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Emergency and Critical

Care
Nurse Licensure
Examination Review
Basic life support (BLS)
 A means of providing oxygen to
the brain, heart and other organs
until help arrives

 Also known as
CARDIOPULMONARY
RESUSCITATION
Basic life support (BLS)
 An adult is a person above age 8

 A child is any person age 1 to 8
years old

 An infant is anyone under 1 year
Basic life support (BLS)
 The BLS follows the A-B-C
principle

• A= airway

• B= breathing

• C= circulation
Basic life support (BLS)
 Causes of cardiac arrest
• Respiratory arrest
• Direct injury
• Drug overdose
• Cardiac arrhythmias
Basic life support (BLS)
ADULT
 STEPS in CPR: First STEP!!!
• ASSESSMENT: determine
Unresponsiveness
• Assess for 5-10 seconds
• Shake the victim’s shoulder and ask:
“are you okay”
Basic life support (BLS)
ADULT
 STEPS in CPR: Second Step
• Survey the area
Basic life support (BLS)
ADULT
 STEPS in CPR: Third Step
• Call for HELP
• Activate emergency medical system

• Note: for child and infant this is done
LAST
Basic life support (BLS)
ADULT
 STEPS in CPR: Fourth step
• Place Victim in Supine position on a
flat firm surface

• Log roll the patient when moving
Basic life support (BLS)
ADULT
 STEPS in CPR: Fifth step
• OPEN the airway

• Head tilt-Chin Lift method

• Jaw thrust maneuver if neck injury is
suspected
Basic life support (BLS)
ADULT
 STEPS in CPR: Sixth step
• Assess BREATHING
 Place ear over the nose and mouth
 Look for chest movement

 Perform for 3-5 SECONDS
Basic life support (BLS)
ADULT
 STEPS in CPR: Sixth step
• Assess BREATHING
 If breathing: place on side if no
neck injury; DO NOT move if with
neck injury

 If NOT BREATHING: deliver
INITIALLY 2 rescue breath via
mouth to mouth
 Then deliver 10-12 breaths/minute
Basic life support (BLS)
ADULT
 STEPS in CPR: Seventh step
• Assess CIRCULATION
 Check for the carotid pulse on the
side close to you for 5-10 SECONDS
 If with (+) pulse ; continue giving

10-12 breaths/minute
Basic life support (BLS)
ADULT
 STEPS in CPR: Seventh step
• Assess CIRCULATION
 If withOUT pulse: START Chest
Compression
 Correct hand placement: LOWER HALF

of sternum one hand over the other
with fingers interlacing
 Depress: 1 ½ to 2 INCHES

80-100 compressions/min
Basic life support (BLS)
ADULT
 STEPS in CPR: Seventh step
• Assess CIRCULATION
 If withOUT pulse: START Chest
Compression
 ONE-rescuer: 15 chest: 2 breaths

 TWO-rescuer: 5 chest: 1 breath

 DO FOUR cycles and re-assess for
pulse
Basic life support (BLS)
CHILD
1-8 years old
 AIRWAY: assess unresponsiveness

and keep airway patent by HTCL or
JT
 BREATHING: assess for airflow and

chest movement
• If breathing: maintain patent airway
• If NOT breathing : deliver 2 rescue
breaths by mouth to mouth
• DELIVER 20 breaths/minute
Basic life support (BLS)
CHILD
1-8 years old
 CIRCULATION: assess the carotid

pulse
• If with pulse: continue to deliver 15-20
breaths/minute
• If WITHOUT pulse: start chest
compression
• Correct hand placement: lower half of
sternum using heel of ONE HAND
• DELIVER: 1 to 1 ½ inches
80- 100 chest compressions/min
5:1 (do 20 cycles  EMS)
Basic life support (BLS)
INFANT
Less than 1
 Determine unresponsiveness

 AIRWAY: Place head of infant in

NEUTRAL position
 BREATHING: assess for rise-fall of

chest and airflow
• If breathing: maintain patent airway
• If NOT breathing: initiate 2 rescue
breathing via mouth to mouth and nose
• DELIVER 20 breaths/min SLOWLY
Basic life support (BLS)
Less than 1
INFANT
 CIRCULATION: assess for pulse: The
BRACHIAL pulse is utilized!!
• If with pulse: continue to deliver 20
breaths/min
• If WITHOUT pulse, start chest
compression
• Correct hand placement: just below the
nipple line in the sternum using 2-3
fingers of one hand!!
• DELIVER: ½ to 1 inch depth
100 chest com/min
5:1 ratio (do 20 cycles EMS)
AIRWAY Obstruction
 Incomplete
• Crowing sound is heard
encourage to cough

 Complete
• Clutching of the neck
• Ask: “Are you choking?”
• Perform Heimlich’s
AIRWAY Obstruction
 Complete
• If patient becomes unconscious:
 Place supine on flat surface
 Perform tongue-jaw lift maneuver

 FINGERSWEEP to remove object

 Open airway and attempt ventilation

 Perform Heimlich while supine

 Reattempt ventilation

 SEQUENCE: TJL finger-sweep  rescue

breaths Heimlich’s TJL
AIRWAY Obstruction
 Pediatric considerations:
 CHILD: NEVER DO Blind Finger

sweep
AIRWAY Obstruction
 Pediatric considerations:
 INFANT: never DO blind finger-

sweep
 Give five back blows in the

interscapular area and turn the
infant with head lower than
trunk then deliver chest thrust
below the nipple line
AIRWAY Obstruction
 Obstetric considerations:
 Hand is placed over the middle

part of sternum: backward chest
thrust

 If unconscious: place pillow
below the RIGHT abdomen to
displace uterus
Shock
 An abnormal physiologic state
where an imbalance exists
between the amount of
circulating blood volume and the
size of the vascular bed.
Pathophysiology of Shock
1. Cellular effects of shock
 In the absence of oxygen, the cell
will undergo Anaerobic metabolism to
produce energy source and with it
comes numerous by-products like
lactic acid
 The cell will swell due to the influx of
Na and H20, mitochondria will be
damaged, lysosomal enzymes will be
liberated, and then cellular death
ensues.
Pathophysiology of Shock
2. Organ System Responses
 When the patient encounters

precipitating causes of shock, the
circulatory function diminishes
there is decreased cardiac output
 Hypotension and decreased
tissue perfusion will result
Shock Stages
There are three stages of
shock
 Compensatory stage

 Progressive stage

 Irreversible stage
Shock Stages
THE COMPENSATORY STAGE OF SHOCK
 In this stage, the patient’s blood pressure is

within normal limits.
 Patient’s blood is shunted from the kidney,

skin and GIT to the vital organs- brain, liver
and muscles
 Manifestations of cold clammy skin, oliguria

and hypoactive bowel sounds can be
assessed.
 Medical management includes IVF and

medication
 Nursing management includes monitoring of

tissue perfusion & vital signs, reduction of
anxiety, administering IVF/ordered
medications and promotion of safety
THE PROGRESSIVE STAGE OF SHOCK
 In this stage, the mechanisms that
regulate blood pressure can no longer
compensate and the mean arterial
pressure falls.
 The overworked heart becomes
dysfunctional. Heart rate becomes
very rapid (as high as 150 bpm)
 Blood flow to the brain becomes
impaired, the mental status
deteriorates due to decreased
cerebral perfusion and hypoxia.
 Laboratory findings will reveal
increased BUN and Creatinine. Urinary
output decreases to below 30
mL/hour.
Shock Stages
THE PROGRESSIVE STAGE OF SHOCK
 Decreased blood flow to the liver
impairing the hepatic functions. Toxic
wastes are not metabolized
efficiently, resulting to accumulation
of ammonia, bilirubin and lactic acids.
 The reduced blood flow to the GIT
causes stress ulcers and increased
risk for GI bleeding.
 Hypotension, sluggish blood flow,
metabolic acidosis (due to
accumulation of lactic acid), and
generalized hypoxemia can interfere
with normal blood function.
Shock Stages
THE IRREVERSIBLE STAGE OF SHOCK
 This stage represents the end point

where there is severe organ damage
that patients do not respond anymore
to treatment. Survival is almost
impossible to maintain.
 Despite treatment, the BP remains

low, anaerobic metabolisms continues
and multiple organ failure results.
 Medical management is the use of life

supporting drugs like epinephrine and
investigational medications.
Assessment of Shock
Assessment Findings
Skin : Cool, pale, moist in hypovolemic and
cardiogenic shock
: Warm, dry, pink in septic and
neurogenic shock
Pulse
 Tachycardia, due to increased sympathetic
stimulation
 Weak and thready

Blood pressure
 1. Early stages: may be normal due to
compensatory mechanisms
 2. Later stages: systolic and diastolic blood
pressure drops.
Assessment of Shock
Assessment Findings
Respirations: rapid and shallow, due to
tissue anoxia and excessive amounts
of CO (from metabolic Acidosis)
Level of consciousness: restlessness
and apprehension, progressing to
coma
Urinary output: decreases due to
impaired renal perfusion
Temperature: decreases in severe
shock (except septic shock).
Management of Shock
Nursing Interventions
 Management in all types and

phases of shock includes the
following:
 Basic life support
 Fluid replacement

 Vasoactive medications

 Nutritional support
Management of Shock
A. Maintain patent airway and adequate
ventilation.
B. Promote restoration of blood volume;
administer fluid and bloodreplacement as
ordered
C. Administer drugs as ordered
D. Minimize factors contributing to shock.
E. Maintain continuous assessment of the
client.
F. Provide psychological support: reassure
client to relieve apprehension, and keep
family advised
G. Provide Nutritional support
Hypovolemic Shock
This is the MOST common form of
shock characterized by a
decreased intravascular volume
Risk factors: external Fluid Losses
Trauma, Surgery, Vomiting,
Diarrhea, Diuresis, DI
Risk factors: internal fluid shifts
Hemorrhage, Burns, Ascites,
Peritonitis, Dehydration
Hypovolemic Shock
 Decreased blood volume
decreased venous return to the
heart decreased stroke
volume decreased cardiac
output decreased tissue
perfusion
 Assessment findings: cold
clammy skin, tachycardia,
mental status changes,
tachypnea
Hypovolemic Shock
 MEDICAL MANAGEMENT:
• The major medical goals are
to restore intravascular
volume, to redistribute the
fluid volume, and to correct
the underlying cause of fluid
loss promptly
Hypovolemic Shock
 NURSNG MANAGEMENT:
• Primary prevention of shock is the
most important intervention of the
nurse.
• General nursing measures include-
safe administration of the ordered
fluids and medications, documenting
their administration and effects. The
nurse must monitor the patient for
signs of complications and response to
treatment. Oxygen is administered to
increase the amount of O2 carried by
the available hemoglobin in the blood.
Cardiogenic shock
This shock occurs when the heart’s
ability to contract and to pump
blood is impaired and the supply of
oxygen is inadequate for the heart
and tissues
 Risk factors: Coronary factor-
Myocardial infarction
 Risks factors: NON coronary:

• Cardiomyopathies
• Valvular damage
• Cardiac tamponade
• Dysrhythmias
Cardiogenic shock
 Precipitating factors will cause
decreased cardiac contractility
Decreased stroke volume and cardiac
output leading to 3 things:
 Damming up of blood in the
pulmonary vein will cause
pulmonary congestion
 Decreased blood pressure will
cause decreased systemic
perfusion
 Decreased pressure causes
decreased perfusion of the
coronary arteries leading to
weaker contractility of the heart
Cardiogenic shock
ASSESSMENT FINDINGS: Angina,
hemodynamic instability, dysrhythmias
 MEDICAL MANAGEMENT:
• The goals of medical management are to
limit further myocardial damage and
preserve and to improve the cardiac
function by increasing contractility.
 NURSING MANAGEMENT:
• The nurse prevents cardiogenic shock by
early detection of patients at risk.
• Safety and comfort measures like proper
positioning, side-rails, and reduction of
anxiety, frequent skin care and family
education.
Circulatory shock
 This is also called distributive
shock. It occurs when the blood
volume is abnormally displaced
in the vasculature.
• Septic Shock
• Neurogenic Shock
• Anaphylactic Shock
Circulatory shock
 Massive arterial and venous
dilation allows pooling of blood
peripherally maldistribution of
blood volume decreased
venous return decreased
stroke volume decreased
cardiac output Decreased blood
pressure decreased tissue
perfusion.
Circulatory shock
 Risk factors for Septic Shock
• Immunosuppression
• Extremes of age (<1 and
>65)
• Malnourishment
• Chronic Illness
• Invasive procedures
Circulatory shock
 Risk factors for Neurogenic Shock
• Spinal cord injury
• Spinal anesthesia
• Depressant action of
medications
• Glucose deficiency
Circulatory shock
 Risk factors for Anaphylactic Shock
• Penicillin sensitivity
• Transfusion reaction
• Bee sting allergy
• Latex sensitivity
SEPTIC SHOCK
This is the most common type of
circulatory shock and is caused by
widespread infection.
The HYPERDYNAMIC PHASE
• High cardiac output with systemic
vasodilatation.
• The BP remains within normal
limits.
• Tachycardia
• Hyperthermic and febrile with
warm, flushed skin and bounding
pulses
SEPTIC SHOCK
The HYPODYNAMIC or irreversible
phase
• LOW cardiac output with
VASOCONSTRICTION
• The blood pressure drops, the skin
is cool and pale, with temperature
below normal.
• Heart rate and respiratory rate
remain RAPID!
• The patient no longer produces
urine.
SEPTIC SHOCK
 MEDICAL MANAGEMENT:
• Current treatment involves
identifying and eliminating the
cause of infection. Fluid
replacement must be instituted
to correct Hypovolemia,
Intravenous antibiotics are
prescribed based on culture and
sensitivity.
SEPTIC SHOCK

 NURSING MANAGEMENT:
• The nurse must adhere strictly to the
principles of ASEPTIC technique in
her patient care.
• Specimen for culture and sensitivity
is collected. Symptomatic measures
are employed for fever, inflammation
and pain. IVF and medications are
administered as ordered.
Neurogenic Shock
This shock results from loss of
sympathetic tone resulting to
widespread vasodilatation.
 The patient who suffers from

neurogenic shock may have
warm, dry skin and
BRADYCARDIA!
Neurogenic Shock
 MEDICAL MANAGEMENT:
• This involves restoring
sympathetic tone, either through
the stabilization of a spinal cord
injury or in anesthesia, proper
positioning.
Neurogenic Shock

 NURSING MANAGEMENT:
• The nurse elevates and maintains
the head of the bed at least 30
degrees to prevent neurogenic
shock when the patient is
receiving spinal or epidural
anesthesia.
Anaphylactic Shock

 This shock is caused by a
severe allergic reaction when
a patient who has already
produced antibodies to a
foreign substance develops a
systemic antigen-antibody
reaction
Anaphylactic Shock
 MEDICAL MANAGEMENT:
• Treatment of anaphylactic shock
requires removing the causative
antigen, administering
medications that restore vascular
tone, and providing emergency
support of basic life functions.
• EPINEPHRINE is the drug of choice
given to reverse the vasodilatation
Anaphylactic Shock
 NURSING MANAGEMENT:
• It is very important for nurses to
assess history of allergies to
foods and medications!
• Drugs are administered as
ordered and the responses to the
drugs are evaluated.
Triage
 “trier”- to sort

 To sort patients in groups based on
the severity of their health problem
and the immediacy with which these
problems must be addressed
Triage in the E.R.
 Berner’s
2. Emergent

4. Urgent

6. Non-urgent
Triage in DISASTER!
 NATO
2. Immediate

4. Delayed

6. Minimal

8. Expectant
Triage
1. Emergent
• Patients have the highest priority
• With life-threatening condition
2. Urgent
• Patients with serious health
problems
• Not life-threatening, MUST be seen
in 1 hour
3. Non-urgent
• Episodic illness that can be
addressed within 24 hours
Triage Priority Color Conditions

category Triage in Disaster
Immediate 1 RED Chest
wounds,
shock, open
fractures, 2-3
burns

Delayed 2 YELLOW Stable
abdominal
wound, eye
and CNS
injuries

Minimal 3 GREEN Minor burns,
minor
fractures,
minor
bleeding

Expectant 4 BLACK Unresponsive,
high spinal
cord injury
Preparing for terrorism
1. Recognition and Awareness
2. Use of personal protective
equipments
3. Decontamination of contaminants
Biological Weapons
ANTHRAX
 Drug of choice is Ciprofloxacin or

Doxycycline

SMALLPOX
 Supportive
Chemical Weapons
Organophosphates
• Supportive care
• Soap and water
• Atropine
• Pralidoxine
Cyanide
• Sodium nitrite, Amyl Nitrite, Methylene
Blue
• Sodium thiosulfate
• Hydrocobalamin
CYANIDE POISONING
Radiation
Alpha Particles Cannot penetrate
skin
Causes local
damage
Beta Particles Moderately penetrate
the skin
Can cause skin damage
and internal injury if
prolonged
Gamma Particles Penetrate skin
Can cause serious
damage
X-ray is an example