma to the chest wall, lungs, heart, great vessels, and
esophagus.
• Blunt thoracic trauma to the chest most often is caused by MVCs or
falls.
• Various types of blunt trauma are associated with specific injury
patterns.
• In penetrating thoracic injury, the object involved determines the
degree of damage to underlying structures.
• Low-velocity weapons (e.g., .22-caliber gun, knife) usually damage
only what is in the direct path of the weapon.
4. Thoracic Emergency
• Stab wounds that involve the anterior chest wall between the
midclavicular lines, the angle of Louis, and the epigastric region are of
particular concern, because of the proximity of the heart and great
vessels.
• High-velocity weapons are capable of causing considerable thoracic
injury because of greater kinetic energy.
Chest Wall Injuries
• Rib fractures
• Fractures of the ribs can be minimal and cause minor discomfort or be
serious and life-threatening, particularly when multiple ribs are
fractured, when preexisting cardiopulmonary disease is present, or
when the patient is an older adult.
• 1st and 2nd ribs: intrathoracic vascular injuries of the brachial plexus, or
great vessels; signifies a very high degree of force applied to the thorax.
• Middle ribs: lung injury, including pulmonary contusion and
pneumothorax.
• Lower ribs (7th to 12th): abdominal trauma, such as spleen and liver
injuries.
Chest Wall Injuries
• Flail chest
• Caused by blunt trauma, disrupts the continuity of chest wall structures.
• Typically, a flail segment occurs when two or more ribs are fractured in
two or more places and are no longer attached to the thoracic cage,
producing a free-floating segment of the chest wall.
• A flail chest is a clinical diagnosis wherein the so-called flail segment (or
floating segment) moves paradoxically compared with the rest of the
chest wall
Lung Injuries
• Pulmonary contusion
• A pulmonary contusion is a bruise of the lung.
• Pulmonary contusion is often associated with blunt trauma and other
chest injuries, such as rib fractures and flail chest.
• Pulmonary contusions can occur unilaterally or bilaterally.
• A contusion manifests initially as a hemorrhage followed by alveolar
and interstitial edema.
• The edema can remain localized in the contused part or can spread to
other areas of the lung.
Lung Injuries
• Pneumothoraces in trauma
• Pleural damage is common in trauma.
• These conditions include pneumothorax (air in the pleural space),
hemothorax (blood in the pleural space), or hemopneumothorax (air
and blood in the pleural space).
• Pneumothoraces may be managed with chest tubes, analgesia, and
surgical consultation, depending on the size of the pneumothorax,
hemodynamic stability of the patient, and effects on oxygenation and
ventilation.
• Open pneumothorax, tension pneumothorax, and massive hemothorax,
three additional and potentially life-threatening respiratory problems in
trauma, warrant special consideration.
Open Pneumothorax
• An open pneumothorax (“sucking chest wound”) is caused by
penetrating trauma.
• Large open thoracic wounds (greater than two-thirds the diameter of
the trachea) allow communication between the atmosphere and
intrathoracic cavity.
• As air moves in and out of the hole in the chest, a sucking sound can
be heard on inspiration.
• Respiratory mechanics become impaired.
• Dyspnea, tachycardia, and hypotension may be observed.
Tension Pneumothorax
• A tension pneumothorax is caused by an injury that perforates the
chest wall or pleural space.
• During inspiration, air flows into the pleural space and becomes
trapped.
• As pressure in the pleural space increases, the lung on the injured
side collapses and causes the mediastinum to shift to the opposite
side.
• As pressure continues to build, the shift exerts pressure on the heart
and thoracic aorta, which results in decreased venous return and
decreased cardiac output.
• Tissue perfusion is affected because the collapsed lung does not
participate in gas exchange.
Massive Pneumothorax
• Blunt or penetrating thoracic trauma can cause bleeding into the
pleural space, resulting in a hemothorax.
• A massive hemothorax results from the accumulation of more than
1500 mL of blood in the thoracic cavity.
• The source of bleeding may be the intercostal or internal mammary
arteries, lungs, heart, or great vessels.
• Lacerations to the lung parenchyma are low-pressure bleeds and
typically stop bleeding spontaneously.
• Arterial bleeding from hilar vessels usually requires immediate
surgical intervention.
• Increasing vascular blood loss into the pleural space causes decreased
venous return and decreased cardiac output.
Heart and Vascular Injuries
• Heart and vascular injuries can result from either blunt or penetrating
trauma.
• The most common causes of blunt cardiac trauma include high-
speed MVCs, direct blows to the chest, and falls.
• Because of its mobility and its location between the sternum and
thoracic vertebrae, the heart is particularly susceptible to blunt
traumatic injury.
• Sudden acceleration (as from contact with a steering wheel) can
cause the heart to be thrown against the sternum.
• Sudden deceleration can cause the heart to be thrown against the
thoracic vertebrae by a direct blow to the chest, such as blows caused
by a baseball, animal kick, or fall.
Blunt Cardiac Injury
• BCI covers a wide spectrum of possible cardiac issues in trauma
patients, including myocardial contusion, myocardial concussion, and
rupture.
• The chambers most often injured are the right atrium and right
ventricle because of their anterior position in the chest.
Cardiac Tamponade
• Progressive accumulation of blood in the pericardial sac.
• With cardiac tamponade, the accumulation of blood increases
intracardiac pressure and compresses the atria and ventricles.
• The amount of blood needed to cause changes in patient
hemodynamics depends on the amount of blood in the pericardial sac
and the speed with which the fluid has accumulated.
• As intracardiac pressure continues to increase, this leads to decreased
venous return and decreased preload, which lead to decreased
cardiac output.
• Myocardial hypoxia, heart failure, and cardiogenic shock may occur.
Blunt Traumatic Aortic Injury
• One of the most lethal thoracic
injuries and the second most
common cause of death in blunt
trauma.
• Associated injuries include a first or
second rib fracture, high sternal
fracture, left clavicular fracture at the
level of the sternal margin, and
massive hemothorax.
5. Cardiac Arrest
• As defined by the American Heart Association and the American
College of Cardiology,
"(sudden) cardiac arrest is the sudden cessation of cardiac activity
so that the victim becomes unresponsive, with no normal breathing
and no signs of circulation. If corrective measures are not taken
rapidly, this condition progresses to sudden death. Cardiac arrest
should be used to signify an event as described above, that is
reversed, usually by CPR and/or defibrillation or cardioversion, or
cardiac pacing. Sudden cardiac death should not be used to describe
events that are not fatal."
Cardiac Arrest
• The cause of cardiac arrest varies by population and age, most
commonly occurring in those with a previous diagnosis of heart
disease.
• Most of all cardiac deaths are sudden and usually unexpected, which
has proven to be uniformly fatal in the past.
• However, bystander cardiopulmonary resuscitation (CPR) and
advances within emergency medical services (EMS) have proven life-
saving interventions.
• Despite this, approximately 10% of those suffering from cardiac arrest
leave the hospital alive, most of which are neurologically impaired
Cardiac Arrest
• Cardiac arrest is usually due to underlying structural cardiac disease.
• 70% of cardiac arrest cases are thought to be due to ischemic coronary
disease, the leading cause of cardiac arrest.
• Other structural causes:
• congestive heart failure,
• left ventricular hypertrophy,
• congenital coronary artery abnormalities,
• arrhythmogenic right ventricular dysplasia,
• hypertrophic obstructive cardiomyopathy, and
• cardiac tamponade.
Cardiac Arrest
• Non-structural cardiac causes:
• Brugada syndrome
• Wolf-Parkinson-White
syndrome
• congenital long QT syndrome
• Non-cardiac etiologies:
• intracranial hemorrhage
• pulmonary embolism
• pneumothorax
• primary respiratory arrest
• toxic ingestions including drug
overdose
• electrolyte abnormalities
• severe infection (sepsis)
• hypothermia
• trauma
Assessment
• In many patients, warning symptoms may precede a cardiac arrest.
• However, many times these symptoms are unrecognized or ignored by
the individual.
• Many patients who survive cardiac arrest have amnesia, not allowing
for the recollection of symptoms before an event.
• Data obtained from those who did not have amnesia, from family
members and/or from those who witnessed the event shows that the
most common symptom was chest pain.
Assessment
• Appropriately, this mirrors the most common presentations of acute
coronary ischemia.
• An individual found to be in cardiac arrest will be unresponsive,
without a pulse, and will not be breathing.
• A quick head-to-toe assessment will help guide treatment.
Management
• A patient in cardiac arrest is treated in multiple different stages.
• The interventions that have proven to reverse cardiac arrest include
early CPR and early defibrillation.
• The initial step involves identification and basic life-support measures.
• If public access defibrillation is available, it should be activated and
utilized if needed.
• Next, ALS measures are used, including IV or intraosseous medication
administration.
• If return of spontaneous circulation (ROSC) is obtained, the patient
will undergo post-resuscitation care with subsequent long-term
management.
Nursing Management
• Check vitals • Check pulses
• Place ECG leads • Apply defibrillator pads
• Have the resuscitation cart at • Obtain blood for analysis
the bedside • Insert foley
• Insert IV cannula • Keep patient warm
• Document
6. External Hemorrhage
• An acute loss of blood from a damaged blood vessel.
• The bleeding can be minor, such as when the superficial vessels in the
skin are damaged, leading to petechiae and ecchymosis.
• It can also be significant, leading to a more ambiguous constellation
of symptoms, including fluctuations in vital signs and altered mental
status.
External Hemorrhage
• Hemorrhaging can be either external or internal.
• External bleeding occurs from a body orifice or a traumatic wound.
• Internal bleeding requires a high level of clinical suspicion obtained
through a thorough history and physical, laboratory tests, imaging, and
close monitoring of vital signs.
• Hemorrhage is a leading cause of potentially preventable death,
especially in the acute trauma population.
Dressing and Bandaging
• Dressing • Bandaging
• Any material used to cover a • Any material used to hold a
wound, help control bleeding, dressing in place
and help prevent additional
contamination
Controlling External Bleeding
A. Direct Pressure
1. Apply direct pressure to wound site with your gloved hand.
2. Apply firm pressure with a sterile dressing or clean cloth.
3. Apply pressure until bleeding is controlled (maybe 10-30 minutes or
longer).
4. Hold dressing in place with bandages after bleeding is controlled.
5. Never remove a dressing once in place.
Controlling External Bleeding
B. Elevation
1. Elevate injured extremity so that wound is higher than the heart.
2. Continue to apply pressure to site of bleeding.
Controlling External Bleeding
C. Pressure Points
1. Temporal artery
2. Facial artery
3. Carotid artery
4. Subclavian artery
5. Brachial artery
6. Radial artery
7. Femoral artery
Controlling External Bleeding
D. Tourniquet
1. Locate the site for tourniquet (between wound and patient’s heart,
usually 2 inches from wound).
2. Place a pad on site over artery.
3. Place tourniquet above limb and secure it.
4. Tighten tourniquet until bleeding has stopped.
5. Do not loosen tourniquet once in place.