Emergency nursing was officially recognized as a specialty in 1970 represented by the Emergency Nurses Association (ENA)

Click to edit Master title style

According to the ENA, the definition of emergency nursing involvesto edit Master text styles Click . . . the assessment, diagnosis, and treatment of perceived, level actual or potential, sudden or urgent, physical Second or psychosocial problems that are primarily episodic or acute. These may require minimal care or life-support Third level measures, education of patient and significant others, appropriate referral and knowledge of legal implications.

Fourth level Responsibilities Fifth level of the Nurse:

1. Provision of direct client care. 2. May be involved in the initial triaging of clients according to illness severity. 3. may perform as a mobile intensive care nurse (MICN) by directing pre-hospital care personnel via telecommunication. 4. may frequently provide client care in the pre-hospital environment.

NATIONAL LEGISLATION Click to edit Master title style

Republic Act No. 8344 - AN ACT PENALIZING THE REFUSAL OF HOSPITALS AND MEDICAL CLINICS TO Click to edit Master textINITIAL stylesMEDICAL ADMINISTER APPROPRIATE AND SUPPORT IN EMERGENCY OR TREATMENT Second level SERIOUS CASES

Third level "SECTION 1. In emergency or serious cases, it shall be for any proprietor, president, director, manager or unlawful Fourth level any other officer, and/or medical practitioner or employee or a or medical clinic to request, solicit, demand or accept hospital Fifth level any deposit or any other form of advance payment as a
prerequisite for confinement or medical treatment of a patient in such hospital or medical clinic or to refuse to administer medical treatment and support as dictated by good practice of medicine to prevent death or permanent disability:
2

Third level Provided, further, That such transfer shall be done only necessary emergency treatment and support have after Fourth level been administered to stabilize the patient and after it has been established that such transfer entails less risks than the Fifth level patient's continued confinement:

Provided, That by reason of inadequacy of the medical capabilities of the hospital or medical clinic, the attending physician may transfer the patient to a facility where the appropriate care can be given, after the patient or his next of kin consents to said transfer and after the receiving hospital or medical clinic agrees to the transfer: Provided, however, That when the patient is Click to edit Master text styles unconscious, incapable of giving consent and/or unaccompanied, the physician can transfer the patient Second level his consent: even without

Click to edit Master title style

Provided, furthermore, That no hospital or clinic, after being informed of the medical indications for such transfer, shall refuse to receive the patient nor demand from the patient or his next of kin any deposit or advance payment: Provided, finally, That strict compliance with the foregoing procedure or transfer shall not be construed as a refusal made punishable 3 by this Act.

 "SEC. 4. Any official, medical practitioner or employee of the hospital or medical clinic who violates the provisions of this Act shall, upon conviction by final judgment, be punished by imprisonment of not less than six (6) months and one (1) day but not more than two (2) years and four (4) months, or a fine of styles not less than Twenty Click to edit Master text thousand pesos (P20,000.00), but not more than One hundred thousand Second level pesos (P100,000.00) or both, at the discretion of the court: Provided, however, That if such violation was committed pursuant to an established Third level policy of the hospital or clinic or upon instruction of its management, the director or officer of such hospital or Fourth level clinic responsible for the formulation and implementation of such policy shall, upon conviction by final judgment, Fifth level suffer imprisonment of four (4) to six (6) years, or a fine of not less than One hundred thousand pesos (P100,000.00), but not more than Five hundred thousand pesos (P500,000.00) or both, at the discretion of the court."

Click to edit Master title style

 Purpose: to encourage health care providers to assist at times of accidents and emergencies

Good Samaritan Law Click to edit Master title style

Click to edit Master text styles Elements Second level Care must be provided in good faith Third Carelevel must be gratuitous; no compensation is made for the care rendered Fourth level Does not cover a person who is soliciting business or representing Fifth level an agency
Does not cover the care rendered in an Emergency Room situation. Care provide should not be willfully or wantonly negligent It is important to know the status in your state and whether you have immunity.

Click to edit Master title style

The UN Definition of Disaster:

Click to edit Master text styles A serious disruption of the The World Health Organization Second level functioning of a society, (WHO) causing widespread human, defines disaster as "a material, or environmental Third level situation where peoples losses which exceed the normal means of support for ability of the affected society life with dignity have failed Fourth level to cope using only its own as a result of natural or resources. human-made catastrophe." Fifth level WHO also considers the
"disaster affected people/population" as "all people whose life or health are threatened by disaster, whether displaced or in their home area."
6

PRINCIPLE

Click to edit Master title style

In contrast to most routine emergencies, introduce need for multi disasters Click to edit Masterthe text styles organizational and multi-disciplinary coordination. Second level

Third level EXECUTIVE ORDER NO. 137 Fourth level Fifth level the month of July of every year as declaring

National Disaster Consciousness Month and institutionalizing the Civil Defense Deputization Program

Definition of disaster

Click to edit Master title style

A sudden event Click to edit Master text styles containing an alterable mixture of four factors: Disasters create the most Second level devastation in developing Injury to humans countries, where the Property Third level death rate is up to 12 damage/destruction times higher than in Fourth s level developed countries. The Exceeding the local Fifthresponse level resources poor suffer the most because their houses are Disruption of less sturdy and they have society and its fewer resources and less normal functioning means of social security. (Stanhope & Lancaster, 2000) 8

Disasters are often classified:

according to their speed of according to their onset cause Click Rapid to edit Master text styles Natural Slow Man-made Second level Complex

Click to edit Master title style

Third level Fourth level Fifth level

Natural or Man-made Disasters Result in: Communicable diseases Injury Illness Click to edit Master Deaths

Click to edit Master title style

text styles

Second level Effects of Disaster

Third level Damage to and Destruction of Property and Crops Fourth level Disruption of Production and Essential Services Disruption of Lifestyle Fifth level Loss of Livelihood, Jobs
Damage to Infrastructure Disruption of Normal Government Economic Loss Sociological and Psychological After-effects Diversion of Funds from Development Subsistence Affecting Satisfactory Recovery

10

Authorities on Disaster OFFICE OF CIVILPreparedness National Disaster Coordinating Council Office of DEFENSE Functions include: Civil Defense Philippine National Red Cross HAS THE PRIMARY TO DEVELOP AND Click to edit Master text styles TASK OF COORDINATE A COORDINATING THE PROGRAM FOR Second level ACTIVITIES AND INFORMING, FUNCTIONS OF EDUCATING AND Third level VARIOUS TRAINING THE GENERAL PUBLIC, GOVERNMENT Fourth level AGENCIES AND MEMBERS OF THE INSTRUMENTALITIES, DISASTER Fifth level PRIVATE INSTITUTIONS COORDINATING AND CIVIC COUNCILS AND ORGANIZATIONS FOR DISASTER CONTROL THE PROTECTION AND GROUPS ON CIVIL PRESERVATION OF DEFENSE AND CIVIL LIFE AND PROPERTY ASSISTANCE DURING MEASURES. EMERGENCIES . . . .

Click to edit Master title style

11

NATIONAL DISASTER Click to edit Master title style COORDINATING COUNCIL

MANAGEMENT PLANS. IT RECOMMENDS TO THE PRESIDENT THE DECLARATION OF STATE OF CALAMITY AND THE RELEASE OF NATIONAL CALAMITY FUND

Click to edit Master text styles Second level HIGHEST POLICY MAKING, COORDINATING AND SUPERVISING Third level BODY AT THE NATIONAL LEVEL FOR DISASTER MANAGEMENT IN THE COUNTRY. Fourth ADVISESlevel THE PRESIDENT ON THE STATUS OF NATIONAL Fifth levelDISASTER PREPAREDNESS &

12

DCC ClickOrganizational to edit Master title Network style

National Click to editDisaster MasterCoordinating text styles Council Second level 16 Regional Disaster Coordinating Councils Third level Fourth level Disaster Coordinating Councils 79 Provincial Fifth level

114 City Disaster Coordinating Councils

1496 Municipal Disaster Coordinating Councils

13

Click to edit Master title style

Click to edit Master text styles Second level Third level Fourth level Fifth level

14

HEALTH SERVICE

Click to edit Master title style

To protect life through health and medical care of the populace. Click to edit Master text styles To preserve life through proper medical aid and Second level provision of medical facilities. minimize To Third levelcasualties through proper information and mobilization of all medical level Fourth Resources

Fifth level

RESCUE SERVICE To remove victims and casualties from areas likely to be affected or are being affected by disaster.
15

STAGES OF DISASTER Click to edit Master title style INVOLVEMENT

PREPAREDNESS to pre-disaster actions text and measures being undertaken to Refers Click to edit Master styles avert or minimize loss of lives and properties, such as, but not limited to, community organizing, training, planning, equipping, stockpiling, hazard mapping and public information and education initiatives.

Second level Third level RESPONSE level Fourth Refers to any concerned effort by two or more agencies, public or private, to provide emergency assistance or relief to persons who victims of disasters or calamities, and in the restoration of are Fifth level
essential public activities and facilities.

RECOVERY/REHABILITATION Recovery occurs as all involved agencies pull together to restore the economic and civil life of the community Refers to the process by which the affected communities/areas or damaged public infrastructure are restored to their normal level or 16 their actual condition prior to the occurrence of the disaster or calamity.

PREPAREDNESS Click to edit Master title style

Personal Preparedness Click to edit Master

text styles

Second level 3 day water supply, food that wont spoil On change of clothing and footwear, blankets Third level First aid kit plus family's prescription Battery powered Fourth level radio, flashlight, batteries Candles, matches Fifth level Car key, credit card, cash

Sanitation supplies Extra eye glasses Special items for child, elderly, disabled member
17

Click to edit Master title style Professional Preparedness

Be understand disaster plans at Click toaware edit and Master text styles workplace and community Second levelin mock drills and disasters Participate Personal items: copy of professional license, Third level equipment (stethoscope), personal flashlight/batteries, cash, warm clothing, jacket, Fourth level record keeping materials, pocket size reference books. Fifth level Certified in 1st aid and CPR Attend comprehensive program of disaster training from NDCC-OCD/PNRC

18

Click to edit Master title style

Community Preparedness

Click to edit Master text styles Communities need : Second level Written disaster plan Third level Yearly mock disaster drills and determine strengths and weaknesses Fourth level Review past disaster history and how disasters affected health care delivery system Fifth level Consider educational programs
Adequate warning system Backup evacuation plan

19

Nursing Role in Disaster Preparedness It is essential that nurses have a personal and family disaster plan Its difficult to provide care to others when one is Click to edit text styles concerned aboutMaster the safety of ones family. Within the employing organization

Click to edit Master title style

Second level Initiate and update disaster plan Provide educational programs and materials Third level Organize disaster drills Provide updated record of vulnerable populations within community Fourth level Assess for & report environmental hazards Educate special populations about impact of disasters Fifth level Review individualized strategies, and availability of specific
resources Become involved in community organizations

Nurses can be optimally prepared for a disaster of any type by being aware of:
community hazards and vulnerabilities, as well as,

being familiar with the community health care system and its level of preparedness.

20

 Hospital Emergency Disaster Preparedness Plan Click to edit Master title style Every facility is required by the Joint on Accreditation of Healthcare Commission Click to edit Master text styles Organization to create a plan for emergency Second level and to practice this plan twice preparedness a year Third level The Labor Code requires every facility to Fourth level promulgate the Occupational Safety and Standards to protect every working Health Fifth level man through injury, sickness and death OCD and DOH requires hospital facility to have an Emergency and Disaster Preparedness Plan
21

Problems facing Emergency Click to edit Master title style Manager

Click to edit Master text styles unclear Secondobjectives level massive needs Third level limited resources security and safety issues Fourth level poor communications /confusion Fifth level

extreme importance of decisions too much to do too little time too many players
22

ANTICIPATORY PLANNING IS Click to edit Master title style THE KEY TO SUCCESSFUL Click to edit Master text styles SURVIVAL. Second level
Third level Fourth level Fifth level

23

 Response by NDCC-OCD is determined by level of and amount of resources needed disaster Click to edit Master text styles LEVELS OF DISASTER Second Level I Disaster level Considered a minor disaster; minimal damage; could result in presidential declaration of an emergency or Third level disaster. Resources could be met by existing regional/provincial/local resources Fourth level Level II Disaster Fifth level a moderate disaster: likely results in major Considered presidential declaration with moderate national assistance. Level III Disaster Considered a massive disaster. Involves massive level of damage, with severe impact or multistage scope. Results in presidential disaster declaration, with major national government involvement and full engagement24 of local and national resources.

RESPONSE Click to edit Master title style Determined by levels of Disaster and Agency Involvement

The Student Manual for Disaster Management and Planning Click to edit Master title for style Emergency Physician's Course Click to edit Master text styles Level I: A localized multiple casualty emergency wherein local medical resources are available and adequate to provide for field medical and stabilization, including triage. The patients will be treatment Second level transported to the appropriate local medical facility for further and treatment. diagnosis Third level Local and emergency personnel and organizations can contain and effectively manage the disaster and its aftermath Fourth level Level II: A multiple casualty emergency where the large number of casualties and/or lack of local medical care facilities are such as to Fifth level require multi-jurisdiction (regional) medical mutual aid.
Regional efforts and aid from surrounding communities are sufficient to manage the effects of disaster Level III: A mass casualty emergency wherein local and regional medical resource's capabilities are exceeded and/or over-whelmed. Deficiencies in medical supplies and personnel are such as to require assistance from state or federal agencies. Local and regional assets are overwhelmed, national assistance is 25 required

 In disasters, emergency organizations are often required to use different procedures and to establish different priorities for action. One example is the hospital, where medical treatment may be carried out in different areas Click to edit Master text styles than usual. of the facility and by different personnel sometimes Nurses Second level end up making medical decisions, such as which patients to discharge to make room for Third disasterlevel victims. Suspected fractures may be splinted without being X-rayed. Arriving patients may have been Fourth level exposed to dangerous chemical or radioactive material and require decontamination. Fifth level Physicians, nurses, medical students, and student nurses who do not usually work in emergency treatment areas may be pressed into service there. Registration of incoming patients may be abandoned in favor of using disaster tags.

Click to edit Master title style

26

Role of the Nurse in Disaster Click to edit Master title style Response
Depends on the specific needs of the facility Click to edit Master text styles Focuses on essential care from the perspective of what is best for all patients Second level May participate in counseling other staff members provide bereavement support and assistance with May Third level identification of deceased loved ones servelevel as a triage officer May Fourth May provide shelter care in a temporary housing area level Fifth Depends on experience, training, etc. Most important attribute - flexibility
Triage (assessment) Communicate - give feedback (plan) Match available resources Ongoing assessments & surveillance reports Shelter management Stress management

27

Click to edit Master title style

Nurses can assist disaster victims by Click to edit Master text styles providing: Activelevel listening Second Emotional support Third level Giving information Referring patients to a therapist or social worker or mental Fourth level health care services Fifth level Discouraging victim from subjecting themselves to repeated
exposure to the event thru media replays and news articles Encouraging them to return to normal activities and social roles when appropriate

28

Click to edit Master title style

Is a French verb meaning to sort prioritizing patients Click to edit Master text styles Process of separating casualties Allocating Second treatment level based on the victims potential for survival level Third Ambulances responding to a routine emergency usually treat one or two casualties and transport them to a single Fourth hospital. level

Fifth level In disasters, however, there are usually more patients than
one ambulance crew or hospital can handle. Therefore, the need often exists for triage (that is, determining priorities for treatment and transport) and initiating a procedure to distribute casualties equitably among the various hospitals

29

Click edit Master Role of a to triage nurse.

title style

Third level Partnership Fourth level Fifth level All of the nurses and organizations in the

Does a brief evaluation of the patient to determine a levelto of edit acuityMaster or prioritytext care styles Click Acts as a gatekeeper, sorting patients into categories Second Ensureslevel that the most seriously ill are treated first

world can only provide partnerships with the victims of a disaster. Ultimately, it is up to individuals to recover on their own."
30

Click to care edit Master style When health providers are title faced with a large number of casualties:
Fundamental principle guiding Click to edit Master text resource stylesallocation: Second Do the level greatest good for the Third level number of people. greatest Fourth level levelBased on the likelihood of survival Fifth Decisions:

and consumption of available resources. Conditions associated with high mortality rate are assigned low triage priority
31

In a disaster scene Click to edit Master title style Triage officer rapidly assesses those injured Victims are immediately transported or get life Click edit Master text styles savingto interventions One person performs initial triage while other Second level EMS personnel perform life-saving measures Third leveland transport patients (intubation)

Fourth level Triage Fifth level

Initial field triage done in the disaster scene Hospital triage Emergency department or triage area in the hospital Subsequent triage
32

Different TEAMS Click to edit Master title style

Click to edit Master text styles Assessment Team Second level Geographic extent of disasters impact level at risk or affected Third Population level Fourth Presence of continuing hazards Fifth level Injuries and deaths Availability of shelter Current level of sanitation Status of health care infrastructure
33

Communications Triage Persons manning communication and decision-making positions may become so overwhelmed with the volume of traffic that they are forced to perform a sort of "communications triage." That is, they must filter out all but most essential information to transmit. the Click to edit Master text styles A problem can occur when the person filtering the not understand its significance to the overall information Second does level disaster effort

Click to edit Master title style

Third level Fourth level Shelter Management Listen to victims tell & retell happenings Fifth level victims to share feelings Encourage

Help victims make decisions Delegate tasks Provide the basic necessities Attempt to recover or gain needed items Provide basic compassion and dignity Refer to mental health counselor if needed

34

Psychological Stress of Disaster Workers Degree of worker stress depends on the nature of the disaster, role in the disaster, individual stamina, and other environmental factors. Other sources of stress: when workers do not think that they are doing enough to help. Click to edit Master text styles Role conflict in nurse if disaster hits her community (also a victim) Second level Role conflict from organizational chaos level Third Anger and resentment if job takes one away from own disaster situation

Click to edit Master title style

Fourth level Symptoms of early stress and burnout Fifth level Minor tremors

Nausea Loss of concentration Difficulty thinking Problems with memory Suppressing feeling: Guilt, powerlessness, anger Irritability, fatigue, headaches, distortions of bodily functions 35

Dealing with stress while working at disaster Get enough sleep Take time away from the disaster Avoid alcohol Eat frequently in small amounts Click edit textand styles Use to humor toMaster break tension provide relief Use positive self talk Second level Take time to defuse or debrief Third Stay level in touch with people at home Keep a journal Fourth level Provide mutual support

Click to edit Master title style

Fifth level

Delayed Stress Reactions Exhaustion Inability to adjust to slower pace Disappointment, frustration & conflict Anger Fantasize about returning to disaster site Mood swings

36

Based on the North Atlantic Click to edit Master title style Treaty Organization (NATO) triage system
Click to edit Master text styles Immediate (Red) Priority 1 Second level Third level Life-threatening injuries but survival with minimal interventions. Fourth level If treatment is delayed, can progress rapidly to Fifth level expectant

Includes: Sucking chest wound, airway obstruction 2 to mechanical cause, shock, hemothorax, tension pneumothorax, asphyxia, unstable chest and abdominal wounds, incomplete amputations, open fractures of long bones, 2nd/3rd degree burns of 15-40% total body 37 surface area

 Delayed (Yellow) Priority 2title Click to edit Master

style

Significant injuries requiring medical care but can Click to edit Master text styles wait hours without threat to life or limb Second level Individuals receive treatment only after immediate casualties Third level are treated Includes: stable abdominal wounds w/o evidence Fourth level of significant hemorrhage, soft tissue injuries, wounds without airway compromise, Fifthmaxillofacial level vascular injuries with adequate collateral circulation; genitourinary tract disruption; fractures requiring open reduction, debridement, and external fixation, most eye and CNS injuries
38

Click to edit Master title style

Minimal (Green) Priority 3 Click to edit Master text styles Second level Minor injuries; treatment can be delayed hours to days. Third level Individuals in this group should be moved away Fourth level from the main triage area Includes: Fifth level upper extremity fractures, minor burns,

sprains, small lacerations w/o significant bleeding, behavioral disorders or psychological disturbances

39

 Expectant Priority title 4 Click to (Black) edit Master

style

Injuries are extensive and styles chances of survival are Click to edit Master text unlikely even with definitive care. Persons in this group should be separated from Second level other casualties, but not abandoned. Comfort Third level should be provided when possible. measures Includes: Fourth levelUnresponsive with penetrating head wounds, high spinal cord injuries, wounds Fifthinvolving level multiple anatomical sites and organs, 2nd/3rd degree burns in excess of 60% of body surface area, seizure or vomiting w/in 24 hr after radiation exposure, profound shock with multiple injuries, agonal respirations; no pulse, no BP, pupils fixed and dilated

40

Hospital TRIAGE Click to edit Master title style (Emergency Department)

Click to edit Master text styles Emergent (RED) Second level 1. Conditions requiring immediate medical interventions. Third level Any delay in treatment is potentially life, limb, or vision threatening Fourth level 2. Include conditions such as: Fifth level Airway compromise
Cardiac arrest Severe shock Cervical spine injury 3. Multisystem trauma 4. Altered level of consciousness 5. Ecclampsia

41

Click to edit Master title style 1. Patients who present a s stable but whose
There is no immediate threat to life or limb or Second level vision for these patients Third level 2. Conditions include: Fourth level Fever level Minors burns Fifth Minor musculoskeletal injuries Dizziness Lacerations
42

Urgent (YELLOW)

condition requires medical intervention Click to edit Master within a few hours text (1-2 styles hours)

Click to edit Master title style 1. Patients who present with chronic or minor
Click Master styles to No edit danger to life ortext vision by having these patients wait to be seen Second level 2. Conditions include: Third level low back pain a) Chronic b) Routine Fourth level medication refills c) Dental problems Fifth level d) Missed menses
injuries.

Non emergent (GREEN)

Black
DEAD
43

Click to edit Master title style RECOVERY/REHABILITATION

Role of nurse in recovery stage

Click to edit Master text styles Stress of clean up and/or moving hopelessness, depression, grief, suicide, domestic abuse Second level Referrals for mental health services Monitor environmental issue on home visits Third level Follow up visits for recovery. Fourth level Ultimately, individuals need to recover on their own Fifth level Role of nurse in recovery stage
Be mindful of physical and psychological problems Be flexible Be careful of self injury (moving objects) Vigilant in teaching proper hygiene, immunizations. Acute and chronic illness may be exacerbated Counseling and referral of clients to a mental health team 44

CODE Management Click to edit Master title style

A code is a commonly used term in the medical community for cardiopulmonary arrest. Breathing stops, Click edit Master text or styles cardiac to contractions are absent ineffective, and little no cardiac output occurs. or Second level For resuscitations to be effective there must be a Third level systematic approach to the delivery of care. Thus a code team is made. Fourth level The code team must have a captain to lead the efforts directs each of the following tasks: and Fifth level managing the airway providing chest compressions starting IV line administering medications handling the monitor, code cart and defibrillators 45 recording the events of the code

Click to edit Master title style Are documents that a person writes in anticipation
of the fact that at some point they will be unable to make their wishes known their health care Click to edit Master texttostyles providers. Second level Two types

Advance Directives

a. A living will describes what kind of health care a person s Third level to receive n the event a certain medical conditions. Fourth level power of attorney for health - appoints another b. A durable person to speak for the patent f he or she s no longer to do Fifth level so.
For purposes of code management we are most concerned of the patients wishes related to the administration of cardiopulmonary resuscitation (CPR) and mechanical 46 ventilation.

Advance Cardiac Life Support Click to edit Master title style (ACLS)
Emergency medical procedures in which basic life Click to edit Master text styles support efforts of cardiopulmonary resuscitation are Second level augmented by establishment of an IV line, possible defibrillation, Third leveldrug administration, control of cardiac endotracheal intubation, and the use arrhythmias, Fourth level of ventilation equipment Fifth level ACLS guidelines organize resuscitation efforts into a primary and a secondary ABCD (Airway, Breathing, Circulation and Defibrillation) survey.
47

Click Primary to editABCD Master Survey title style

Click edit Master Airway : Isto the airway open? text styles Airway : Open the airway?
Breathing: If not breathing, provide ventilation? Circulati0n: If theres no pulse, begin chest compression? Defibrillation: Is the rhythm VF? Is an AED available?
48

Second level Breathing: Is the patient Third level breathing? Fourth level Circulati0n: Does the patient Fifth level have pulse?
Defibrillation: Does the rhythm require defibrillation?

Click Secondary to edit Master ABCD title Survey style

Airway : Provide advance Click to edit Master airway management

Second level Breathing: Confirm endo Third level tracheal tube placement and adequate oxygenation Fourth level Fifth level Circulati0n: Obtain IV access
and determine rhythm

Airway : Provide intubation text styles with an ET if possible Breathing: by listening to breath sounds and ABG Circulati0n: Identify the cardiac rhythm. Prepare for d administration Differential Diagnosis: What is wrong with this patient? Why did they go into cardiac arrest 49

Differential Diagnosis: Search for and find reversible causes

Equipments needed Click to edit Master title style

Oral airway Emergency Cart (E Click styles Plaster cart) to edit Master text

Laryngoscope Second level Wire guide Third level Ambubag Fourth ET (of level different sizes) Syringes Fifth level(3 100 cc)

IVF (PNSS) Disposable needle G19 - 26 Glucometer and lancet

IV catheter and tubings Emergency drugs Suction catheters KY jelly

Suction Machine Cardiac Monitor (Defibrillator) Cardiac Board Oxygen Tank

50

Pharmacologic Intervention Click to edit Master title style

Adenosine

Click to edit Master text styles Amiodarone HCl V-tach, SV, A-fib and AF Second level Atropine Sulfate Symptomatic Bradycardia (hypotension, Third level ventricular ectopy, chest pain, change in mentation Fourth level Beta-adrenergic WPW syndrome, digoxin toxic rhythm, Fifth agent level ventricular rhythms refractory to other Blocking
Bicarbonate Na Bretylium tosylate drugs Metabolic acidosis VF resistant to defibrillation and lidocaine, V-tach resistant to lidocaine and procanamaide (Pronestyl)

Narrowed complex paroxysmal SVT, WPW syndrome

51

Calcium gluconate

Hypermagnesemia, hyperkalemia, hypocalcemia, calcium channel blocker toxicity, hyperphosphatemia Dobutamine Undergoing cardiac surgery, short term treatment fortext cardiac decompensation, Click to edit Master styles pulmonary congestion with low cardiac Second level output and in hypotensive patients whom vasodilators cannot be utilized. Third level Dopamine Treatment for all kinds of shock (except Fourth level hypovolemic), to improve renal perfusion and for correction of hypotension Fifth level Digoxin CHF, AF or A-fib, SVT

Click to edit Master title style

Diltiazem

Disopyramide

A-fib or AF with rapid ventricular response, narrow complex SVT refractory to other medications PVC, V-tach not requiring defibrillation, AF 52 or A-fib

Epinephrine

Lidocaine HCl Magnesium Click to Sulfate

Click to edit Master style Frequent, multifocal, title paired or R on T

PVC,V-tach, VF

VF, pulseless V-tach, Asystole

Torsade de pointes, refractory V-fib, edit Master text styles cardiac arrest or ventricular Second leveldysrhythmias due to digitalis toxicity, Third level trycyclic overdose, or hypomagnesemia Norepinephrine Hemodynamically significant Fourth level hypotension refractory to other agents bitartrate Fifth level and in shock Quinidine Tocainide Verapamil A-fib, AF, PSVT Symptomatic ventricular dysrhythmias when lidocaine is not effective Supraventricular tachyarrhythmia when heart rate is > 120 53

Respiratory Arrest Click to edit Master title style

of breathing Absence Click to edit Master text styles Is often preceded by progressively worsening Second level respiratory distress or compromise (or both) level arrest is not treated cardiac arrest Third If respiratory follow will Fourth level Occasional gasping breaths, known as agonal Fifth level are ineffective. These patients must respiration, be treated as if they were in respiratory arrest. If the patient shows any kind of respiratory distress, assessment is critical.
54

Cardiac Arrest Click to edit Master title style Identified by the absence of a palpable pulse.

No blood pressure, CO or breathing is detected. death has occurred. Clinical Click to edit Master text styles rhythms may be seen in cardiac arrest 3 Second level

Fourth level Fifth level

Ventricular fibrillation (VF) or pulseless Ventricular Third level tachycardia

55

 Pulseless Electrical Activity

Click to edit Master title style

Click to edit Master text styles Second level Third level Fourth level Fifth level(flat line) Asystole

56

Adult Emergency Cardiac Care Click to edit Master title style Algorithm
Click to edit Master text styles Assess Responsiveness Second level Third level Not Responsive Responsive Activate EMS Observe Fourth level Call for Defibrillator Treat as indicated Assess breathing (open airway Fifth level look, listen and feel)

Breathing Place in rescue position If no trauma

Not breathing Give 2 slow breaths Assess circulation

57

Oxygen IV Cardiac Monitor Vital Signs

No pulse Click style Has pulse to edit Master title start CPR History Physical Exam 12 lead ECG

Click to edit Master text styles Ventricular fibrillation or Second level tachycardia present on cardiac monitor Thirdcauses level Suspected Acute MI NO YES Fourth level Hypotension or Fifth level Shock or Follow VF/VT Intubate
Acute pulmonary edema Dysrhythmia Bradycardia Tachycardia
58

Confirm tube placement Confirm ventilation Determine rhythm and cause

algorithm

Hypotension, Shock and Acute Click to edit Master title style Pulmonary Edema Algorithm
Clinical signs of hypoperfusion, congestive heart failure, acute pulmonary edema

Click to edit Master text styles Assess ABCDs Assess vital signs Second level Secure airway Review history Administer oxygen Perform physical examination Third level Start IV Order 12-lead ECG Attach monitor pulse oximeter, Order portable chest X-ray automatic Fourth level sphygmomanometer Fifth levelWhat is the nature of the problem
Pump problem What is the BP? Administer Fluids Blood Transfusion Cause Specific inventions Vasopressor (if indicated)

Volume problem

Rate problem bradycardia tachycardia

59

Systolic BP < 70 mmHg Fluid bolus of 250-500 ml NSS should be tried. If no Response, consider sympathomimetics

Systolic BP > 100 mmHg Systolic Master BP 70 - 100 mmHg Click to edit title style And diastolic BP normal Fluid bolus of 250-500 ml NSS should be tried. If no Response, consider sympathomimetics

Click to edit Master text styles Second level Dobutamine 2.-20 g/kg Dopamine 2.5-20 g/kg/min Consider: Third level /min (add norepinephrine if Norepinephrine 0.5-3.0 Dopamine is > 2.5-20 g/ g/min IV or Fourth level kg/min) Dopamine 5-20 g/kg Per min Fifth level Consider further actions
Nitroglycerin Start 10-20 g/min IV (use if ischemia persists And BP remains elevated Titrate to effect and/or Nitroprusside Start 0.1-5.0 g/kg/min IV Especially if the pt is in Acute pulmonary edema

Diastolic BP > 110 mmhg

60

Click to edit Master title style First-line actions: Second-line actions: Third-line actions:
Furosemide IV 0.5-1.0 mg/kg Morphine IV 1-3 mg Nitroglycerin SL Oxygen/ intubate

Click to edit Master text styles Second level Third level Fourth level Fifth level

Nitroglycerin IV (if BP > 100 mmHg Nitroprusside IV (if BP > 100 mmHg Dopamine (if BP < 100 mmHg) Dobutamine (if BP > 100 mmHg) PEEP CPAP

Amrinone 0.75 mg/kg then 5-15 mg/kg/min (if other drugs fail) Aminophyllinee 5 mg/kg (if wheezing) Thrombolytic therapy (if not in shock) Digoxin (if a-fib, SVT) angioplasty (if drugs fail) Intra-aortic balloon pump (bridge to surgery) Surgical interventions (valves, coronary artery bypass grafts, heart transplant)

61

Ventricular Fibrillation / Pulseless Click to edit Master title style Ventricular Tachycardia (VF/VT)
ABCs Click to edit Master text styles Perform CPR until defibrillator is attached May deliver precordial thump in witnessed arrest with no pulse Second VF/VT presentlevel on defibrillator Third level Defibrillate up to 3 times if needed for persistent VF/VT Fourth level (200 J, 200-300 J, 360 J) Rhythm after 3 shocks Fifth level Persistent or Recurrent VF/VT Return to spontaneous circulation PEA Asystole

Continue CPR Intubate at once Obtain IV access

Assess V/S Support airway Support breathing Provide medications appropriate for BP, HR and rhythm

62

1 mg IV push, Click toEpinephrine edit Master title style repeat every 3-5 mins

Click to edit Master text styles Defibrillate 360 J with in 30 60 secs Second level Administer medications of probable benefit in Persistent or recurrent VF/VT Third Lidocaine 1.5 level mg/kg IV push. Repeat in 3-5 mins to total loading dose of 3 mg/kg Bretylium 5 mg/kg IV push. Repeat in 5 mins at 10 mg/kg Fourth level Magnesium sulfate 1-2 g IV in torsades de pointes or suspected hypomagnesemic stat of severe refractory Fifth level Procainamide 30 mg/min in refractory VF (max total of 17 mg/kg
Sodium bicarbonate (1 meq/kg IV)

Defibrillate with 360 J, 30 -60 secs after each dose or medication Pattern should be drug-shock, drug shock
63

Pulseless Click to edit Electrical Master title Activity style

Click to edit Master text styles PEA includes: Electromechanical dissociation (EMD) Second level Pseudo EMD Idioventricular rhythm Third level Ventricular escape rhythms Bradyasystolic rhythms Fourth level Postdefibrillation idioventricular rhythms Fifth level
Continue CPR Intubate at once Obtain IV access Assess blood flow using doppler UTZ

64

Click to edit Master title style

Click to edit Master text styles Second level Third level Fourth level Fifth level Epinephrine 1mg IV push , repeat every 3-5 mins

Consider possible causes: (Possible therapies and treatments) Hypovolemia (volume infusion) Hypoxia (ventilation) Cardiac tamponade (pericardiocentesis) Tension pnuemothorax (needle decompression) Hypothermia Massive pulmonary embolism (surgery, thrombolytics) Drug overdose such as tricyclics, digitalis, B-blockers, ca channe blockers Hyperkalemia (sodium bicarbonate) Acidosis (Sodium bicarbonate) Massive acute myocardial infarction

If this approach fails, the ff dosing regimens can be considered Intermediate : epinephrine is 2-5 mg IV push every 3-5min Escalating : epinephrine 1,3 or 5 mg Iv push (3 mins apart) High : epinephrine 0.1mg/kg push every 3-5 mins If absolute bradycardia or relative bradycardia, give atropine 1 mg 65 IV Repeat every 3-5 mins up to a total of 0.04mg/kg

Asystole Algorithm Click to edit Master title style

Click to edit Master text styles Second level Consider possible causes Third level Hypoxia Preexisting acidosis Hyperkalemia Drug overdose Fourth level Hypokalemia Hypothermia Fifth level
Consider immediate transcutaneous pacing Epinephrine 1 mg IV push, repeat every 3-5 mins If this approach fails, other dosing can be considered Intermediate : epinephrine is 2-5 mg IV push every 3-5min Escalating : epinephrine 1,3 or 5 mg Iv push (3 mins apart) High : epinephrine 0.1mg/kg push every 3-5 mins Continue CPR Intubate at once Obtain IV access Confirm asystole in more than 1 lead

66

Click to edit Master title style

Consider Click to edit Master text styles Termination of efforts patient remains in asystole or other Second If level agonal rhythms after successful intubation and initial medications and Third level no reversible causes are identified, consider termination of resuscitative Fourth level efforts by a physician. Fifth level

67

Bradycardia Algorithm Click to edit Master title style (patient not in cardiac arrest)
Click to edit Master text styles Assess v/s Assess ABCs Second Review history Secure airway level Perform physical examination Administer oxygen Third level Order 12 lead ECG Start IV Order portable X-ray Attach monitor, pulse oximeter and automatic sphygmomanometer Fourth level Fifth level
Bradycardia either absolute (< 60 beats/min) or relative Serious signs and symptoms related to rate? Symptoms (chest pain, SOB, dec LOC,) and Signs (low BP, shock, pulmonary congestion, CHF, acute MI)

68

Click to edit Master title style

Type II second-degree or Third-degree AV Heart block? (never treat third Degree heart block plus Ventricular escape beats With lidocaine)

NO

YES

Click to edit Master text styles Second level Third level Fourth level NO YES Fifth level

Intervention sequence Atropine 0.5-1.0 mg atropine should be given in repeat doses 3-5 mins up to total of 0.04 mg/kg. Consider shorter dosing intervals in sever clinical conditions TCP Dopamine 5 20 ug/kg/min Epinephrine 2-10 ug/min Isoproterenol (should be use with extreme caution)

Observe

Prepare for transvenous pacer Use TCP as a bridge device Verify patient tolerance and mechanical capture use analgesia and sedation as needed Never treat third-degree heart block plus ventricular escape beats with lidocaine

69

Tachycardia Algorithm Click to edit Master title style

Click to edit Master text styles Second level Third level Fourth level Unstable, with serious signs or symptoms signs and symptoms may include chest Fifth level pain, SOB, dec LOC, low BP, shock,
pulmonary congestion, CHF, acute MI Assess ABCs Secure airway Administer oxygen Start IV Attach monitor, pulse oximeter and automatic sphygmomanometer Assess v/s Review history Perform physical examination Order 12 lead ECG Order portable X-ray

YES

If ventricular rate > 150 beats/min Prepare for immediate cardioversion May give brief trial of medications on arrythmia Immediate cardioversion is seldom 70 needed for heart rates <150 beats/min

No or borderline

Click to edit Master title style Wide complex Paroxysmal V-tach AF/A-fib
Click to edit Master text styles Consider use of: Vagal manuevers Lidocaine Lidocaine Diltiazem 1-1.5 mg/kg IV push 1-1.5 mg/kg IV push Second level B-blockers Every 5-10 mins Verapamil Third level Adenosine Digoxin Lidocaine Lidocaine 6 mg rapid IV push Procainamide 0.5-0.75 mg/kg IV push 0.5-0.75 mg/kg IV push Over 1-3 sec Fourth level Quinidine Max total 3 mg/kg Max total 3 mg/kg Anticoagulants Fifth level
Adenosine 12 mg rapid IV push Over 1-3 sec May repeat once in 1-2min Adenosine 6 mg rapid IV push Over 1-3 sec Adenosine 12 mg rapid IV push Over 1-3 sec May repeat once in 1-2min Supraventricular Tachycardia (PSVT) Tachycardia with Uncertain type

71

Click to edit Master title style Complex width

Procainamide 20-30 mg/min Max total 17 mg/kg

Click to edit Master text styles Bretylium Narrow Wide 5-10 mg/kg over 8-10 min (max total 30 mg/kg over Second level Lidocaine Blood pressure 24 hours) 1-1.5 mg/kg IV push ThirdLow level Normal or or elevated unstable Fourth level Procainamide 20-30 mg/min Verapamil mg Fifth level Max total 17 mg/kg 2.5-5 IV
Verapamil 5-10 mg IV
Consider use of: Diltiazem B-blockers Digoxin

Synchronized cardioversion

72

Click to edit Master text styles Second level Tachycardia with serious signs and symptoms related to the tachycardia Third level If ventricular rate is > 150 bpm, prepare for immediate cardioversion Fourth level May give brief trial of medications based on specific dysrhythmias Fifth level
Check Oxygen saturation Suction device IV line Intubation equipment
73

Electrical Cardioversion Click to edit Master title style Algorithm (patient not in cardiac arrest)

Click to edit Master title style Premedicate whenever possible

Effective regimens have included a sedative (eg. Diazepam, midazolam, barbiturates, etomidate, ketomine, methohexital) with or wothout an analgesic agent (eg. Fentanyl, morphine, meperidine). Many experts recommend anesthesia if service is readily available

Click to edit Master text styles Second level Third level Synchronized cardioversion If in synchronization delays Fourth level occur and clinical conditions are critical go to Immediate unsynchronized shocks Fifth VT level

PSVT 100 J, 200 -300 J, 360 J A-fib AF Treat polymorphic VT (irregular form and rate) like VF: 200 J, 200-300 J, 360 J PSVT and AF often respond to lower energy levels (start with 50 J)
74

Acute MI Algorithm Click to edit Master title style

Click to edit Master text styles Second level Treatment to consider if there is no evidence of Assessment: Third level Coronary thrombosis plus no reaction for Immediate Exclusion (some but not all may be appropriate) V/S with automatic BP Oxygen at 4 lpm Fourth Oxygen saturation level Nitroglycerin SL or paste (if BP is > 90 mmhg) Start IV Morphine IV Fifth 12 lead ECG level
Briefed targeted history and physical Decide on eligibility for thrombolytic therapy Soon Chest Xray Blood studies (electrolytes, enzymes, coagulation studies) Consult as needed Emergency Department: Door-to-drug team protocol approach Rapid TRIAGE pf patients with chest pain Clinical decision maker established (emergency physician, cardiologist or other)

Aspirin PO Thrombolytic agents Nitroglycerin IV (limit BP drop to 10 % if Normotensive; 30% if hypertensive; never drop Below 90 mmhg systolic) B-blockers IV Percutaneous transluminal coronary angioplasty 75 Routine lidocaine administration Magnesium sulfate

Sample Cases Click to edit Master title style

Case 1 bring in by ambulance a man "Found On Paramedics Click to edit Master text styles Sidewalk". He vocalizes some unintelligible sounds, are open, and he is agitated and restless moving all eyes Second level extremities equally and does not respond to soothing Third level efforts nor answers any questions or performs any commands. He appears to have been well-dressed and Fourth level well-kempt. There is no obvious trauma but his hands abraded and scratched which could have come from are Fifth level resisting his restraints. He has a 100% Oxygen NonRebreather Mask. There are no IVs; they were too close to have time to start any. What are your immediate actions?:
76

Click to edit Master title style

Click to edit Master text styles The patient becomes more agitated and heart rate Second dropslevel into 40s and respiratory rate drops 10 with into Third levelperiods of apnea. Whats going on? Fourth level Fifth level neurologic disaster demonstrated Impending
due to increased intracranial pressure. What do you expect the physician to do next (after initial exam)?
77

Continue oxygen while assessing breathing Apply monitors beginning with pulse oximetry [SpO2=100%] Insert double IV access; draw & send labs.

 Prepare for Rapid Sequence Intubation {Why is Click to edit Master title style this important?}

Prepare for CT scan of the head.

Click to edit Master text styles Second level Diagnosis Third level: Epidural Hematoma [head injury] Fourth level Fifth level

78

Case 2:

Click to edit Master title style

A basic life support ambulance brings a patient from a SNF with "fever & weakness." No other history is available. Click to edit Master text styles The patient is 86 years old, female, appears to be s/p CVA with LUE flexion contracture, and a nasogastric feeding Second level tube. She has a diaper. T=39 C, p.o., Pulse= 116 bpm, Third level RR= 36 BP= 157/90 SpO2=92%

Fourth level level Fifth Your next actions after informing the Charge Nurse
and the physicians are:

79

1. Apply Monitors, order CXR and EKG. 2. Arterial Blood Gas specimen obtained from Radial Artery after satisfactory Allens Test. 3. Administer Oxygen, titration of flow rate to SpO2 97% Click to edit Master text styles 4. Start IV, with "culture prep" so that one of the two Second sets oflevel Blood Cultures can be drawn from the IV line. Draw BC first, then regular lab tubes. Arrange Third for level second BC draw. 5. Start IV fluids at a rate commensurate with degree Fourth level and cardiac status. of dehydration 6. Get an Acetaminophen order for a suppository. Fifth level 7. Obtain urine specimen by either "straight cath" or inserting a Foley catheter; after which give Acetaminophen suppository. 8. If wheezing is present, start a bronchodilator nebulizer treatment.

Click to edit Master title style

80

9. If aeration of lung fields is poor without wheezing, and patient appears dehydrated, consider administering heated mist by mask at an FIO2 that provides satisfactory oxygenation. [ FIO2 mist Click to edit Master styles by the Venturi delivery as less room text air is entrained port\ less mist is carried] Second level 10. If the patient is able to provide a sputum specimen Third level or one can be suctioned, send to Microbiology laboratory Fourth levelfor stat. Grams Stain, Culture & Sensitivity. If urine "dips" +Esterase for leukocytes, send for stat. Grams Stain as well as C&S. Fifth level 11. Give antibiotics at earliest opportunity. Arrange admission.

Click to edit Master title style

Diagnosis: Pneumonia; Possible Aspiration

81

Case 3

Click to edit Master title style

A 3 year old boy who has had a URI is brought in by parents because "hes having trouble breathing!" They Click to edit Master styles report coughing spells, a littletext vomiting, no fever at present. Upon questioning, they say, "yes, it did sound like a barking Second level seal!" They add "it got better on the way once we were in Third level the cool night air.

Fourth level Fifth You level surmise the diagnosis is:

1. Croup (Acute laryngotrachealbronchitis)

82

 Then you notify the pediatrician, and

Administer cool saline mist blow-by Be prepared to change mist to Racemic Epinephrine Click to editinMaster (0.25-0.5ml 2.5ml NStext usestyles plastic dropper or syringe without Second level needle to measure no metal) Dexamethasone, IM, 0.6mg/kg may be needed at discharge Third levelto minimize recurrence) If diagnosis is doubtful, soft-tissue Neck X-Ray Fourth level looking for a "Steeple" sign of a trachea narrowed by mucosal swelling {may be needed to rule out Fifth level epiglottitis}.

Click to edit Master title style

Diagnosis: Croup (Acute LaryngoTrachealBronchitis)

83

 Case 4:

Click to edit Master title style

Several youths bring in a friend saying "We were just minding our own business but some guys jumped us, Click Master text styles and he to gotedit cut!" There is an incised wound of the right palm, assorted abrasions and swellings. Pulse oximetry Second level is normal, and vital signs are OK, although pulse is 116 bpm (but theyre all still pretty excited); still, he looks a Third level little pale and anxious. "Did you get hurt anywhere else?" "Nah." You take him back to an exam room. "Take off Fourth level your clothes and put on this gown." "Do I gotta? I only got cut" "Yes!" As he takes off his football team stadium Fifth level coat, you notice a tear in the fabric, and his skinny chest does not seem to be symmetrical in its rise and fall; the right chest seems to lag behind corresponding with the side of the jacket hole.
84

 Your next actions are: 1. Inspect the chest. (You find a small wound just medial to the right scapula. It seems to hiss and splatter a little respirations.) blood Clickwith to edit Master text styles 2. Cover the wound. (Gauze and tape is all that you have Second on hand.) level 3. the chest. (No breath sounds on the right.) Auscultate Third level 4. Notify the Attending Physician. Fourth 5. Call for a level stat. portable chest X-ray. 6. Apply Fifth oxygen level by 100% non-rebreather mask.

Click to edit Master title style

What is the most likely thing that has happened? 1. He has either been stabbed or shot during the fracas which may not have been noticed during the scuffle. He has a "sucking chest wound."
85

 Why bother with a CXR? You already know the problem. Click to edit Master title style

1. Its the only Master way to determine if there are any Click to edit text styles metal fragments in the chest (broken knife blade Second level or bullets) or any other traumatic pathology.

Third level By the time the chest X-ray is done, the patient Fourth level is more restless, with a slight sheen of diaphoresis Fifth level on his skin which seems a little
cooler. You now have (with the help of another nurse) two large bore IV lines. You reassess the patient, his pressure is down, breathing is more labored, and the trachea is now moved somewhat over to the left. You tell the physician. 86

What happens next?

Click to edit Master title style

1. A colleague is grabbing a thoracostomy tray, tube, and Pleur-Evac. to editopens Master text styles 2. Click The physician up the dressing and tries to insert a gloved finger into the wound to enlarge it (convert the Second level tension pneumothorax to an open pneumothorax and decompress Third levelthe chest to allow better cardiac output) but is unsuccessful. 3. Fourth "Get me level a needle!" Betadine is poured on the chest wall, and a 14 gauge needle is inserted into the Anterior Fifth level Space at the Mid-Clavicular Line with a 2nd Intercostal rewarding "Hisssssss" into the room. The heart rate of 136 slows to 110, and the patient looks less pale. 4. A tube thoracostomy is placed and the Pleur-Evac is connected to suction.
87

 The heart rate is 125 bpm and the BP is 90 torr systolic. The breath sounds are decreased on the left base 1/3rd up, you quickly percuss the chest (listening carefully because of background noise) and feel that the percussion note Master is dull. You nowstyles surmise, and a doctor Click to edit text bursts in to report on the CXR . . .

Click to edit Master title style

Second level Third level "Theres a small caliber bullet on the left side and a hemothorax! Fourth level Fifth level

88

You now expect, and help to make happen the following activities:

Click to edit Master title style

1. Tube Thoracostomy, low on the left side(5th Intercostal Space to in the Mid-Axillary Click edit Master Line) text . styles 2. Insert Foley Catheter. 3. Second Repeat CXR. level 4. Call Cardio-Thoracic Surgery. level 5. Third Prepare a "Pre-Op Check List". 6. Notify the Nursing Supervisor to obtain a critical care Fourth level bed, if not already done by the Charge Nurse. 7. Fifth Ask the physicians if the patient is going to OR, if so, level they may wish to have a Cell-Saver set up to permit autotransfusion. 8. Verify that "Type & Cross-match" for 6 units of packed red blood cells has been sent, and that a "Check Specimen" to reconfirm ABO typing has been obtained by a second individual, and that both tubes have been 89 correctly labeled and signed.

9. Ask the physicians if the patient is to be transfused now, do they wish type-specific blood without waiting for cross-match (if so, a licensed physician must sign the "Emergency Cross-Match Release" on the blood bank form). 10. If the patient is going to OR, call ahead and warn them, Click to edit Master text styles give report if possible even if the patient is already rolling out the door. Second level 11. If the patient is going to a critical care unit rather than OR, the ICU resident will need to be notified. Third level

Click to edit Master title style

Fourth level been done, and must be done? What else hasnt If the hand wound was bleeding, it too should have Fifth level earlier. been bandaged
The police must be notified of the GSW. The patients clothes must be placed in labeled and stapled paper bags for evidence.

Diagnosis: Assault w/ Occult Wound, Pneumothorax; 90 Tension Pneumothorax; & Hemothorax