Adult Emergency

primary survey

- airway/cervical spine immobilization - breathing - circulation/control hemorrhage - disability - exposure

chest pain

- always triage as emergent - MI pain relieved with NTG or rest d/t lack of blood flow - angina = chest pain or discomfort d/t myocardial ischemia

SBATIR

- situation - brief medical history - assessment and diagnostic findings - transmission based precautions - interventions - response to interventions

triage

- sorting or classifying clients into priority levels depends on illness or injury severity - performed by an RN, physician or PA - highest acuity needs receive the soonest evaluation, tx and prioritized resource utilization

emergent triage

implies the condition poses an immediate threat to life, limb, or vision; requires immediate care and intervention

level III trauma center

smaller, rural hospitals, serve areas with low population densities, primary focus is stabilization and pt transfer

emergency medicine physicians

specialized education and training in emergency client mgmt- board certification

paramedics

- advanced life support providers - perform advanced techniques such as cardiac monitoring, airway mgmt, establish IV access, adm of meds in route to ED

frostbite

- accompanied by initial pain, loss of sensation and paresthesia; are may be edematous, red, blistered, white, hard, cold to touch, necrotic pallor of affected area - remove from cold and immerse the areas in warm water - do not rub affected area b/c it can cause more tissue damage - deep damage requires aggressive mgmt - newly thawed areas will be very painful - anticipate tetanus prophylaxis, topical and parenteral antibiotics, analgesics

emergency nursing

- "rapid change is the role" - provide care for clients across the lifespan - acuity from minor to life-threatening - most common reason of seeking care is pain - average age is 35.7 - clients over 75 have highest rate of visits - crucial communication with ambulance staff, helicopter personnel and other nursing staff

near-drowning event

- asphyxia can be caused by laryngotracheal spasm, water filled lungs, emesis - obtain a pre-hospital hx including length of submersion, tx and client progress - handle pt gently, a cold heart can cause v-fib with rough handling - continuous temp monitoring with rectal probe, intrabladder cath or esophageal probe - recovery after submersion, safe rescue of victim - after removal, airway and cardiopulmonary support intervention, including CPR - establish patent airway- intubation and mechanical ventilation - IV access- LR for salt water, NSS for fresh water

airway/cervical spine immobilization

- assess airway and maintain patency - chin lift/jaw thrust; suction; oro- or naso- pharyngeal intubation; cricothyroidotomy; tracheostomy

circulation/control hemorrhage

- assess for presence of adequate circulation - direct pressure to control bleeding, IV access 16 gauge AC, fluid volume replacement with warmed RL or NS, blood or blood products, CPR, pericardiocentesis, autotransfusion

disability

- assess with a brief neuro exam A: Alert V: responsive to verbal stimuli P: responsive to pain U: Unresponsive GCS - continual reassessment while identifying causes- metabolic abnormalities, hypoxia, neuro injuries

breathing

- auscultate breath sounds; evaluate chest excursion, resp effort, evidence of chest wall trauma; observe for distended neck veins, retractions, tracheal deviation, subQ emphysema - O2, BVM ventilation, chest tube insertion, cover open chest wound, needle thoracostomy, pressure dressing for flail chest

heat related illness prevention

- avoid alcohol and caffeine - prevent overexposure to the sun, use SPF and UVB protection - rest frequently and take break from being in hot environment - wear clothing suited to the environment - pay attention to personal physical limitation - take cool baths and showers to help reduce body temp - stay indoors in air-conditioned building - check on older adults 2x a day

EMTs

- basic life support providers - administer O2, provide basic wound care, spinal immobilization, VS monitoring, may be authorized to administer EpiPen or NTG

arthropod bites and stings

- bites from brown recluse spiders result in ulcerative lesions - central bite appears a bleb or vesicle - use cold compress never heat - dapsone may be given PO - debridement and skin grafting may assist wound healing

tension pneumothrorax

- blunt penetrating trauma, fractured ribs, barotraumas, injured tracheobronchial tree, infection - hyperinflation, lung collapse on injured side, mediastinal shift unaffected side = compressed vena cave, decreased CO - labored resp, dyspnea, tachypnea, hypoxia, decreased or absent lung sounds, trachea deviation away from injured side, decreased CO - O2, needle thoracostomy, chest thoracostomy, monitor for hypoxia = restlessness, anxiety, mental status change - analgesics

lightning injuries

- cardio and CNS profoundly affected - most lethal initial effect on cardiac system is asystole or v-fib - tx includes immediate CPR

patient safety

- client identification - client safe from falls and skin breakdown - risk for med errors and adverse events resulting from episodic and chaotic nature or ED mgmt, including hospital acquired infections

head trauma

- control pt environment, decrease stimuli - maintain airway needs and provide O2 - continuous assessment of neuro status, changes, VS and increasing ICP = mental status, LOC , cranial nerve assessment, motor status, sensory, resp pattern and rate

debriefing

- critical incident stress mgmt (CISM) program should be implemented ASAP following the event; encourage group discussion by all participants - addresses pre-crisis through post-crisis interventions for all involved - designed to mitigate the impact of a critical event and to assist the persons in recovery from the stress associated with the event - facilitated by specially trained team including professional and peer support personnel PTSD can lead to multiple characteristic psychological and physical effects

hypothermia

- decreased clotting and impairment of the immune system - occurs at core body temp of <95 - stabilize airway, breathing, adm O2 - re-warming methods include blankets, packs, heaters; heated and humidified O2, heated gastric lavage, heated peritoneal lavage, heated pleural irrigation through chest tube - CPR and defibrillation unsuccessful - retry after rewarming

uncontrolled hemorrhage

- decreased tissue perfusion results in hypoxia, vasoconstriction, blood shunting may lead to metabolix acidosis, MODS, resp failure and cardiac arrest - cool, clammy, pale skin and extremities, delayed cap refill, weak and thready pulses, hypotension, tachypnea, decreased LOC, cardiac dysrhythmias, decreased UO - stop obvious bleeding, warmed IV fluids, blood replacement, monitor cardiac rhythm, VS, CVP, mental status, UO - anticipate crystalloids and blood products, sodium bicarb to correct acidosis and vasopressors

burns

- depth of burn injury varies - emergent phase of burn injury is first phase and continues for 48 hours - secure airway, fluid replacement, prevent infection, maintain body temp, provide emotional support

snakebites

- determine whether envenomation from N. American pit viper - keep bitten extremity at level of heart in a position of function - obtain hospital acute care ASAP - IV adm of crotalidae polyvalent immune fab (Crofab) therapy treats bites of all N. and S. American crotalids. - supportive care and opioids for pain - monitor for coagulopathy - coral snake bite requires continuous monitoring- delayed symptoms and flaccid paralysis

scorpion sting

- effects of a sting that injects venom from a scorpion are typically self-limiting and best treated by analgesics, supportive mgmt, basic wound care - one species of scorpion can inflict a sting associated with a severe, potentially fatal systemic response

heat stroke presentation

- elevated body temp >105 - mental status changes, anxiety, confusion - hypotension - tachycardia - tachypnea - severe renal impairment and disseminated intravascular coagulation

altitude related illness

- elevations >5000 ft can produce physiologic consequences as a result of lowered levels of available O2 - hypoxia can result in AMS, ACE, HAPE - relocate to safer, lower altitude, adm O2

black widow spider

- envenomation produces latrodectism, severe abd pain, muscle rigidity and spasm, HTM, and n/v - other symptoms include facial edema, ptosis, diaphoresis, weakness, increased salivation, priapism, resp difficulty, increased resp secretions, fasciculations, and paresthesias - tx with icepack and transfer to medical facility ASAP

respiratory emergencies

- establish open airway - airway positioning - airway foreign object removal - oral/nasal airway insertion - ER department intubation practices - assisting in airway mgmt - supplemental O2

airway obstruction

- facial & neck trauma, mechanical obstruction, allergic rxns, infections, exposure to irritants, medical or neuro conditions - inability to cough, breathe or speak, stridor, wheezing, choking or gagging, - cyanosis, SOB, altered LOC, bradycardia, hypotension, cardiopulmonary arrest - chin lift, jaw thrust maneuver, ET intubation, cricothoracotomy, tracheostomy - antibiotics, bronchodilators, sedation

pre-hospital care providers

- first caregivers encountered by client - local protocols define skill level of EMS responders

nursing assessment

- follow establish protocols - maintain privacy, dignity, and confidentiality - implement physician orders - re-assess and re-prioritize as needed

MVA- Blunt and multiple trauma

- hypovolemia, resp distress, pneumothorax, hemothorax, blunt trauma to head, fractures - serial assessment of VS, LOC, pain - treat shock with modified trendelenburg, control obvious bleeding, 2 large bore IVs with RL and NSS, NG tube, urinary cath - positioning, splinting, ice and elevation of closed fractures - immobilize cervical spine - anticipate fluid resuscitation with LR or NSS, tetanus immunization, antibiotics, analgesics, vasopressors

spinal cord immobilization

- initial tx of suspected injury include ABCs of resuscitation, spinal immobilization, prevention of further injury, transport - perform complete sensory and motor neuro exam - maintaining spinal immobilizing devices until xray studies are confirmed is a must to prevent further damage

heat stroke treatment

- initiate rapid cooling after ensuring patent airway - evaporation and/or immersion cooling with icepack placement

penetrating and perforating ocular injuries

- injuries are major cause of vision loss - failure of aggressive mgmt of laceration of the cornea and sclera will likely result in visual loss - monitor for s/s of infection, further vision loss, increasing pain, hemorrhage or other complications, report to PCP immediately

psychiatric crisis nurse

- interact with clients and families in crisis - evaluates clients with psych complaints or disorders - facilitates follow up of admission to psychiatric facility

penetrating injuries- stab wounds/gun shot wounds

- low velocity missiles with low kinetic energy result in little dissipation as it enters the body - high velocity missiles with high kinetic energy result in much damage to tissue directly affected by the missile and those tissues affected by cavitation's, shock wave and heart of missile - open wound and shock - extent of organ and tissue damage determines mgmt, anticipate tetanus immunization, antibiotics and analgesics

traumatic amputations

- massive blood loss can lead to hypovolemic shock and death - restore cardiovascular stability - soft tissue edema at amputated site can cause sluggish venous return, increasing muscle compartment volume = neurovascular compromise - extremity assessment q1-2 hr, compared to unaffected side - affected extremity shoud remain elevated and cooled to promote venous return and minimize edema - turning and positioning the immobilized pt is essential to prevent skin breakdown - antibiotic therapy - cardio assessment, VS, neuro eval, pulse ox and fluid volume status

carbon monoxide inhalation

- mild = n/v, h/a, flu-like symptoms - moderate = dyspnea, dizziness, confusion - severe = coma, resp arrest, hypotension, dysrhythmia

technical skills

- multitasking in a stressful, high pressure environment; assisting with suturing, foreign body removal, central line insertions, ET intubation and initiation of mechanical ventilation, transvenous pacemaker insertions, lumbar puncture, pelvic exam, chest tube insertion, paracentesis, fracture mgmt

forensic nurse examiners

- obtain histories - collect forensic evidence - offer counseling and follow-up care for rape, child abuse and domestic violence

spinal cord evaluation

- ongoing assessment - airway and ventilation functioning - urine output - further degenerative losses of movement, sensation, muscle spasms, and contractures are essential for immediate interventions, including surgery or transport to a higher-level facility

bees and wasps

- potential for anaphylactic rxn - emergency care to remove stinger and apply ice pack - advanced emergency care in hospital to ensure ABCs - EpiPen adm - carry prescription epinephrine autoinjector and antihistamines if known allergy

staff safety

- precautions to protect the personal safety of emergency department staff - transmission based precautions- standard precautions - security measures- guards, metal detectors, panic buttons, staff controlled entry, canine - recognizing volatile situations

physical evidence and chain of custody

- preservation of evidence - collecting and documenting - recognizing and preserve evidence by observing, colleting and handling, labeling, proper storage of any materials and lab collection - CONSENT THAN PICS before any tx

exposure

- remove all clothing to facilitate a thorough exam; use caution when preserving evidence; care to prevent hypothermia - assess for hazardous chemicals/impaled objects, gun shots

flail chest

- result of blunt force trauma to chest - dyspnea, poor air movement, chest wall pain, ecchymosis, splinting resp, hypoxia, pain on inspiration, paradoxical chest wall movement, subQ emphysema - supplemental O2, IV access to avoid over hydration, pain mgmt to avoid splinting, hypoventilation and atelectasis - pain mgmt with opioids, intercostal nerve blocks, epidural

organ donation

- should be considered with severe brain assault - major head injury d/t trauma, non-traumatic event from severe stroke or ruptured aneurysm, extended anoxic event - early intervention with the family is crucial

heat exhaustion

- syndrome primarily caused by dehydration, stemming from heavy perspiration and inadequate fluid and electrolyte consumption during heat exposure over a period of hours to days - tx = immediate termination of physical activity and transfer to a cool place

heat stroke

- true medical emergency, sudden onset of external heat stroke typically d/t strenuous physical activity in hot humid conditions. classically occurs over a period of time as a result of chronic exposure to a hot and humid environment. high mortality and complications

tarantula

- urticating hair can produce inflammatory response in skin and mucous membrane consisting of edematous papules and intense pruritus that can last for several weeks - tx with supportive mgmt and analgesics - remove hair from skin with sticky tape followed by thorough irrigation

emergency medical treatment and active labor act

EMTALA - federal law governing patient transfers - everyone presenting on hospital property requesting emergency medical tx gets a medical screening exam and stabilizing tx and that this exam is not based on anyone's ability to pay

disposition

OR, interventional radiology, inpatient, LTC, home with VNA, transfer tertiary

medical command physician

determines the number, acuity, and medical resource needs of the victim

class IV or expectant

black tag; expected or allowed to die

hospital staff

alter routine roles based upon the institutional plan

hospital incident commander

assumes overall leadership for implementing

knowledge of emergency care

broad base of med-surg diseases, pluse emergency care principles of recognition, mgmt, and legal implications of societal problems

history and head-to-toe assessment

checking for any obvious injuries, hidden deformities, impaled object, bruises, bleeding and any complaints of pain 1. head and face 2. neck 3. chest 4. abdomen and flanks 5. pelvis and perineum 6. extremities 7. posterior surface

mandatory reporting

child abuse, spousal abuse, client abuse in hospitals/nursing homes, attempted suicide, animal bites, illegal abortions, reportable illnessess

implied consent

client would have consented to the tx required to maintain health when the alternative could be death or serious disability

secondary survery and resuscitation interventions

comprehensive head-to-toe assessment to identify other injuries or medical issues that need to be managed or that impact the course of treatment

priority setting/critical thinking skills

depends on accurate assessment

drug overdose

depends on substance ingested- n/v, CNS depression, agitation, altered papillary response, altered resp and temp control, seizures, cardiac arrest

client and family health teaching

discharge teaching, community health teaching, injury prevention

case management

facilitate referrals to PCP, disease mgmt programs, working with homeless and victims of domestic violence

get vitals

get VS, cardiac monitor, pulse ox, urinary cath, NG tube, labs, diagnostics

vulnerable populations

homeless, poor, elderly

tularemia

infected by bites from blood sucking insect, handling meat and skins of infected animals, contaminated food or water, breathing in the bacteria. occurs naturally and can be purchased from commercial sources. most commonly spread by air or water/food

viral hemorrhagic fever (ebola)

internal and external bleeding; do not occur naturally in the US; close contact with infected individuals or bites from infected animals; spreads easily through contact with body fluids or droplet spread

botulism

most lethal substance known to man; contact spread; very toxic in contained areas or through a food vector

food poisoning

n/v/d, abdominal cramps, fever, chills, dehydration, HA

insecticide surface absorption

n/v/d, h/a, dizziness, weakness, tremors, resp distress, slurred speech, seizures, cardiopulmonary arrest

fahrenheit

prevent heat loss; use of warmed IV solutions and blankets

support staff

professional and ancillary staff including xray and US techs, resp therapists, lab techs and social workers

assessment

rapidly and accurately assess according to client acuity and age

triage officer

rapidly evaluates each victim, re-evaluating acuity

class I or emergent

red tag; immediate threat to life

urgent triage

requires care within 1 hour because condition has potential for causing deterioration of health state if not treated ASAP; no immediate threat to life at this moment

non-urgent triage

routine care; conditions where treatment delays greater than 2 hours will not result in client deterioration

anthrax

spread through air

plague

spread through fleas

level I trauma center

total collaborative care from prevention through rehab, professional and community education programs, conduct research, usually located in large teaching hospitals

level II trauma center

usually located in community hospitals, capable of providing care to vast majority of injured pts, usually transfer pts in need of complex injury mgmt

smallpox

vaccine incubated in eggs; contact spread. was eradicated in the 1970s and the discontinuation of worldwide vaccination, have opened the door for it to be used as a weapon

bioterrorism

weaponizing biologic agents

emergency doctrine

when the client is unconscious or unable to give consent, tx can proceed under the doctrine which implies consent. Frees the nurse from liability for violation of the common law

class II or urgent

yellow tag; major injuries requiring immediate treatment