Emergency Nursing Hinkle 72

Multiple Traumas Assessment and Diagnosis

External evidence of trauma may be sparse or absent. Patients with multiple trauma should be assumed to have a spinal cord injury until it is proven otherwise. The injury regarded as the least significant in appearance may be the most lethal. For example, the pelvic fracture not identified until an x-ray is obtained may cause rapid and massive hemorrhage into the pelvic cavity, but an obvious amputation of the arm may have already stopped bleeding from the body's normal response of vasoconstriction.

Decompression Sickness Assessment and Diagnosis

To identify decompression sickness, a detailed history is obtained from the patient or diving partner. Evidence of rapid ascent, loss of air in the tank, buddy breathing, recent alcohol intake or lack of sleep, or a flight within 24 hours after diving suggests possible decompression sickness. Some patients describe a perfect dive yet still have the signs and symptoms of decompression sickness, in which case they must receive treatment for the condition. Signs and symptoms include joint or extremity pain, numbness, hypesthesia, and loss of range of motion. Neurologic symptoms mimicking those of a stroke or spinal cord injury can indicate an air embolus. Cardiopulmonary arrest can also occur in severe cases and is usually fatal. Any neurologic symptoms should be rapidly assessed. All patients with decompression sickness need rapid transfer to a hyperbaric chamber.

Sexual Assault Follow-Up Care

The patient is informed of counseling services to prevent long-term psychological effects. Counseling services should be made available to both the patient and the family. A referral is made to the National Sexual Assault Hotline (see the Resources section) or directly to a local crisis intervention center. Appointments for follow-up surveillance for pregnancy and for STI and HIV testing also are made. The patient is encouraged to return to their previous level of functioning as soon as possible. When leaving the ED, the patient should be accompanied by a family member or friend.

Tricyclic Antidepressants

amitriptyline (Elavil) doxepin (Sinequan) nortriptyline (Aventyl) imipramine (Tofranil) Clinical Manifestations: Dysrhythmia: ventricular fibrillation/tachycardia, sinus tachycardia Hypotension Pulmonary edema, hypoxemia, acidosis Confusion, agitation, coma Visual hallucinations Clonus, tremors, hyperactive reflexes, nystagmus, myoclonic jerking Seizures Blurred vision, flushing, hyperthermia Therapeutic Management: Provide airway support, ventilation, cardiac monitoring; insert IV line with normal saline solution. If within 1-2 hours after overdose, insert a nasogastric tube and instill activated charcoal every 4 hours × 3. Administer a sodium bicarbonate drip to decrease dysrhythmias; the alkaline environment increases the protein binding of the metabolite. Synchronized cardioversion may be indicated with some dysrhythmias refractory to sodium bicarbonate. Torsades de pointes should be treated with IV magnesium sulfate. Administer vasopressors. Manage seizure activity with benzodiazepines (e.g., diazepam) as necessary. Refer patient for psychiatric evaluation for potential suicide intent and evaluation of medication regimen for effectiveness.

Amphetamine-Type Drugs (pep pills, "uppers," "speed," "crystal meth")

amphetamine (Benzedrine) dextroamphetamine (Dexedrine) methamphetamine (Desoxyn, "speed") 3,4-methylenedioxymethamphetamine (MDMA) ("Ecstasy," "Adam")a 3,4-methylenedioxy-N-ethylamphetamine (MDEA) ("Eve") 3,4-methylenedioxyamphetamine (MDA); methylphenidate (Ritalin) "ice," "rocks," "crystal meth" 3,4-methylenedioxypyrovalerone (MDPV) or 4-methylmethcathinone (mephedrone); "Bath salts" (synthetic stimulant) Clinical Manifestations: Nausea, vomiting, anorexia Palpitations, tachycardia Increased blood pressure Tachypnea, anxiety Nervousness Diaphoresis, mydriasis Repetitive or stereotyped behavior Irritability, insomnia, agitation Visual misperceptions, auditory hallucinations Fearfulness, anxiety, depression, hostility, paranoia Hyperactivity, rapid speech, euphoria, hyperalertness Decreased inhibition Seizures, coma, hyperthermia Cardiovascular collapse Rhabdomyolysis MDMA is both a hallucinogenic and stimulant. MDPV and mephedrone effects last >24 hours. Therapeutic Management: Provide airway support, ventilation, cardiac monitoring; insert IV line. Use GI evacuation in cases of oral overdose; activated charcoal, gastric lavage if within 1 hour of ingestion. Keep in calm, cool, quiet environment; elevated temperature potentiates amphetamine toxicity. Maintain normothermia, cooling the patient as necessary. Administer small doses of diazepam (Valium) (IV) or haloperidol (Haldol) as prescribed for CNS and muscular hyperactivity. Administer appropriate pharmacologic therapy as prescribed for severe hypertension and ventricular dysrhythmias. Treat seizures with benzodiazepines (e.g., diazepam) as prescribed. Treat sympathetic stimulation with beta-blocker agents as prescribed. Try to communicate with patient if delusions or hallucinations are present. Place in a protective environment (preferably psychiatric security room with video monitoring) to observe for suicide attempt. Refer for psychiatric and drug rehabilitation evaluation.

Anabolic Steroids

"roids," "juice," methandrostenolone, stanozolol, nandrolone Synthetic testosterone Clinical Manifestations: Increase in LDL, decrease in HDL Alter carbohydrate metabolism Hyponatremia, hypokalemia Hypocalcemia/osteoporosis Mood swings/violent behaviors Invincibility, depression, potential for suicide attempts Memory loss, cognitive disabilities Immunosuppression Used to bulk up muscles, so skeletal muscle hypertrophy is a common manifestation. Therapeutic Management: Provide supportive therapy appropriate to patient's emotional manifestations. Protect the patient from self-harm/harming others. Encourage the patient to stop use; refer patient for psychiatric evaluation.

Emergency Severity Index (ESI)

Assigns patients into five levels, from level 1 (most urgent) to level 5 (least urgent). With the ESI, patients are assigned to triage levels based on both their acuity and their anticipated resource needs.

Poisoning

A poison is any substance that, when ingested, inhaled, absorbed, applied to the skin, or produced within the body in relatively small amounts, injures the body by its chemical action. Poisoning from inhalation and ingestion of toxic materials, both intentional and unintentional, constitutes a major health hazard and an emergency situation. Emergency treatment is initiated with the following goals: Removal or inactivation of the poison before it is absorbed Provision of supportive care in maintaining vital organ function Administration of a specific antidote to neutralize a specific poison Implementation of treatment that hastens the elimination of the absorbed poison

Carbon Monoxide Poisoning Clinical Manifestations

Because the CNS has a critical need for oxygen, CNS symptoms predominate with carbon monoxide toxicity. A person with carbon monoxide poisoning may appear intoxicated (from cerebral hypoxia). Other signs and symptoms include headache, muscular weakness, palpitation, dizziness, and confusion, which can progress rapidly to coma. Skin color, which can range from pink or cherry-red to cyanotic and pale, is not a reliable sign. Pulse oximetry may reveal a high hemoglobin saturation, which may be deceiving, since the hemoglobin molecule is saturated with carbon monoxide rather than oxygen.

Three Components of Injury Prevention

Education: Providing information and materials to help prevent violence and to maintain safety at home and in vehicles is important. Involvement in local injury prevention organizations, nursing organizations, and health fairs promotes wellness and safety. In practice, nursing and other health care professionals should avoid using the word accident, because trauma events are preventable and should be viewed as such rather than as "fate" or "happenstance." Responsibility and accountability must be assigned to traumatic incidents, particularly because of the high rate of trauma recidivism (repeated trauma). People who are at risk for trauma and trauma recidivism should be identified and provided with education and counseling directed toward altering risky behaviors and preventing further trauma. Legislation: Nurses should be actively involved in safety legislation at the local, state, and federal levels. Such legislation is meant to provide universal safety measures, not to infringe on rights. Protection: Airbags and automotive design are included in this category. These mechanisms provide for safety without requiring personal intervention.

Hallucinogens or Psychedelic-Type Drugs

Lysergic acid diethylamide (LSD) Phencyclidine HCl (PCP, "angel dust") Mescaline, psilocybin Cannabinoids (marijuana) Ketamine ("special K") Synthetic cannabinoids ("spice," "incense," "K2") Butane honey oil (BHo)—"dabs," "shatter" Clinical Manifestations: Nystagmus Pupil dilation PsychedelicsSluggish pupillary responseIncreased pulse and temperatureMuscle rigidity Mild hypertension Marked confusion bordering on panic Incoherence, hyperactivity Withdrawn Combative behavior; delirium, mania, self-injury (lasts 6-12 hours) Hallucinations, body image distortion Hypertension, hyperthermia, acute kidney injury Flashback—recurrence of LSD-like state without having taken the drug; may occur weeks or months after drug was taken Ketamine—"out-of-body" experience; increased aggressiveness Synthetic cannabinoids—euphoria, increased sensory experience, relaxation Manufacturing can result in burns Therapeutic Management: Evaluate and maintain patient's circulation, airway, and breathing. Determine by urine or serum drug screen whether the patient has ingested hallucinogenic drug or has a toxic psychosis. Try to communicate with and reassure the patient."Talking down" involves understanding the process through which the patient is proceeding and helping the patient overcome fears while establishing contact with reality.Remind the patient that fear is common with this problem.Reassure the patient that he is not losing his mind but is experiencing the effect of drugs and that this will wear off.Instruct the patient to keep the eyes open; this reduces the intensity of reaction.Reduce sensory stimuli by minimizing noise, lights, movement, tactile stimulation. Sedate the patient as prescribed if hyperactivity cannot be controlled; diazepam or a barbiturate may be prescribed. Search for evidence of trauma; patients who use hallucinogens have a tendency to "act out" their hallucinations. Manage seizures with benzodiazepines (e.g., diazepam) as necessary. Observe patient closely; patient's behavior may become hazardous. Have safety officers stationed near the patient's room. Monitor for hypertensive crisis if patient has prolonged psychosis due to drug ingestion. Place patient in a protected environment under proper medical supervision to prevent self-inflicted bodily harm. Management for Phencyclidine Abuse: Place patient in a calm, supportive environment to minimize stimuli; protect from self-injury. Avoid talking down. Do not leave patient unobserved. Treat symptoms as they occur.Drug effects are unpredictable and prolonged.Symptoms are likely to exacerbate; patient becomes out of control. Refer all patients in this category for psychiatric and drug evaluation/rehabilitation.

Carbon Monoxide Poisoning

May occur as a result of industrial or household incidents or attempted suicide. It is the most common cause of fatality from poisoning and is frequently under-reported to poison control centers or misdiagnosed. Carbon monoxide exerts its toxic effect by binding to circulating hemoglobin and thereby reducing the oxygen-carrying capacity of the blood. Hemoglobin absorbs carbon monoxide 200 times more readily than it absorbs oxygen. Carbon monoxide-bound hemoglobin, called carboxyhemoglobin, does not transport oxygen.

Ingested Poisons

Swallowed poisons may be corrosive. Corrosive poison include alkaline and acid agents that can cause tissue destruction after coming in contact with mucous membranes. Alkaline products include lye, drain cleaners, toilet bowl cleaners, bleach, nonphosphate detergents, oven cleaners, and button batteries. Acid products include toilet bowl cleaners, pool cleaners, metal cleaners, rust removers, and battery acid. Control of the airway, ventilation, and oxygenation are essential. In the absence of cerebral or renal damage, the patient's prognosis depends largely on successful management of respiration and circulation. Measures are instituted to stabilize cardiovascular and other body functions. ECG, vital signs, and neurologic status are monitored closely for changes. Shock may result from the cardiodepressant action of the substance ingested, from venous pooling in the lower extremities, or from reduced circulating blood volume resulting from increased capillary permeability. An indwelling urinary catheter is inserted to monitor kidney function. Blood specimens are obtained to determine the concentration of drug or poison. Measures are instituted to remove the toxin or decrease its absorption. If there is a specific chemical or physiologic antagonist (antidote), it is given as early as possible to reverse or diminish the effects of the toxin. If this measure is ineffective, procedures may be initiated to remove or dilute the ingested substance. These procedures include administration of multiple doses of activated charcoal, dialysis, or hemoperfusion. Hemoperfusion involves detoxification of the blood by processing it through an extracorporeal circuit and an adsorbent cartridge containing charcoal or resin, after which the cleansed blood is returned to the patient. The patient who has ingested a corrosive poison, which can be a strong acid or alkaline substance, is given water or milk to drink for dilution. However, dilution is not attempted if the patient has acute airway edema or obstruction; potential for vomiting; or if there is clinical evidence of esophageal, gastric, or intestinal burn or perforation. The following gastric emptying procedures may be used as prescribed: Gastric lavage for the patient who is obtunded is only useful within 1 hour of ingestion, for sustained-release substances, or massive life-threatening amounts of a substance; however, complications of aspiration and stomach or esophageal perforation outweigh its usefulness. If performed, gastric aspirate is saved and sent to the laboratory for testing (toxicology screens). Activated charcoal administration if the poison is one that is absorbed by charcoal; given orally or by nasogastric tube, it is effective in small intermittent doses to decrease vomiting. It should be diluted as a slurry so that it is easier to drink or pass through the nasogastric tube. Activated charcoal absorbs most commonly ingested poisons except corrosives, heavy metals and hydrocarbons, iron, and lithium. Throughout detoxification, the patient's vital signs, CVP, and fluid and electrolyte balance are monitored closely. Hypotension and cardiac dysrhythmias are possible. Seizures are also possible because of CNS stimulation from the poison or from oxygen deprivation. If the patient complains of pain, analgesic agents are given cautiously. Severe pain causes vasomotor collapse and reflex inhibition of normal physiologic functions. After the patient's condition has stabilized and discharge is imminent, written material should be given to the patient indicating the signs and symptoms of potential problems related to the poison ingested and signs or symptoms requiring evaluation by a health care provider. If poisoning was determined to be a suicide or self-harm attempt, a psychiatric consultation should be requested before the patient is discharged. In cases of inadvertent poison ingestion, poison prevention and home poison-proofing instructions should be provided to the patient and family.

Penetrating Abdominal Injuries

Gunshot wounds, stab wounds, etc. Serious and usually require surgery. Penetrating abdominal trauma results in a high incidence of injury to hollow organs, particularly the small bowel. The liver is the most frequently injured solid organ due to its size and anterior placement in the right upper quadrant of the abdomen. In gunshot wounds, the most important prognostic factor is the velocity at which the missile enters the body. High-velocity missiles (bullets) produce extensive tissue damage. All abdominal gunshot wounds that cross the peritoneum or are associated with peritoneal signs require surgical exploration. On the other hand, some stab wounds may be managed nonoperatively due to low velocity and less penetration of the implement.

Crush Injuries

Occur when a person is caught between opposing forces (e.g., run over by a moving vehicle, crushed between two cars, crushed under a collapsed building).

Hypovolemic Shock

Shock is a condition in which there is loss of effective circulating blood volume. Inadequate organ and tissue perfusion follows, ultimately resulting in cellular metabolic derangements. In any emergency situation, the onset of shock should be anticipated by immediately assessing all people who are injured. The underlying cause of shock (hypovolemic, cardiogenic, neurogenic, anaphylactic, or septic) must be determined. Of these, hypovolemia is the most common cause.

Canadian Triage and Acuity Scale (CTAS)

The CTAS system's five levels include time parameters that guide how frequently patients must be reassessed by either a nurse or provider. Patients assigned to the resuscitation category must receive continuous nursing surveillance, those in the emergent category must be reassessed at least every 15 minutes, patients in the urgent category must be reassessed at least every 30 minutes, patients in the less urgent category must be reassessed at least every 60 minutes, and those in the nonurgent category must be reassessed at least every 120 minutes.

Acute Alcohol Intoxication

The CDC advocates routine screening for alcohol abuse in all outpatient settings, including EDs. Therefore, screenings, brief interventions, and referral to treatment (SBIRT) for patients presenting with suspected alcohol abuse are recommended. All level I and II verified trauma centers are required to provide this service. SBIRT is considered cost-effective in saving quality of life-years lost and preventing the morbid consequences of continued alcohol abuse. Alcohol, or ethanol, is a multisystem toxin and CNS depressant that causes drowsiness, impaired coordination, slurring of speech, sudden mood changes, aggression, belligerence, grandiosity, and uninhibited behavior. In excess, it can also cause stupor and eventually coma and death (i.e., alcohol poisoning). Increasingly, underage minors and college students arrive at the ED with alcohol poisoning from binge drinking. In the ED, the patient who is intoxicated with alcohol or who presents with alcohol poisoning is assessed for head injury, hypoglycemia (which mimics intoxication), and other health problems. Possible nursing diagnoses include ineffective breathing pattern related to CNS depression and ineffective impulse control related to severe intoxication from alcohol. Treatment involves detoxification of the acute poisoning, recovery, and rehabilitation. Commonly, the patient uses mechanisms of denial and defensiveness. The nurse should approach the patient in a nonjudgmental manner, using a firm, consistent, accepting, and reasonable attitude. Speaking in a calm and slow manner is helpful because alcohol interferes with thought processes. If the patient appears intoxicated, hypoxia, hypovolemia, and neurologic impairment must be ruled out before it is assumed that the patient is intoxicated. Typically, a blood specimen is obtained for analysis of the blood alcohol level. If drowsy, the patient should be allowed to sleep off the state of alcoholic intoxication. During this time, maintenance of a patent airway and observation for symptoms of CNS depression are essential. The patient should be undressed and kept warm with blankets. On the other hand, if the patient is noisy or belligerent, sedation may be necessary. If sedation is used, the patient should be monitored carefully for hypotension and decreased LOC. In addition, the patient is examined for alcohol withdrawal delirium and for injuries and organic disease (such as head injury, seizures, pulmonary infections, hypoglycemia, and nutritional deficiencies) that may be masked by alcoholic intoxication. People with alcoholism suffer more injuries than the general population. Acute alcohol intoxication is the cause of trauma for many patients without alcoholism as well. Pulmonary infections are also more common in patients with alcoholism, resulting from respiratory depression, an impaired defense system, and a tendency toward aspiration of gastric contents. The patient may show little increase in temperature or WBC count. The patient may be hospitalized or admitted to a detoxification center in an effort to examine problems underlying the substance abuse.

Heat Illness Management

The main goal is to reduce the high body temperature as quickly as possible, because mortality in heat stroke or morbid progression to heat stroke with less serious forms of heat-induced illnesses is directly related to the duration of hyperthermia. For the patient with heat stroke, simultaneous treatment focuses on stabilizing oxygenation using the CABs (circulation, airway, and breathing) of basic life support. This includes establishing IV access for fluid administration. After the patient's clothing is removed, the core (internal) temperature is reduced to 39°C (102°F) as rapidly as possible, preferably within 1 hour. One or more of the following methods may be used as prescribed: Cool sheets and towels or continuous sponging with cool water Ice applied to the neck, groin, chest, and axillae while spraying with tepid water Cooling blankets Immersion of the patient in a cold water bath is the optimal method for cooling (if available) During cooling procedures, an electric fan is positioned so that it blows on the patient to augment heat dissipation by convection and evaporation. The patient's temperature is constantly monitored with a thermistor placed in the rectum, bladder, or esophagus to evaluate core temperature. Caution is used to avoid hypothermia and to prevent hyperthermia, which may recur spontaneously within 3 to 4 hours. The cooling process should stop at 38°C (100.4°F) in order to avoid iatrogenic hypothermia. Throughout treatment, the patient's status is monitored carefully, including vital signs, ECG findings (for possible myocardial ischemia, myocardial infarction, and dysrhythmias), central venous pressure (CVP), and level of responsiveness, all of which may change with rapid alterations in body temperature. A seizure may be followed by recurrence of hyperthermia. To meet tissue needs exaggerated by the hypermetabolic condition, 100% oxygen is given. Endotracheal intubation and mechanical ventilation to support failing cardiopulmonary systems may be required. IV infusion therapy of normal saline or lactated Ringer solution is initiated as directed to replace fluid losses and maintain adequate circulation. Fluids are given carefully because of the dangers of myocardial injury from high body temperature and poor kidney function. Cooling redistributes fluid volume from the periphery to the core. Urine output is also measured frequently, because ATN may occur as a complication of heat stroke from rhabdomyolysis. Blood specimens are obtained for serial testing to detect bleeding disorders, such as disseminated intravascular coagulation, and for serial enzyme studies to estimate thermal hypoxic injury to the liver, heart, and muscle tissue. Permanent liver, cardiac, and CNS damage may occur. Additional supportive care may include dialysis for AKI, anticonvulsant medications to control seizures, potassium for hypokalemia, and sodium bicarbonate to correct metabolic acidosis. Benzodiazepines such as diazepam (Valium) may be prescribed to suppress seizure activity, while a phenothiazine such as chlorpromazine (Thorazine) may be prescribed to suppress shivering. Patients with heat exhaustion or heat cramps may be managed less aggressively. These patients should lie supine in a cool environment. Patients with heat exhaustion may require IV fluids but may also take oral fluids, if they are tolerated. Patients with heat cramps are given oral sodium supplements and oral electrolyte solutions. Patients who have experienced a heat-induced illness should receive education to prevent another heat-related illness

Airway Obstruction Assessment and Diagnosis

Assessment of the patient who has a foreign object occluding the airway may involve simply asking the person whether he or she is choking and requires help. If the person is unconscious, inspection of the oropharynx may reveal the offending object. X-rays, laryngoscopy, or bronchoscopy also may be performed. Oxygen supplementation should be considered immediately.

ABCDE Approach to Injury Prevention

A—describes assessment of the community for common injury mechanisms B—is used to describe building a coalition of key community members C—refers to communicating awareness of the trauma mechanisms and risks prevalent in the local community D—stands for developing and implementing interventions, which may be educational or legislative E—refers to evaluating the injury prevention program soon after it is launched, which may result in either continuation or revision of the program.

Internal Bleeding

Hemorrhage frequently accompanies abdominal injury, especially if the liver or spleen has been traumatized. Therefore, the patient is assessed continuously for signs and symptoms of external and internal bleeding. The front of the body, flanks, and back are inspected for bluish discoloration, asymmetry, abrasion, and contusion. Abdominal CT scans permit detailed evaluation of abdominal contents and retroperitoneal examination. Abdominal ultrasounds can be used to rapidly assess patients who are hemodynamically unstable to detect intraperitoneal bleeding. This is referred to as the focused assessment with sonography for trauma (FAST). During the resuscitation period, pain is managed using administration of small dosages of opioids. The location of pain can indicate certain types of intra-abdominal injuries. Pain in the left shoulder is common in a patient with bleeding from a ruptured spleen, whereas pain in the right shoulder can result from laceration of the liver.

Hypothermia Assessment and Diagnosis

Hypothermia leads to physiologic changes in all organ systems. There is progressive deterioration, with apathy, poor judgment, ataxia, dysarthria, drowsiness, pulmonary edema, acid-base abnormalities, coagulopathy, and eventual coma. Shivering may be suppressed at a temperature of less than 32.2°C (90°F), because the body's self-warming mechanisms become ineffective. The heartbeat and blood pressure may be so weak that peripheral pulses become undetectable. Cardiac dysrhythmias may also occur. Other physiologic abnormalities include hypoxemia and acidosis.

Hypothermia Management

Management consists of removal of wet clothing, continuous monitoring, rewarming, and supportive care. The CABs of basic life support are a priority. The patient's vital signs, CVP, urine output, arterial blood gas levels, blood chemistry determinations (blood urea nitrogen, creatinine, glucose, electrolytes), and chest x-rays are evaluated frequently. Core body temperature is monitored with an esophageal, bladder, or rectal thermistor. Continuous ECG monitoring is performed, because cold-induced myocardial irritability leads to conduction disturbances, especially ventricular fibrillation. An arterial line is inserted and maintained to record blood pressure and to facilitate blood sampling.

Sexual Assault Management

The goals of management are to provide support, to reduce the patient's emotional trauma, and to gather available evidence for possible legal proceedings. All of the interventions are aimed at encouraging the patient to gain a sense of control over their life. Throughout the patient's stay in the ED, the patient's privacy and sensitivity must be respected. The patient may exhibit a wide range of emotional reactions, such as hysteria, stoicism, or feelings of being overwhelmed. Support and caring are crucial. The patient should be reassured that anxiety is natural and asked whether a person who can provide support may be called. Appropriate support is available from professional and community resources. The National Sexual Assault Hotline (see the Resources section) will automatically route the patient to the nearest assault or crisis intervention center for services, as needed. The patient should never be left alone.

Multiple Traumas Management

The goals of treatment are to determine the extent of injuries and to establish priorities of treatment. Any injury interfering with a vital physiologic function (e.g., airway, breathing, circulation) is an immediate threat to life and has the highest priority for immediate treatment. Essential lifesaving procedures are performed simultaneously by the emergency team. As soon as the patient is resuscitated, clothes are removed or cut off and a rapid physical assessment is performed. Transfer from field management to the ED must be orderly and controlled, with attention and silence given to listen to the verbal report from EMS personnel. Treatment in a trauma center is appropriate for patients experiencing major trauma.

Documentation of Consent and Privacy

The patient needs to give consent for invasive procedures (e.g., angiography, lumbar puncture) unless he or she is unconscious or in a critical condition and unable to make decisions. If the patient is unconscious and brought to the ED without family or friends, this fact must be documented. Monitoring of the patient's condition, as well as all instituted treatments and the times at which they were performed, must be documented. After treatment, a notation is made on the record about the patient's condition, response to the treatment, and condition at discharge or transfer and about instructions given to the patient and family for follow-up care. The patient is also provided with a statement of the privacy policy of the health care agency, according to federal law. Patients involved in violent events can be provided with an alias, and access to the electronic health record is limited to protect the privacy of the patient. A patient may also request extra privacy by limiting access to their room and by choosing not to receive phone calls, mail, flowers, other gifts, or certain visitors. These practices relate to the federally mandated privacy policy stipulated in the Health Insurance Portability and Accountability Act (HIPAA). According to the Emergency Medical Treatment and Active Labor Act (EMTALA), every ED with a Medicare provider agreement must perform a medical screening examination on all patients arriving with an emergency medical complaint if their acute signs and symptoms could result in serious injury or death if left untreated. EDs are also required to provide treatment aimed at stabilizing each patient's condition. If the patient must be transferred to another facility, the patient's consent for transfer should be obtained, if possible. In addition, acceptance by the receiving facility and physician must be obtained, and an appropriate method of transfer for the patient should be secured. Documentation of assessment and treatment must be sent with the patient upon transfer.

Sexual Assault Assessment and Diagnosis

The patient's reaction to rape has been termed rape trauma syndrome and is seen as an acute stress reaction to a life-threatening situation. The nurse performing the assessment is aware that the patient may go through several phases of psychological reactions, which have been described as follows: An acute disorganization phase, which may manifest as an expressed state in which shock, disbelief, fear, guilt, humiliation, anger, and other such emotions are encountered or as a controlled state in which feelings are masked or hidden and the victim appears composed A phase of denial and unwillingness to talk about the incident, followed by a phase of heightened anxiety, fear, flashbacks, sleep disturbances, hyperalertness, and psychosomatic reactions that is consistent with PTSD A phase of reorganization, in which the incident is put into perspective. Some victims never fully recover and go on to develop chronic stress disorders and phobias.

Endotracheal Intubation

The purpose of endotracheal intubation is to establish and maintain the airway in patients with respiratory insufficiency or hypoxia. Endotracheal intubation is indicated to establish an airway for a patient who cannot be adequately ventilated with an oropharyngeal or nasopharyngeal airway, bypass an upper airway obstruction, prevent aspiration, permit connection of the patient to a resuscitation bag or mechanical ventilator, or facilitate the removal of tracheobronchial secretions. Because of the level of skill required, endotracheal intubation is performed only by those who have had extensive training. These may include physicians, nurse anesthetists, respiratory therapists, flight nurses, and nurse practitioners. However, the emergency nurse commonly assists with intubation. Rapid sequence intubation may be indicated, which provides management of the patient in a situation similar to that in the operating room. Medications used to facilitate rapid sequence intubation include a sedative, an analgesic, and a neuromuscular blockade agent; these are usually given by the practitioner performing the intubation.

Skin Contamination Poisoning (Chemical Burns)

The severity of a chemical burn is determined by the mechanism of action, the penetrating strength and concentration, and the amount and duration of exposure of the skin to the chemical. The skin should be drenched immediately with running water from a shower, hose, or faucet, except in the case of lye and white phosphorus, which should be brushed off the skin dry. Water should not be applied to burns from lye or white phosphorus because of the potential for an explosion or for deepening of the burn. All evidence of these chemicals should be brushed off the patient before any flushing occurs. The skin of health care personnel assisting the patient should be appropriately protected if the burn is extensive or if the agent is significantly toxic or still present. Prolonged lavage with generous amounts of tepid water is important. The decontamination shower (deluge) in the ED is the optimal place for total body flushing. The staff attending the patient should wear proper personal protective equipment (PPE) to prevent cross-contamination. Attempts to determine the identity and characteristics of the chemical agent are necessary in order to specify future treatment. The standard burn treatment appropriate for the size and location of the wound (antimicrobial treatment, débridement, tetanus prophylaxis, antidote administration as prescribed) is instituted. The patient may require plastic surgery for further wound management. The patient is instructed to have the affected area reexamined at 24 and 72 hours and in 7 days because of the risk of underestimating the extent and depth of these types of injuries.

Substance Abuse

"Rave parties" are large-scale parties attended by hundreds of people involved in illicit drug use. At these events, one of the most commonly used drugs is 3,4-methylenedioxymethamphetamine (MDMA), or Ecstasy, a methamphetamine-based drug that users believe produces a "harmless high." ED nurses should be aware of rave parties in their geographic area so that they can prepare for a potential influx of patients who abuse this drug. Others may combine Ecstasy with sildenafil (Viagra); this drug combination is nicknamed "sextasy." Spice is a synthetic cannabinoid sold commercially as a smoking mixture under the names "spice," "incense," or "K2." Its chemical structure and effects are similar to marijuana, targeting the same receptor sites in the brain. Spice is sold with variable concentrations and unregulated potency. Bath salts are synthetic stimulants similar to Ecstasy known as "mephedrone," "drone," or "MCAT." Their effects are similar to amphetamines, MDMA, and cocaine. Although bath salts are most commonly swallowed or snorted, they may also be smoked or injected; the method of intake affects the severity and duration of effects. The structural formula 3,4-methylenedioxypyrovalerone (MDPV) is the most common type of bath salt abused. Abuse of various inhalants has also increased in popularity; these products generally result more often in cravings than withdrawal when their use is stopped. The method of inhalation varies with the product chosen and requires several deep inhalations to reach euphoria. Methods include sniffing or snorting by directly inhaling the fumes. "Bagging" (from a bag) or "huffing" (from a rag or cloth) provide the greatest concentration; "dusting" is another method that delivers the inhalant by directly spraying it into the nostrils. Long-term use results in cortical atrophy and brainstem dysfunction, in addition to cardiomyopathy and emphysemalike abnormalities of the lung. Significant others or parents may report that the patient has had poor school or work performance or attendance, weight loss, poor hygiene, fatigue, nosebleeds, and decreased appetite. Treatment goals for a patient with a drug overdose are to support the respiratory and cardiovascular functions, to enhance clearance of the agent, and to provide for safety of the patient and staff. People who abuse IV/injection drugs are at increased risk for HIV infection, acquired immune deficiency syndrome, hepatitis B and C, and tetanus. Cannabis remains popular, available, and in some states, is now legal. A newer method of cannabis abuse is butane honey oil (BHO) or "dabs." BHO is created at home by heating cannabis with butane to strip the chemical from the plant, which is then heated further to remove the butane. It may be further distilled to "shatter" by being placed in a vacuum to remove any residual butane. The product results in a "dab" which can then be inhaled. Butane in the presence of an ignition source can result in explosion and fire resulting in chemical and thermal burns.

Priority Management in Patients with Multiple Injuries

1. Establish airway and ventilation 2. Control Hemorrhage 3. Prevent and treat hypovolemic shock 4. Assess for head and neck injuries 5. Evaluate for other injuries - expose and reassess head, neck, and chest; assess abdomen, back, and extremities 6. Splint fractures and then reassess pulses and neurovascular status 7. Perform a more thorough and ongoing examination and assessment; diagnostic studies

Injury Prevention

A component of the emergency nurse's daily role is to provide injury prevention information to every patient with whom there is contact, including patients admitted for reasons other than injury.

Genitourinary Injury

A focused genitourinary examination, which typically includes a rectal and/or vaginal examination, is performed to determine any injury to the pelvis, bladder, urethra, vagina, or intestinal wall. In the male patient, a high-riding prostate gland (abnormal position) discovered during a rectal examination indicates a potential urethral injury. A digital vaginal examination is performed on female patients to determine if there is an open pelvic fracture that has torn the vagina. To decompress the bladder and monitor urine output in a patient with a genitourinary injury, an indwelling catheter is inserted after a rectal examination has been completed, not before the examination. In addition, urethral catheter insertion when a possible urethral injury is present is contraindicated; a urology consultation and further evaluation of the urethra are required.

Frostbite Assessment and Diagnosis

A frozen extremity may be hard, cold, and insensitive to touch and may appear white or mottled blue-white. The extent of injury from exposure to cold is not always initially known. The patient history should include environmental temperature, duration of exposure, clothing worn, humidity, and the presence of wet conditions. Protective clothing may partially prevent exposure to cold environments; however, wearing wet socks and exercise/movement may diminish the protective effects of insulation.

Emergency Nursing and the Continuum of Care

A key principle underlying emergency care is that the patient is rapidly assessed, treated, and referred to the appropriate setting for ongoing care. This makes the ED a temporary point on the continuum of care. Only 11.9% of patients who receive emergency care are admitted to the hospital, which means emergency nurses must plan and facilitate the patient's safe discharge and follow-up care in the home, community, and the transitional care environment.

Decompression Sickness Management

A patent airway and adequate ventilation are established, as described previously, and 100% oxygen is given throughout treatment and transport. A chest x-ray is obtained to identify aspiration, and at least one IV line is started with lactated Ringer's or normal saline solution. Research findings suggest that among patients requiring air transport, oxygen saturations and symptoms improve when both oxygen and IV fluids are given and the transport flight remains at low altitude. The cardiopulmonary and neurologic systems are supported as needed. If an air embolus is suspected, the head of the bed should be lowered. If the patient's wet clothing is still present, it is removed. The patient is kept warm. Transfer to the closest hyperbaric chamber for treatment is initiated. If air transport is necessary, low-altitude flight (below 300 m) is required. However, the patient who is awake and alert without central neurologic deficits may be able to travel by ground ambulance or by automobile, depending on the severity of symptoms. Throughout treatment, the patient is continually assessed, and changes are documented. If aspiration is suspected, antibiotic agents and other treatment may be prescribed.

Psychiatric Emergencies

A psychiatric emergency is an urgent, serious disturbance of behavior, affect, or thought that makes the patient unable to cope with life situations and interpersonal relationships. A patient presenting with a psychiatric emergency may display overactive or violent, underactive or depressed, or suicidal behaviors. The most important concern of the ED personnel is determining whether the patient is at risk for injuring self or others. The aim is to try to maintain the patient's self-esteem (and life, if necessary) while providing care. Determining whether the patient is under psychiatric care is important so that contact can be made with the therapist or physician who works with the patient.

Control of External Hemorrhage

A rapid physical assessment is performed as the patient's clothing is cut away in an attempt to identify the area of hemorrhage. Direct, firm pressure is applied over the bleeding area or the involved artery at a site that is proximal to the wound. Most bleeding can be stopped or at least controlled by application of direct pressure. Otherwise, unchecked arterial bleeding results in death. A firm pressure dressing is applied, and the injured part is elevated to stop venous and capillary bleeding, if possible. If the injured area is an extremity, the extremity is immobilized to control blood loss. A tourniquet is applied to an extremity when the external hemorrhage cannot be controlled in any other way and until surgery can be performed. The tourniquet is applied just proximal to the wound and tied tightly enough to control arterial blood flow. The patient is tagged with a skin-marking pencil or on adhesive tape on the forehead with a "T," stating the location of the tourniquet and the time applied. If the patient has suffered a traumatic amputation with uncontrollable hemorrhage, the tourniquet remains in place until the patient is in the operating room. Time of tourniquet application and removal should be documented. Tourniquet placement among military personnel with battle-associated trauma has demonstrated clear mortality reduction, although it occasionally has led to amputation or fasciotomy.

Sexual Assault Physical Examination

A written, witnessed informed consent must be obtained from the patient (or parent or guardian if the patient is a minor) for examination, for taking of photographs, and for release of findings to police. A history is obtained only if the patient has not already talked to a police officer, social worker, or crisis intervention worker. The patient should not be asked to repeat the history. Any history of the event that is obtained should be recorded in the patient's own words. The patient is asked whether he or she has bathed, douched, brushed his or her teeth, changed clothes, urinated, or defecated since the attack, because these actions may alter interpretation of subsequent findings. The time of admission, time of examination, date and time of the alleged rape, and the patient's emotional state and general appearance (including any evidence of trauma, such as discoloration, bruises, lacerations, secretions, or torn and bloody clothing) are documented. If the patient has no recollection of the event, drugs that induce retrograde amnesia may have been involved, such as alcohol, ketamine, gamma-hydroxybutyrate, benzodiazepines, or flunitrazepam (Rohypnol). Urine drug test must be completed within 96 hours of the event to capture the presence of these drugs. Emesis can also be collected for testing. The patient is examined (from head to toe) for injuries, especially injuries to the head, neck, breasts, thighs, back, and buttocks. Body diagrams and photographs aid in documenting the evidence of trauma. The physical examination focuses on the following: External evidence of trauma (bruises, contusions, lacerations, stab wounds) Dried semen stains (appearing as crusted, flaking areas) on the patient's body or clothes Broken fingernails and body tissue and foreign materials under nails (if found, samples are taken) Oral examination, including a specimen of saliva and cultures of gum and tooth areas Pelvic and rectal examinations are also performed. The perineum and other areas are examined with a Wood lamp or other filtered ultraviolet light. Areas that appear fluorescent may indicate semen stains. The color and consistency of any discharge present is noted. A water-moistened, rather than lubricated, vaginal speculum is used for the examination. Lubricant contains chemicals that may interfere with later forensic testing of specimens and acid phosphatase determinations. The rectum is examined for signs of trauma, blood, and semen. During the examination, the patient should be advised of the nature and necessity of each procedure and given the rationale for each.

Critical Stress Management

After serious events, critical incident stress management (CISM) is necessary to critique individual and group performance and to facilitate healthy coping. Optimally, this may consist of three steps: defusing, debriefing, and follow-up. Defusing occurs immediately after the critical incident. During this session, affected staff are encouraged to discuss their feelings about the incident and are given contact information so that they may talk to someone if they have disturbing symptoms (e.g., sleeplessness, excessive worry). Debriefing typically occurs 1 to 10 days after the critical incident. Debriefing sessions follow a format similar to the initial defusing session; however, during these sessions, participating staff are encouraged to discuss their feelings about the incident and are reassured that their negative reactions and feelings are normal and that their negative feelings will diminish over time. At the end of these sessions, participants should have a feeling of closure and be able to resume their professional roles at an emotional level commensurate to that prior to the critical incident. Some staff may require further professional follow-up, however. Follow-up may occur after the debriefing session is completed for those participants who have persistent negative symptoms and may consist of continued individual or group counseling and therapy.

Maintaining Ventilation

After the airway is determined to be unobstructed, the nurse must ensure that ventilation is adequate by checking for equal bilateral breath sounds. Satisfactory management of ventilations may prevent hypoxia and hypercapnia. The nurse must quickly assess for absent or diminished breath sounds, open chest wounds, and difficulty delivering artificial breaths for the patient. The nurse should monitor pulse oximetry, capnography, and arterial blood gases if the patient requires airway or ventilatory assistance. A tension pneumothorax can mimic hypovolemia, so ventilatory assessment precedes assessment for hemorrhage. A pneumothorax (both simple and tension) or sucking (open) chest wound is managed with a chest tube and occlusion of the sucking wound; immediate relief of increasing positive intrathoracic pressure and maintenance of adequate ventilation should occur.

Treating Potential Consequences of Rape

After the initial physical examination is completed and specimens have been obtained, any associated injuries are treated as indicated. The patient is given the option of prophylaxis against sexually transmitted infections (STIs) (also referred to as sexually transmitted disease [STDs]). Ceftriaxone (Rocephin), given intramuscularly with 1% lidocaine (Xylocaine), may be prescribed as prophylaxis for gonorrhea. In addition, a single oral dose of metronidazole (Flagyl) and either a single oral dose of azithromycin (Zithromax) or a 7-day oral regimen of doxycycline may be prescribed as prophylaxis for syphilis and chlamydia. Antipregnancy measures may be considered if the patient is a female of childbearing age. A postcoital contraceptive medication, such as an oral contraceptive medication that contains levonorgestrel and ethinyl estradiol (Alesse, Seasonique), may be prescribed after a pregnancy test. To promote effectiveness, the contraceptive medication should be given within 12 to 24 hours and no later than 72 hours after intercourse. The 21-day package is prescribed so that the patient does not mistakenly take the inert tablets included in the 28-day package. An antiemetic agent may be given as prescribed to decrease discomfort from side effects. A cleansing douche, mouthwash, and fresh clothing are usually offered.

Inhalants

Amyl nitrate Freon Propane Trichloroethylene Gasoline Perchloroethylene Toluene (metallic paint spray) Helium Canned air Hand sanitizer Routes may include: Sniffing/snorting—direct inhalation of fumes "Bagging"—sniff from a bag "Huffing"—sniff from a rag/cloth "Dusting"—direct spray into the nostrils Clinical Manifestations: Effects mimic those of alcohol, with dizziness and imbalance: Euphoria, headache, disinhibition, altered level of consciousness to coma Renal, hepatic, and cardiac toxicity Aplastic anemia Fetal growth retardation Respiratory depression, arrest from CNS depression Vasodilation Nosebleeding Vertical and horizontal nystagmus Lack of convergence of eyes Sluggish pupils Temperature fluctuations Circumoral red spots/rash Air embolus Therapeutic Management: Provide airway support, ventilation, and oxygen. Treat cardiac dysrhythmias and hypotension. Provide advanced cardiac life support as needed. Monitor for profound hypotension when amyl nitrate is combined with MDMA and sildenafil or with anesthetic agents. Monitor for hypertension when volatile solvents used.

Administration of Antivenin

An assessment of progressive signs and symptoms is essential before considering administration of antivenin, which is most effective if given within 4 hours and no greater than 12 hours after the snakebite. The decision to administer antivenin depends on worsening tissue injury and evidence of systemic and coagulopathic symptoms. Rattlesnakes are more likely to cause coagulation abnormalities as well as more systemic effects. The most readily available antivenin in the United States is Crotalidae polyvalent immune Fab antivenom (FabAV or CroFab). The dose depends on the type of snake and the estimated severity of the bite. Indications for antivenin depend on the progression of symptoms, including coagulopathy and systemic reaction. Crotalidae polyvalent immune Fab antivenom does not require pretesting (i.e., skin sensitivity screening for an allergic reaction), albeit monitoring for a hypersensitivity reaction is still necessary. FabAV must be given cautiously to patients receiving anticoagulation therapy. Administration of FabAV may result in a recurring coagulopathy. Before administering antivenin and every 15 minutes thereafter, the circumference of the affected part is measured. Premedication with diphenhydramine (Benadryl) or cimetidine (Tagamet) may be indicated, because these antihistamines may decrease the allergic response to antivenin. Antivenin is given as an IV infusion whenever possible, although intramuscular administration can be used. Depending on the severity of the snakebite, the antivenin is diluted in 500 to 1000 mL of normal saline solution. The infusion is started slowly, and the rate is increased after 10 minutes if there is no reaction. The total dose should be infused during the first 4 to 6 hours after the bite. The initial dose is repeated until symptoms decrease, after which time the circumference of the affected part should be measured every 30 to 60 minutes for the next 48 hours to detect symptoms of compartment syndrome. There is no limit to the number of antivenin vials that can be given. The decision to continue to administer vials is based upon patient symptoms. Consultation with a snakebite expert is essential at this point; this consultant may be identified and found through contacting the Poison Control Center or a local zoo reptile center. The most common cause of allergic reaction to the antivenin is too-rapid infusion. Reactions may consist of a feeling of fullness in the face, urticaria, pruritus, malaise, and apprehension. These symptoms may be followed by tachycardia, shortness of breath, hypotension, and shock. In this situation, the infusion should be stopped immediately and IV diphenhydramine given. Vasopressors are used for patients in shock, and resuscitation equipment must be on standby while antivenin is infusing. It is important to note that serum sickness (hypersensitivity) can occur within the first few weeks after discharge. The patient and the patient's family members should be educated about the clinical manifestations of serum sickness (i.e., fever; rash starting on the chest and spreading to the back; arthralgia; GI disturbances [e.g., nausea, vomiting, diarrhea, abdominal pain], and headache) and return to the ED if they occur.

Secondary Survey

An assessment of the patient triaged to the emergent or resuscitation category that commences after the primary survey is completed and life-threatening insults addressed; includes obtaining vital signs, completing a head-to-toe examination, and obtaining the patient's pertinent medical-surgical history, including the history of the current event. Complete health history, including the history of the current event Head-to-toe assessment (includes a reassessment of airway and breathing parameters and vital signs) Diagnostic and laboratory testing Insertion or application of monitoring devices such as ECG electrodes, arterial lines, or urinary catheters Splinting of suspected fractures Cleansing, closure, and dressing of wounds Performance of other necessary interventions based on the patient's condition

Primary Survey

An assessment of the patient triaged to the emergent or resuscitation category that focuses on stabilizing life-threatening conditions; uses the mnemonic ABCDE, which stands for airway, breathing, circulation, disability, and exposure. Establish a patent airway. Provide adequate ventilation, employing resuscitation measures when necessary. Patients who have experienced trauma must have the cervical spine protected and chest injuries assessed first, immediately after the airway is established. Evaluate and restore cardiac output by controlling hemorrhage, preventing and treating shock, and maintaining or restoring effective circulation. This includes the prevention and management of hypothermia. In addition, peripheral pulses are examined, and any immediate closed reductions of fractures or dislocations are performed if an extremity is pulseless. Determine neurologic disability by assessing neurologic function using the Glasgow Coma Scale (GCS) and a motor and sensory evaluation of the spine. A quick neurologic assessment may be performed using the AVPU mnemonic:A—alert. Is the patient alert and responsive?V—verbal. Does the patient respond to verbal stimuli?P—pain. Does the patient respond only to painful stimuli?U—unresponsive. Is the patient unresponsive to all stimuli, including pain? Undress the patient quickly but gently so that any wounds or areas of injury are identified; this may entail cutting away articles of clothing.

Oropharyngeal/Nasopharyngeal Airway Insertion

An oropharyngeal airway is a semicircular tube or tubelike plastic device that is inserted over the back of the tongue into the lower posterior pharynx in a patient who is breathing spontaneously but who is unconscious. This type of airway prevents the tongue from falling back against the posterior pharynx and obstructing the airway. It also allows health care providers to suction secretions. The nasopharyngeal airway provides the same airway access but is inserted through the nares. With an airway in place the patient may breathe spontaneously. If breathing is ineffective or absent, bag-valve-mask ventilation is necessary. In the case of potential facial trauma or basal skull fracture, the nasopharyngeal airway should not be used because it could enter the brain cavity instead of the pharynx.

Anxiety and Denial, Remorse and Guilt, Anger, and Grief

Anxiety and Denial: During these crises, family members are encouraged to recognize and talk about their feelings of anxiety. Asking questions is encouraged. Honest answers given at the level of the family's understanding must be provided. Although denial is an ego-defense mechanism that protects one from recognizing painful and disturbing aspects of reality, prolonged denial is not encouraged or supported. The family must be prepared for the reality of what has happened and what may come. Remorse and Guilt: Expressions of remorse and guilt are common, with family members accusing themselves (or each other) of negligence or minor omissions. Family members are urged to verbalize their feelings to help them cope appropriately. Anger: Expressions of anger, common in crisis situations, are a way of handling anxiety and fear. Anger is frequently directed by the family at the patient, but it is also often expressed toward the physician, the nurse, or admitting personnel. The therapeutic approach is to allow the anger to be expressed and to assist the family members to identify their feelings of frustration. Grief: Grief is a complex emotional response to anticipated or actual loss. The key nursing intervention is to help family members work through their grief and to support their coping mechanisms, letting them know that it is normal and acceptable for them to cry, feel pain, and express loss. The hospital chaplain and social services staff serve as invaluable members of the team when assisting families to work through their grief.

Abdominal Injuries Assessment and Diagnosis

As the history of the traumatic event is obtained, the abdomen is inspected as a part of the secondary survey for obvious signs of injury, including penetrating injuries, bruises, and abrasions. Abdominal assessment continues with auscultation of bowel sounds to provide baseline data from which changes can be noted. Absence of bowel sounds may be an early sign of intraperitoneal involvement, although stress can also decrease or halt peristalsis and thus bowel sounds. Further abdominal assessment may reveal progressive abdominal distention, involuntary guarding, tenderness, pain, muscular rigidity, or rebound tenderness along with changes in bowel sounds, all of which are signs of peritoneal irritation. Hypotension and signs and symptoms of shock may also be noted. In addition, the chest and other body systems are assessed for injuries that frequently accompany intra-abdominal injuries.

Salicylate Poisoning

Aspirin (present in compound analgesic tablets) Toxic levels (150-200 mg/kg body weight) Chronic toxicity (occurs in older adults due to decreased kidney function) Long-term intoxication (>100 mg/kg/day for more than 2 days) Clinical Manifestations: Restlessness Tinnitus, deafness Blurring of vision Hyperpnea Hyperpyrexia Sweating Epigastric pain, vomiting Dehydration Respiratory alkalosis and metabolic acidosis Disorientation, coma Cardiovascular collapse Coagulopathy Therapeutic Management: Treat respiratory depression. Induce gastric emptying by lavage (if within 1 hour after ingestion). Give activated charcoal to adsorb aspirin. Support patient with IV infusions as prescribed to establish hydration and correct electrolyte imbalances, including administration of sodium bicarbonate. Enhance elimination of salicylates as directed by forced diuresis, alkalinization of urine, peritoneal dialysis, or hemodialysis, according to severity of intoxication. Monitor serum salicylate level for efficacy of treatment. Administer specific prescribed pharmacologic agent for bleeding and other problems. Recognize that concretions formed in the gut may result in prolonged exposure as they are digested. Refer patient for psychiatric evaluation (potential suicide intent). Monitor thromboelastography for platelet function.

Preventing Heat-Induced Illnesses

Avoid immediate re-exposure to high temperatures; hypersensitivity to high temperatures may remain for a considerable time. Maintain adequate fluid intake, wear loose clothing, and reduce activity in hot weather. Monitor fluid losses and weight loss during workout activities or exercise and replace fluids and electrolytes. Use a gradual approach to physical conditioning, allowing sufficient time for return to baseline temperature. Plan outdoor activities to avoid the hottest part of the day (between 10 AM and 2 PM). For older patients living in urban settings with high environmental temperatures: The nurse directs these patients to places where air conditioning is available (e.g., shopping mall, library, church) and advises them that fans alone are not adequate to prevent heat-induced illness.

Limiting Exposure to Health Risks

Because of the increasing numbers of people infected with hepatitis, human immune deficiency virus (HIV), tuberculosis, and other infectious diseases, health care providers are at an increased risk for exposure to communicable diseases through blood, respiratory droplets, or other body fluids. This risk is further compounded in the ED because of the common use of invasive treatments in patients who may have a wide range of conditions and are unable to provide a comprehensive medical history. All emergency health care providers must adhere strictly to standard precautions for minimizing exposure. The re-emergence of tuberculosis as a major health problem is complicated by multidrug-resistant tuberculosis and by tuberculosis concomitant with HIV infection. Nurses in the ED are usually fitted with personal high-efficiency particulate air (HEPA) filter masks to use when treating patients with airborne diseases. To limit the risk of exposure to airborne diseases, early identification and strict adherence to transmission-based precautions for patients who are potentially infectious is crucial. The potential for exposure to highly contagious organisms, hazardous chemicals or gases, and radiation related to acts of terrorism or natural or man-made disasters presents additional risks to ED staff.

Community and Transitional Services

Before discharge, some patients require the services of a social worker to help them meet continuing health care needs. Home care resources may be contacted before discharge to arrange services. This is particularly important for patients who are older adults or who have disabilities and who need assistance. Identifying continuing health care needs and making arrangements for meeting these needs can prevent return visits to the ED or readmission to the hospital. For patients who are returning to long-term care facilities and for those who already rely on community agencies for continuing health care, communication about the patient's condition and any changes in health care needs that have occurred must be provided to the appropriate facilities or agencies. This communication is essential to promote continuity of care and to ensure ongoing care that meets the patient's changing health care needs. Many patients who utilize EDs have health problems that are nonurgent. Moreover, some patients return repeatedly to the ED with nonurgent problems. It is posited that patients who present to the ED with nonurgent problems do so because there is a dearth of outpatient health care resources to fill their needs. In order to fill these gaps, some areas of the United States, particularly rural areas, are offering mobile integrated health-community paramedicine programs. Emergency medical system (EMS) personnel provide in-home visits, without emergency call, to identify needs, and provide education and in-home care. If necessary, they can also transport patients to the ED. These programs have decreased unnecessary EMS calls without transport or unnecessary transports

Discharge Planning

Before discharge, verbal and written instructions for continuing care are given to the patient and the family or significant others. Many EDs have preprinted standard instruction sheets for the more common conditions (i.e., concussion), which can then be individualized. Discharge instructions should be available in a variety of languages. A language interpreter should be used as necessary to provide both written and verbal instructions. Instructions should include information about prescribed medications, treatments, diet, activity, and when to contact a health care provider or schedule follow-up appointments. Discharge planning is the "teachable moment" for the patient, providing the opportunity to present injury prevention or smoking cessation strategies, alcohol counseling opportunities, and more. It is imperative that instructions are written legibly, use simple language, and are clear in their important points. When providing discharge instructions, the nurse also considers any special needs the patient may have related to hearing or visual impairments. Alternate formats of instruction (e.g., large print, Braille, audiotape) should be available to meet the needs of patients with hearing or visual impairments.

Multiple Trauma

Caused by a single catastrophic event that causes life-threatening injuries to at least two distinct organs or organ systems. Patients with single-system trauma still receive full assessment, because even single-system injuries can be life threatening or more severe than they initially appear. Mortality in patients with multiple trauma is related to the severity of the injuries, the number of systems and organs involved, and the severity of each injury alone and in combination. Immediately after injury, the body is hypermetabolic, hypercoagulable, and severely stressed. Care of the patient with multiple injuries requires a team approach, with one person responsible for coordinating the treatment. The nursing staff assumes responsibility for assessing and monitoring the patient, ensuring/maintaining airway and IV access, administering prescribed medications, collecting laboratory specimens, and documenting activities and the patient's subsequent responses.

Snakebites

Children between 1 and 9 years of age are the most likely victims. The greatest number of bites occurs during the daylight hours and early evening of the summer months. The most frequent poisonous snakebite in the United States occurs from Crotalidae, otherwise called pit vipers, such as water moccasins, copperheads, and rattlesnakes. The most common site is the upper extremity. Of pit viper bites, 75% to 80% result in envenomation (injection of a poisonous material by sting, spine, bite, or other means); the rest result in what are called dry bites. Venomous snakebites are medical emergencies. Nurses should be familiar with the types of snakes common to the geographic region in which they practice. However, the exotic pet industry sells atypical snakes as "pets." Because of this, venomous snakes such as cobras and asps may be found outside of their native region.

Acetaminophen

Clinical Manifestations: Lethargy to encephalopathy and death GI upset, diaphoresis Right upper quadrant pain Abnormal liver function tests, prolonged prothrombin time, increased bilirubin, disseminated intravascular coagulation Hepatomegaly leading to liver failure Metabolic acidosis Hypoglycemia Stage I—within 24 hours; GI irritation, possible metabolic acidosis and coma if severe ingestion Stage II—24-48 hours; monitor liver and coagulation studies. Stage III—after 48 hours; hepatic encephalopathy/jaundice, vomiting, right upper quadrant pain, coagulopathy, hypoglycemia, acute kidney injury Therapeutic Management: Maintain airway. Obtain acetaminophen level. Levels ≥140 mg/kg are toxic. Laboratory studies—liver function tests, prothrombin time/partial thromboplastin time, complete blood count, blood urea nitrogen, creatinine. Lavage (if within 1 hour after ingestion); activated charcoal. Prepare for possible hemodialysis, which clears acetaminophen but does not halt liver damage. Administer N-acetylcysteine (Mucomyst) as soon as possible. N-acetylcysteine replenishes essential liver enzymes and requires a total of 18 doses every 4 hours. Charcoal absorbs N-acetylcysteine; do not administer together. Repeat N-acetylcysteine dose if patient vomits. Refer patient for psychiatric evaluation (potential suicide intent).

Patient-Focused Interventions

Clinicians caring for the patient should act confidently and competently to relieve anxiety and promote a sense of security. Explanations should be given that the patient can understand. Human contact and reassuring words reduce the panic of the person who is severely injured or ill and aid in dispelling fear of the unknown. The patient who is unconscious should be treated as if conscious—that is, the patient should be touched, called by name, and given an explanation of every procedure that is performed. As the patient regains consciousness, the nurse should orient the patient by stating their name, the date, and the location. This basic information should be provided repeatedly, as needed, in a reassuring way. Ensuring patient safety is a major focus in clinical practice settings. Some of the most common sentinel event (unanticipated events that result in patient harm) in the ED include delays to care and medication errors. Common root causes for these sentinel events revolve around nurse staffing patterns, patient volume, and specialty availability. Solutions to patient safety issues in the ED include ensuring optimal nurse staffing, pharmacy presence, and rapid diagnostics turnaround times to minimize wait time to diagnosis and fostering teamwork and support by leadership. All errors should be reported and investigated even if a patient was not harmed. In this way, future injury or death may be avoided.

Caring for Emergency Personnel

Concerted efforts have been made to focus on the needs of the ED staff, especially after serious and stressful events. Events can range from a local trauma case involving children; to treating someone known to the emergency worker, such as a colleague or family member; to a more complex natural disaster or multicasualty situation. It is important to remember that all staff members may not necessarily respond in the same way; an event that is stressful to one person may not be as stressful to another. Compassion fatigue may result from the continuous exposure to suffering and injury, and energy is expended on a daily basis. Fatigue occurs when the affected staff members cannot replenish the energy stores. In addition, because stress is a daily occurrence in the ED, the staff may not recognize the personal effect of any one event or the cumulative effect of day-to-day crisis interventions. ED leadership should be aware of staff coping patterns and support systems, patterns of interactions between staff members, staff members' health problems, including addiction, and appropriately assist with identifying behaviors caused by workplace stress. The availability of nonjudgmental counseling is essential to promoting a healthy staff.

Decompression Sickness

Decompression sickness, also known as "the bends," occurs in patients who have engaged in diving (lake/ocean diving), high-altitude flying, or flying in commercial aircraft within 24 hours after diving. It occurs relatively infrequently in the United States, but its effects can be hazardous. Being aware of decompression sickness and assessing the patient properly ensures appropriate management and results in decreased morbidity. Decompression sickness results from formation of nitrogen bubbles that occur with rapid changes in atmospheric pressure. They may occur in joint or muscle spaces, resulting in musculoskeletal pain, numbness, or hypesthesia. More significantly, nitrogen bubbles can become air emboli in the bloodstream and thereby produce stroke, paralysis, or death. Taking a rapid history about the events preceding the symptoms is essential.

Nonfatal Drowning

Defined as survival for at least 24 hours after submersion that caused a respiratory arrest. The most common consequence is hypoxemia. Children under 5 years of age and those over the age of 85 have the highest risk of drowning. Drowning and nonfatal drowning can be prevented by avoiding rip currents offshore. Pool drownings can be prevented by surrounding the pool with fencing, a self-latching/closing gate, and providing swimming lessons. Supervision near water is still the best prevention measure. When boating, a personal flotation device (PFD), even for swimmers, prevents drowning events. Factors associated with drowning and nonfatal drowning include alcohol ingestion, inability to swim, diving injuries, hypothermia, and exhaustion. The majority of drowning events occur in pools, lakes, and bathtubs. Suicide by drowning rarely occurs in pools and rarely involves alcohol. Efforts to save the patient should not be abandoned prematurely. Successful resuscitation with full neurologic recovery has occurred in patients who have experienced nonfatal drowning after prolonged submersion in cold water. This is possible because of a decrease in metabolic demands and/or the diving reflex. The nonfatal drowning process involves the onset of hypoxia, hypercapnia, bradycardia, and dysrhythmias. If there is a violent struggle associated with the nonfatal drowning episode, exercise-induced acidosis and tachypnea can result in aspiration. Hypoxia and acidosis cause eventual apnea and loss of consciousness. When the victim loses consciousness and makes a final effort to breathe, the terminal gasp occurs. Water then moves passively into the airways prior to death. After resuscitation, hypoxia and acidosis are the major complications experienced by a person who has experienced nonfatal drowning; immediate intervention in the ED is essential. Resultant pathophysiologic changes and pulmonary injury depend on the type of fluid (fresh or salt water) and the volume aspirated. Freshwater aspiration results in a loss of surfactant and, therefore, an inability to expand the lungs. Salt-water aspiration leads to pulmonary edema from the osmotic effects of the salt within the lungs. If a person survives submersion, acute respiratory distress syndrome (ARDS), resulting in hypoxia, hypercarbia, and respiratory or metabolic acidosis, can occur.

Delayed Primary Closure

Delayed primary closure may be indicated if tissue has been lost or there is a high potential for infection. A thin layer of gauze (to ensure drainage and prevent pooling of exudate), covered by an occlusive dressing, may be used. The wound is splinted in a functional position to prevent motion and decrease the possibility of contracture. If there are no signs of suppuration (formation of purulent drainage), the wound may be sutured (with the patient receiving a local anesthetic). The use of antibiotic agents to prevent infection depends on factors such as how the injury occurred, the age of the wound, and the risk of contamination. The site is immobilized and elevated to limit accumulation of fluid in the interstitial spaces of the wound. Tetanus prophylaxis is given as prescribed, based on the condition of the wound and the patient's immunization status. If the patient's last tetanus booster was given more than 5 years ago, or if the patient's immunization status is unknown, a tetanus booster must be given. The patient is instructed about signs and symptoms of infection and is instructed to contact the primary provider or clinic if there is sudden or persistent pain, fever or chills, bleeding, rapid swelling, foul odor, drainage, or redness surrounding the wound.

Animal and Human Bites

Dog bites constitute 80% to 90% of these bites and are responsible for the majority of deaths from bites by a nonvenomous animal. Cat bites have a high risk of infection because of the presence of Pasteurella in their saliva. All animal bites must be reported to public health authorities, which must provide follow-up screening of the offending animal for rabies. If the animal cannot be located and rabies vaccination verified, rabies prophylaxis for the person who has been bitten must be instituted. Human bites are frequently associated with rapes, sexual assaults, or other forms of battery. The human mouth contains more bacteria than that of most other animals, so a high risk of bite-related infection exists. Depending on the circumstances surrounding the event, the victim may delay seeking treatment. The ED nurse should inspect any bitten tissue for pus, erythema, or necrosis. A health care provider should take photographs, which can be used as evidence in criminal and legal proceedings. Guidelines for collecting forensic evidence for photographing with and without a measuring device should be followed. Cleansing with soap and water is then necessary, followed by the administration of antibiotics and tetanus toxoid as prescribed.

Sexual Assault Specimen Collection

During the physical examination, numerous laboratory specimens may be collected, including the following: Vaginal aspirate, examined for presence or absence of motile and nonmotile sperm. Secretions (obtained with a sterile swab) from the vaginal pool for acid phosphatase, blood group antigen of semen, and precipitin test against human sperm and blood. Separate smears from the oral, vaginal, and anal areas. Culture of body orifices for gonorrhea. Blood serum for syphilis and HIV testing and deoxyribonucleic acid (DNA) analysis. A sample of serum for syphilis may be frozen and saved for future testing. Pregnancy test if there is a possibility that the female patient may be pregnant. Any foreign material (leaves, grass, dirt), which is placed in a clean envelope. Pubic hair samples obtained by combing or trimming. Several pubic hairs with follicles are placed in separate containers and identified as the patient's hair. To preserve the chain of evidence, each specimen is labeled with the name of the patient, the date and time of collection, the body area from which the specimen was obtained, and the names of personnel collecting specimens. The specimens are then given to a designated person (e.g., crime laboratory technician), and an itemized receipt is obtained

Emergency Nursing Triage

Emergency nurses spend many hours learning to classify different illnesses and injuries to ensure that patients most in need of care do not needlessly wait. Protocols may be followed to initiate laboratory or x-ray studies while the patient is in the triage area. Collaborative protocols are developed and used by the triage nurse based on their level of experience. Nurses in the triage area collect additional crucial baseline data: full vital signs including pain assessment, history of the current event and past medical history, neurologic assessment findings, weight, allergies (especially to latex and medications), domestic violence screening, and necessary diagnostic data. Some facilities collect these data in a computerized system, which help guide the nurse through assessment and documentation. Asking questions is key to appropriate triage decisions. In addition to the collection of initial vital signs and medical history, triage consists of providing basic first aid, which may include application of ice, bleeding control, and basic wound care, as well as initiating protocol-based prescriptions (e.g., x-rays, administering antipyretic or mild analgesic agents, obtaining an electrocardiogram [ECG] or urinalysis, removing sutures). The triage nurse also is responsible for and monitors the waiting area, maintains a safe environment, reassesses patients who are waiting, and is the initial liaison to the families of patients. Routine ED triage protocols differ significantly from the triage protocols used in disasters and mass casualty incidents (field triage). Routine triage directs all available resources to the patients who are most critically ill, regardless of potential outcome. In field triage (or hospital triage during a disaster), scarce resources must be used to benefit the most people possible. This distinction affects triage decisions

Issues in Emergency Nursing Care

Emergency nursing is demanding because of the diversity of conditions and situations that present unique challenges. These challenges include legal issues, occupational health and safety risks for ED staff, and the challenge of providing holistic care in the context of a fast-paced, technology-driven environment in which serious illness and death are encountered on a daily basis. Another dimension of emergency nursing is nursing in disasters. With the increasing use of weapons of terror and mass destruction, both internationally and at home, the emergency nurse must recognize and treat patients exposed to biologic and other weapons, anticipating nursing care in the event of a mass casualty incident from natural causes or a terrorist event.

Establishing an Airway

Establishing an airway may be as simple as repositioning the patient's head to prevent the tongue from obstructing the pharynx. Alternatively, other maneuvers, such as the head-tilt/chin-lift maneuver, the jaw-thrust maneuver, or insertion of specialized equipment, may be needed to open the airway, remove a foreign body, or maintain the airway. In all maneuvers, the cervical spine must be protected from injury. After these maneuvers are performed, the patient is assessed for breathing by watching for chest movement and listening and feeling for air movement. In such a case, nursing diagnoses would include ineffective airway clearance related to obstruction of the airway by the tongue, an object, or fluids (blood, saliva) and ineffective breathing pattern related to airway obstruction or injury.

Carbon Monoxide Poisoning Management

Exposure to carbon monoxide requires immediate treatment. Goals of management are to reverse cerebral and myocardial hypoxia and to hasten elimination of carbon monoxide. Whenever a patient inhales a poison, the following general measures apply: Carry the patient to fresh air immediately; open all doors and windows. Loosen all tight clothing. Initiate traditional cardiopulmonary resuscitation. Prevent chilling; wrap the patient in blankets. Keep the patient as quiet as possible. Do not give alcohol in any form or permit the patient to smoke. In addition, for the patient with carbon monoxide poisoning, carboxyhemoglobin levels are analyzed on arrival at the ED and before treatment with oxygen if possible. To reverse hypoxia and accelerate the elimination of carbon monoxide, 100% oxygen is given at atmospheric or preferably hyperbaric pressures. Oxygen is given until the carboxyhemoglobin level is less than 5%. The patient is monitored continuously. Psychoses, spastic paralysis, ataxia, visual disturbances, and deterioration of mental status and behavior may persist after resuscitation and may be symptoms of permanent brain damage. When unintentional carbon monoxide poisoning occurs, the health department should be contacted so that the dwelling or building in question can be inspected. A psychiatric consultation is warranted if it has been determined that the poisoning was a suicide attempt.

Rewarming Supportive Care

External cardiac compression (typically performed only as directed in patients with temperatures higher than 31°C [88°F]) Defibrillation of ventricular fibrillation. A patient whose temperature is less than 32°C [90°F] experiences spontaneous ventricular fibrillation if moved or touched. Defibrillation is ineffective in patients with temperatures lower than 31°C (88°F); therefore, the patient must be rewarmed first. Mechanical ventilation with positive end-expiratory pressure (PEEP) and heated humidified oxygen to maintain tissue oxygenation Administration of warmed IV fluids to correct hypotension and to maintain urine output and core rewarming, as described previously Administration of sodium bicarbonate to correct metabolic acidosis if necessary Administration of antiarrhythmic medications Insertion of an indwelling urinary catheter to monitor urinary output and kidney function

Food Poisoning

Food poisoning is a sudden illness that occurs after ingestion of contaminated food or drink. Botulism is a serious form of food poisoning that requires continual surveillance. Food, gastric contents, vomitus, serum, and feces are collected for examination. The patient's respirations, blood pressure, level of consciousness (LOC), CVP (if indicated), and muscular activity are monitored closely. Measures are instituted to support the respiratory system. Death from respiratory paralysis can occur with botulism, fish poisoning, and some other food poisonings. Because large volumes of electrolytes and water are lost by vomiting and diarrhea, fluid and electrolyte status should be assessed. Severe vomiting produces alkalosis, and severe diarrhea produces acidosis. Hypovolemic shock may also occur from severe fluid and electrolyte losses. The patient is assessed for signs and symptoms of fluid and electrolyte imbalances, including lethargy, rapid pulse rate, fever, oliguria, anuria, hypotension, and delirium. Baseline weight and serum electrolyte levels are obtained for future comparisons. Measures to control nausea are also important to prevent vomiting, which could exacerbate fluid and electrolyte imbalances. An antiemetic medication is given parenterally as prescribed if the patient cannot tolerate fluids or medications by mouth (Tintinalli et al., 2016). For mild nausea, the patient is encouraged to take sips of weak tea, carbonated drinks, or tap water. After nausea and vomiting subside, clear liquids are usually prescribed for 12 to 24 hours, and the diet is gradually progressed to a low-residue, bland diet.

Precautions to be Taken to Avoid Injury

For prisoners, the hand or ankle restraint (handcuff) is never released, and a guard is always present in the room. A mask can be placed on the patient to prevent spitting or biting. Nonrestraint techniques should be tried when possible—e.g., talking with the patient, minimizing environmental stimulation. Physical restraints are used on any patient who is violent only as needed and, if used, should be humanely and professionally given; nonetheless, the staff should be cognizant that the patient could head-butt, even if restrained. Distance should be maintained from the patient to avoid grabbing; staff should not wear items that can be grabbed by the patient, such as dangling jewelry and stethoscopes. Furthermore, distance should be maintained between the patient and the door so that an escape route for the staff member is preserved. Objects should not be left within patient reach; even an intravenous (IV) line spike can become a tool of violence if the patient is determined. Courses on safety (de-escalation and physical restraint techniques) assist the staff with preparing for various violent situations.

Wound Cleansing

Hair around the wound may be clipped (only as directed) if it is anticipated that the hair will interfere with wound closure. Typically, the area around the wound is cleansed with normal saline solution or a polymer agent (e.g., Shur-Clens). The antibacterial agent povidone-iodine (Betadine) should not be allowed to get deep into the wound without thorough rinsing. Povidone-iodine is used only for the initial cleansing because it injures exposed and healthy tissue, resulting in further tissue damage. If indicated, the area is infiltrated with a local intradermal anesthetic through the wound margins or by regional block. Patients with soft tissue injuries usually have localized pain at the site of injury. The nurse then assists with cleaning and débriding the wound. The wound is irrigated gently and copiously with sterile isotonic saline solution to remove surface dirt. Devitalized tissue and foreign matter are removed because they impede healing and may promote infection. Any small bleeding vessels are clamped, tied, or cauterized. After wound treatment, a nonadherent dressing is applied to protect the wound and to serve as a splint and as a reminder to the patient that the area is injured.

The Emergency Nurse

Has had specialized education, training, experience, and expertise in assessing and identifying patients' health care problems in crisis situations. In addition, the emergency nurse establishes priorities, monitors, and continuously assesses patients who are acutely ill and injured, supports and attends to families, supervises allied health personnel, and educates patients and families within a time-limited, high-pressured care environment. Nursing interventions are accomplished interdependently, in consultation with or under the direction of a physician or advanced practitioner such as a nurse practitioner or physician assistant. The roles of nursing and medicine are complementary in an emergency situation. Appropriate nursing and medical interventions are anticipated based on assessment data. Members of the emergency health care staff work as a team in performing the highly technical, hands-on skills required to care for patients in emergency situations.

Heat Illness Assessment and Diagnosis

Heat stroke, whether the cause is exertional or nonexertional, causes thermal injury at the cellular level, resulting in coagulopathies and widespread damage to the heart, liver, and kidneys. Recent patient history reveals exposure to elevated ambient temperature or excessive exercise during extreme heat. When assessing the patient, the nurse notes the following symptoms: profound central nervous system (CNS) dysfunction (manifested by confusion, delirium, bizarre behavior, coma, seizures); elevated body temperature (40.6°C [105°F] or higher); hot, dry skin; and usually anhidrosis (absence of sweating), tachypnea, hypotension, and tachycardia. The patient with heat exhaustion, on the other hand, may exhibit similarly high body temperatures accompanied by headaches, anxiety, syncope, profuse diaphoresis, gooseflesh, and orthostasis. The cardinal manifestations of heat cramps include muscle cramps, particularly in the shoulders, abdomen, and lower extremities; profound diaphoresis; and profound thirst.

Opioids

Heroin Opium or paregoric Morphine, codeine, semisynthetic derivatives: oxycodone (OxyContin), methadone, meperidine (Demerol), tramadol (Ultram), fentanyl (Sublimaze) Clinical Manifestations: Pinpoint pupils (may be dilated with severe hypoxia) Decreased blood pressure Marked respiratory depression/arrest Pulmonary edema Stupor → coma Seizures Fresh needle marks along course of any superficial vein Skin abscesses (from "popping") Therapeutic Management: Support respiratory and cardiovascular functions. Establish IV lines; obtain blood for chemical and toxicologic analysis. Patient may be given bolus of glucose to eliminate possibility of hypoglycemia. Administer narcotic antagonist (naloxone hydrochloride IV, IM [Narcan]) as prescribed to reverse severe respiratory depression and coma. Continue to monitor level of responsiveness and respirations, pulse, and blood pressure. Duration of action of naloxone hydrochloride is shorter than that of heroin; repeated dosages may be necessary. Send urine for analysis; opioids can be detected in urine. Obtain an ECG. Do not leave patient unattended; he or she may lapse back into coma rapidly. Clinical status may change from minute to minute. Hemodialysis may be indicated for severe drug intoxication. Activated charcoal may be considered if opioids were taken orally and if the patient is alert. Monitor for pulmonary edema, which is frequently seen in patients who abuse/overdose on narcotics. Refer patient for psychiatric and drug rehabilitation evaluation before discharge.

Human Trafficking

Human trafficking is defined as the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude. Human trafficking may involve forced sex or labor or both. These people have limited access to health care and the ED may be the only access point to identify their situation. A victim of trafficking may present to the ED with injury, accompanied by a significantly older boyfriend or travel partner. The victim may have a history of being a chronic runaway, or of homelessness, and of self-mutilation. Common behaviors exhibited by these patients may include cowering or deferring to the person accompanying them, who may appear controlling, and appearing frightened or agitated. The patient may have a special mark/tattoo present, poor dentition, and multiple injuries in various stages of healing. Common physical complaints include injuries, poor healing or poorly healed old injuries, abdominal pain, dizziness, headaches, rashes or sores. Patients may demonstrate addiction, panic attacks, impulse control, hostility, and suicidal ideation. The ED nurse may be well positioned to offer an opportunity for the patient to speak, alone without an accompanying companion, who could be a perpetrator of abuse. Targeted, appropriate questions may include asking patients if they are in control of their own money; whether or not they are able to come and go as they please; and who is the person or persons accompanying them. Patients may decline assistance. The National Human Trafficking Hotline may be tapped into as a resource

Airway Obstruction Management

If the patient can breathe and cough spontaneously, a partial obstruction should be suspected. The victim is encouraged to cough forcefully and to persist with spontaneous coughing and breathing efforts as long as good air exchange exists. There may be some wheezing between coughs. If the patient demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis, the patient should be managed as if there were complete airway obstruction. After the obstruction is removed, rescue breathing is initiated. If the patient has no pulse, cardiac compressions are instituted. These measures provide oxygen to the brain, heart, and other vital organs until definitive medical treatment can restore and support normal heart and ventilatory activity.

Intubation With a King Tube or Laryngeal Mask Airway

If the patient is not hospitalized and cannot be intubated in the field, emergency medical personnel may insert a King Tube, which rapidly provides pharyngeal ventilation. When the tube is inserted into the trachea, it functions like an endotracheal tube. The two balloons that surround the tube are inflated after the tube is inserted. One balloon is large and occludes the oropharynx. This permits ventilation by forcing air through the larynx. The smaller balloon is inflated with air and occludes the esophagus at a site distal to the glottis. Breath sounds are auscultated after balloon inflation to make sure that the oropharyngeal balloon (or cuff) does not obstruct the glottis. One variant type of King Tube is designed so that a gastric tube may also be passed for suction. If it is difficult to establish an airway, a laryngeal mask airway (LMA) may be inserted as an interim airway device. The design of the LMA provides a "mask" in the subglottic airway with a cuff inflated within the esophagus. It allows easy insertion for rapid airway control until a more definitive airway can be placed. Some LMAs also permit removal of secretions from the esophagus.

Control of Internal Bleeding

If the patient shows no external signs of bleeding but exhibits tachycardia, falling blood pressure, thirst, apprehension, cool and moist skin, or delayed capillary refill, internal hemorrhage is suspected. Typically, packed red blood cells, plasma, and platelets are given at a rapid rate, and the patient is prepared for more definitive treatment (e.g., surgery, pharmacologic therapy). In addition, arterial blood gas specimens are obtained to evaluate pulmonary function and tissue perfusion and to establish baseline hemodynamic parameters, which are then used as an index for determining the amount of fluid replacement the patient can tolerate and the response to therapy. The patient is maintained in the supine position and monitored closely until hemodynamic or circulatory parameters improve, or until he or she is transported to the operating room or intensive care unit.

Fractures

Immediate appropriate management of a fracture may determine the patient's eventual outcome and may mean the difference between recovery and disability. When the patient is being examined for fracture, the body part is handled gently and as little as possible. Clothing is cut off to visualize the affected body part. Assessment is conducted for pain over or near a bone, swelling (from blood, lymph, and exudate infiltrating the tissue), and circulatory disturbance. The patient is assessed for ecchymosis, tenderness, and crepitation. The nurse must remember that the patient may have multiple fractures accompanied by head, chest, spine, or abdominal injuries.

Fracture Management

Immediate attention is given to the patient's general condition. Assessment of airway, breathing, and circulation (which includes pulses in the extremities) is conducted. The patient is also evaluated for neurologic or abdominal injuries before the extremity is treated, unless a pulseless extremity is detected. If a pulseless extremity is identified, repositioning of the extremity to proper alignment is required. If the pulseless extremity involves a fractured femur, Hare traction (a portable in-line traction device) may be applied to assist with alignment. If repositioning is ineffective in restoring the pulse, a rapid total-body assessment must be completed, followed by transfer of the patient to the operating room for arteriography and possible arterial repair versus amputation. After the initial evaluation has been completed, all injuries identified are evaluated and treated. The fractured body part is inspected. Using a systematic head-to-toe approach, the nurse inspects the entire body, observing for lacerations, swelling, and deformities, including angulation (bending), shortening, rotation, and asymmetry. All peripheral pulses, especially those distal to the fractured extremity, are palpated. The extremity is also assessed for coolness, blanching, and decreased sensation and motor function, which are indicative of injury to the extremity's neurovascular supply. A splint is applied before the patient is moved. Splinting immobilizes the joint at a site distal and proximal to the fracture, relieves pain, restores or improves circulation, prevents further tissue injury, and prevents a closed fracture from becoming an open one. To splint an extremity, one hand is placed distal to the fracture and some traction is applied while the other hand is placed beneath the fracture for support. The splints should extend beyond the joints adjacent to the fracture. Upper extremities must be splinted in a functional position. If the fracture is open, a moist, sterile dressing is applied. After splinting, the vascular status of the extremity is checked by assessing color, temperature, pulse, and blanching of the nail bed. In addition, the patient is assessed for neurovascular compromise if pain or pressure is reported.

Crush Injuries Management

In conjunction with maintaining the airway, breathing, and circulation, the patient is observed for acute kidney injury (AKI). Injury to the back can cause renal trauma. Severe muscular damage may cause rhabdomyolysis, a toxic syndrome caused by a release of myoglobin from ischemic skeletal muscle, resulting in ATN. Rhabdomyolyis may also result from major burns, heat stroke, and abuse of illicit drugs, in addition to crush injuries. The classic triad of clinical manifestations suggestive of rhabdomyolysis includes myalgias (muscle cramps), generalized muscle weakness, and darkened urine. The serum creatine kinase (CK) is monitored as the most sensitive indicator of rhabdomyolyis; levels in excess of 6000 IU/L are considered diagnostic. In addition to treatment aimed at preventing or treating ATN, major soft tissue injuries are splinted promptly to control bleeding and pain. The serum lactic acid level is monitored; a decrease to less than 2.5 mmol/L is an indication of successful resuscitation. If an extremity is injured, it is elevated to relieve swelling and pressure. If compartment syndrome develops, the physician may perform a fasciotomy to restore neurovascular function. Medications for pain and anxiety are then given as prescribed, and the patient is quickly transported to the operating suite for wound débridement and fracture repair. A hyperbaric oxygen chamber (if available) may be used to hyperoxygenate crushed tissue, if indicated.

Patients Who are Underactive or Depressed

In the ED, depression may be seen as the main condition bringing the patient to the health care facility, or it may be masked by anxiety and somatic complaints. The person who is depressed has a mood disturbance. Any patient who is depressed may be at risk for suicide. Attempts are made to find out whether the patient has thought about or attempted suicide. Questions such as "Have you ever thought about taking your own life?" may be helpful. In general, the patient is relieved to have an opportunity to discuss personal feelings. If the patient is seriously depressed, relatives should be notified. The patient should never be left alone, because suicide is usually committed in solitude.

Triage

In the daily routine of the ED, triage is used to sort patients into groups based on the severity of their health problems and the immediacy with which these problems must be treated. A basic and widely used triage system that had been in use for many years utilized three categories: emergent, urgent, and nonurgent. In this system, emergent patients had the highest priority, urgent patients had serious health problems but not immediately life-threatening ones, and nonurgent patients had episodic illnesses. The goal of all triage is rapid assessment and decision-making, preferably under 5 minutes. Although the ESI and the CTAS are valid and reliable triage severity rating systems, many EDs in the United States have high patient volumes and slow flow. Patients arriving at the ED may experience bottlenecks at triage. To further refine the system, triage bypass moves an incoming patient directly to a bed if open beds are available in the department. This eliminates the patient waiting and the receiving nurse performs the initial assessment and vital signs. In team triage (or provider in triage [PIT]), the triage nurse works with the physician or advanced practitioner within the triage area itself. Team triage can move patients to diagnostics and possibly discharge without full admission to the ED. Both of these additional concepts added to triage decrease wait time for treatment and maintain flow in the department. Many patient flow problems are driven by availability of in-house beds. The ED needs to be as efficient as possible to decrease wait times, maintain flow for EMS agencies, and be available for true emergencies.

Snakebites Management

Initial first aid at the site of the snakebite includes having the person lie down, removing constrictive items such as rings, providing warmth, cleansing the wound, covering the wound with a light sterile dressing, and immobilizing the injured body part below the level of the heart. Airway, breathing, and circulation are the priorities of care. Ice, incision and suction, or a tourniquet is not applied. Tetanus and analgesia should be given as necessary. Initial evaluation in the ED is performed quickly and includes information about the following: Whether the snake was venomous or nonvenomous; discourage bringing the snake for identification—even a dead snake's venom is poisonous. Do not handle any snake brought to the ED. If the snake is transported to the ED, caution should be taken because the snake is frequently in a stunned, not dead, state. The bite reflex can remain intact for up to 90 minutes after the death of the snake. Where and when the bite occurred and the circumstances of the bite. Sequence of events, signs, and symptoms (fang punctures, pain, edema, and erythema of the bite and nearby tissues). Severity of poisonous effects. Call the local poison control phone number to gain access to information about an exotic snakebite presentation and management, as necessary. The poison control center may also be able to assist with retrieving antivenin for these particular species. Vital signs. Circumference of the bitten extremity or area at several points. The circumference of the extremity that was bitten is compared with the circumference of the opposite extremity. Laboratory data (complete blood count, urinalysis, and coagulation studies). The course and prognosis of snakebite injuries depend on the kind and amount of venom injected; where on the body the bite occurred; and the general health, age, and size of the patient. There is no one specific protocol for treatment of snakebites. In general, ice, tourniquets, heparin, and corticosteroids are not used during the acute stage. Corticosteroids are contraindicated in the first 6 to 8 hours after the bite because they may depress antibody production and hinder the action of antivenin. Parenteral fluids may be used to treat hypotension. If vasopressors are used to treat hypotension, their use should be short term. Surgical exploration of the bite is rarely indicated. Typically, the patient is observed closely for at least 6 hours. The patient is never left unattended.

Patients Who are Suicidal

Males are at greater risk of successfully committing suicide than females, who attempt suicide more often. Others at risk are older adults; young adults; people who are enduring unusual loss or stress; those who are unemployed, divorced, widowed, or living alone; those showing signs of significant depression (e.g., weight loss, sleep disturbances, somatic complaints, suicidal preoccupation); and those with a history of a previous suicide attempt, suicide in the family, or psychiatric illness. Being aware of people at risk and assessing for specific factors that predispose a person to suicide are key management strategies. Specific signs and symptoms of potential suicide include the following: Communication of suicidal intent, such as preoccupation with death or speaking of someone else's suicide (e.g., "I'm tired of living. I've put my affairs in order. I'm better off dead. I'm a burden to my family.") History of a previous suicide attempt, with risk being much greater in these cases Family history of suicide Loss of a parent at an early age Specific plan for suicide A means to carry out the plan Emergency management focuses on treating the consequences of the suicide attempt (e.g., gunshot wound, drug overdose) and preventing further self-injury. A patient who has made a suicidal attempt may do so again. Crisis intervention is used to determine suicidal potential, to discover areas of depression and conflict, to find out about the patient's support system, and to determine whether hospitalization or psychiatric referral is necessary. Depending on the patient's potential for suicide, the patient may be admitted to the intensive care unit, referred for follow-up care, or admitted to the psychiatric unit.

Mandatory Reporting of Violence, Abuse, and Neglect

Mandatory reporting laws in most states require health care workers to report suspected child abuse or abuse of older adults to an official agency, usually Adult (or Child) Protective Services. All that is required for reporting is the suspicion of abuse; the health care worker is not required to prove abuse or neglect. Likewise, health care workers who report suspected abuse are immune from civil or criminal liability if the report is made in good faith. Subsequent home visits resulting from the report of suspected abuse are a part of gathering information about the patient in the home environment. In addition, many states have resource hotlines for use by health care workers and by patients who seek answers to questions about abuse and neglect.

Blunt Abdominal Trauma

May result from motor vehicle crashes, falls, blows, or explosions. Blunt trauma is commonly associated with extra-abdominal injuries to the chest, head, or extremities. Patients with blunt trauma are a challenge because injuries may be difficult to detect. The incidence of delayed and trauma-related complications is greater than for penetrating injuries. This is especially true of blunt injuries involving the liver, kidneys, spleen, or blood vessels, which can lead to massive blood loss into the peritoneal cavity.

Inserting an Oropharyngeal Airway

Measure the oral airway alongside the head. The airway should reach from lip to ear. Extend the patient's head by placing one hand under the bony chin (only if the cervical spine is uninjured). With the other hand, tilt the head backward by applying pressure to the forehead while simultaneously lifting the chin forward. Open the patient's mouth. A. Insert the oropharyngeal airway with the tip facing up toward the roof of the mouth until it passes the uvula. B. Rotate the tip 180 degrees so that the tip is pointed down toward the pharynx. This displaces the tongue anteriorly, and the patient then breathes through and around the airway. An alternate method is to use a tongue blade to hold the tongue and insert the oropharyngeal airway directly without rotation. The distal end of the oropharyngeal airway is in the hypopharynx, and the flange is approximately at the patient's lips. Make sure that the tongue has not been pushed into the airway.

Heat-Induced Illness Gerontologic Considerations

Most heat-related deaths occur in older adults because their circulatory systems are unable to compensate for stress imposed by heat. Older adults have a decreased ability to perspire as well as a decreased ability to vasodilate and vasoconstrict. They have less subcutaneous tissue, a decreased thirst mechanism, and a diminished ability to concentrate urine to compensate for heat. Many older adults do not drink adequate amounts of fluid, partly because of fear of incontinence, and thus have a greater risk of heat stroke. In addition, many older adults fear being victims of crime, so even if their residence lacks air conditioning, they tend to keep windows closed despite high temperatures and humidity levels.

Violence, Abuse, and Neglect Assessment and Diagnosis

Nurses in EDs are in an ideal position to provide early detection and interventions for victims of IPV. This requires an acute awareness of the signs of possible abuse, maltreatment, and neglect. Nurses must be skilled in interviewing techniques that are likely to elicit accurate information. A careful history is crucial in the screening process. Asking questions in private—away from others—may be helpful in eliciting information about abuse, maltreatment, and neglect. Nurses need to be aware that women may withhold directly answering questions regarding IPV in fear of retaliation, loss of children, and retribution against the children. Whenever evidence leads the nurse to suspect abuse or neglect, an evaluation with careful documentation of descriptions of events and drawings or photographs of injuries is important, because the medical record may be used as part of a legal proceeding. Assessment of the patient's general appearance and interactions with significant others, an examination of the entire surface area of the body, and a mental status examination are crucial.

Treatment after Primary and Secondary Survey

Once the patient has been assessed, stabilized, and tested, appropriate medical and nursing diagnoses are formulated, initial important treatment is started, and plans for the proper disposition of the patient are made. Many emergent and urgent conditions and priority emergency interventions are discussed in detail in the remaining sections of this chapter. In addition to the management of the illness or injury, the ED nurse must also focus on providing comfort and emotional support to the patient and family. Included in this is pain management. Effective pain management must be instituted early and should include rapid-acting agents that result in minimal sedation so that the patient can continue to interact with the staff for ongoing assessment. Moderate sedation can help facilitate short procedures in the ED; the patient will not remember the procedure later. The patient is closely monitored during the procedure and then rapidly awakens when it is complete. It is essential that family crisis intervention services are available for families of patients in the ED.

Violence in the Emergency Department

Patients and families waiting for assistance may be emotionally volatile. Often, waiting rooms are the sites where feelings of dissatisfaction, fear, and anger are channeled violently. Some EDs assign security officers or off duty police to the area and have installed silent alarm systems or metal detectors to identify weapons in order to protect patients, families, and staff. Safety is the first priority. Patients and family members under the influence of illicit drugs or alcohol, or who may have psychiatric disorders, including delirium or dementia, or who may be influenced by social situations such as gang membership, are at risk for committing a violent act, whether intentional or not. The environment of the ED, including being subjected to long wait times and crowded conditions, may also increase their risk of committing violent events. Physical threats are most often accompanied by verbal abuse, which is the most common type of violence. To avoid angry confrontations, members of gangs and families who are feuding need to be separated in the ED, in the waiting room, and later in the inpatient nursing unit. Nurses and other personnel must be prepared to deal with these circumstances. The ED should be locked against entry if security is questionable. Patients who are violent or potentially violent must be vigilantly monitored by the ED staff. Care must be taken to avoid injury. Patients from prison and those who are under guard need to be handcuffed to the bed and appropriately assessed to ensure the safety of hospital staff and other patients. The emergency nurse must understand how to employ safe use of restraints. The Joint Commission has strict standards regarding documentation of the reason, monitoring for safety, and ensuring the dignity of the patient who is restrained. In the case of gunfire in the ED, self-protection is a priority. There is no advantage to protecting others if health care providers are injured. Security officers and police must gain control of the situation first, and then care is provided to the injured.

Barbituates

Pentobarbital (Nembutal), secobarbital (Seconal), amobarbital (Amytal), gamma-hydroxybutyrate (GHB, "liquid Ecstasy") Clinical Manifestations: Acute intoxication (may mimic alcohol intoxication): Respiratory depression Flushed face Decreased pulse rate; decreased blood pressure Increasing nystagmus (to vertical and horizontal gaze) Sluggish pupils Lack of convergence of eyes Depressed deep tendon reflexes Decreasing mental alertness Difficulty in speaking Poor motor coordination and flaccid muscles Coma, death GHB: Sexual disinhibition Amnesia, myoclonus, agitation Overdoses when mixed with alcohol Therapeutic Management: Maintain airway and provide respiratory support. Endotracheal intubation or tracheostomy is considered if there is any doubt about the adequacy of airway exchange. Check airway frequently. Perform suctioning as necessary. Support cardiovascular and respiratory functions; most deaths result from respiratory depression or shock. Start infusion through large-gauge needle or IV catheter to support blood pressure; coma and dehydration result in hypotension and respond to infusion of IV fluids with elevation of blood pressure. Evacuate stomach contents or lavage if within 1 hour of ingestion to prevent absorption; repeated doses of activated charcoal may be given. Assist with hemodialysis for patient with severe overdose. Maintain neurologic and vital sign flow sheet. Patient awakening from overdose may demonstrate combative behavior. Refer for psychiatric and drug rehabilitation consultation to evaluate suicide potential and drug abuse.

Hypothermia Rewarming

Rewarming methods include active internal (core) rewarming and passive (spontaneous) or active external rewarming. Active internal rewarming methods are used for moderate to severe hypothermia (less than 28°C to 32.2°C [82.5°F to 90°F]) and include cardiopulmonary bypass, warm fluid administration, warmed humidified oxygen by ventilator, and warmed peritoneal lavage. Monitoring for ventricular fibrillation as the patient's temperature increases from 31°C to 32°C (88°F to 90°F) is essential. Passive or active external rewarming is used for mild hypothermia (32.2°C to 35°C [90°F to 95°F]). Passive external rewarming uses over-the-bed heaters to the extremities and increases blood flow to the acidotic, anaerobic extremities. The cold blood from peripheral tissues has high lactic acid levels. As this blood returns to the core, it causes a significant drop in the core temperature (i.e., core temperature afterdrop) and can potentially cause cardiac dysrhythmias and electrolyte disturbances. Active external rewarming uses forced-air warming blankets. Care must be taken to prevent extremity burn from these devices, because the patient may not have effective sensation to feel the burn.

Cocaine

Routes: Intranasally By smoking ("freebasing")—cocaine hydrochloride dissolved in ether to yield a pure cocaine alkaloid base ("crack," "rocks"); smoking in a small pipe delivers large quantities of cocaine to lungs. IV Polysubstance (cocaine and heroin) Clinical Manifestations: Increased heart rate and blood pressure Hyperpyrexia Seizures Sluggish, dilated pupillary response Muscle rigidity Increased energy, agitation, aggression Ventricular dysrhythmias Intense euphoria, then anxiety, sadness, insomnia, and sexual indifference Cocaine hallucinations with delusions Psychosis with extreme paranoia and ideas of persecution Hypervigilance Chronic psychotic symptoms may persist. Overall psychotic symptoms are short-lived compared to methamphetamines Therapeutic Management: Maintain airway and provide respiratory support. Control seizures. Monitor cardiovascular effects; have antiarrhythmic drugs and defibrillator available. Treat for hyperthermia. If cocaine was ingested, evacuate stomach contents and use activated charcoal to treat. Whole bowel irrigation may be necessary to treat body packers ("mules"). Refer for psychiatric evaluation and treatment in an inpatient unit that eliminates access to the drug. Include drug rehabilitation counseling.

Labs that Aid in Abdominal Assessment and Diagnosis

Serial hemoglobin and hematocrit levels to evaluate trends reflecting the presence or absence of bleeding Lactate to determine acidosis and need for continued resuscitation Arterial blood gas (ABG) for pH (acidosis), base deficit for resuscitation evaluation, and ventilation parameters (PaCO2, PaO2) International normalized ratio (INR) to identify coagulopathy or presence of chemically induced anticoagulation White blood cell (WBC) count to detect elevation (generally associated with trauma)

Alcohol Withdrawal Syndrome/Delirium Tremens

Severity of symptoms depends on how much alcohol was ingested and for how long. Delirium tremens may be precipitated by acute injury or infection (pneumonia, pancreatitis, hepatitis) and is the most severe form of alcohol withdrawal syndrome. Delirium tremens is a life-threatening condition and carries a high mortality rate if untreated. Patients with alcohol withdrawal syndrome show signs of anxiety, uncontrollable fear, tremor, irritability, agitation, insomnia, and incontinence. They are talkative and preoccupied and experience visual, tactile, olfactory, and auditory hallucinations that often are terrifying. Autonomic overactivity occurs and is evidenced by tachycardia, dilated pupils, and profuse perspiration. Usually, all vital signs are elevated in the alcoholic toxic state. The goals of management are to give adequate sedation and support to allow the patient to rest and recover without danger of injury or peripheral vascular collapse. A physical examination is performed to identify pre-existing or contributing illnesses or injuries (e.g., head injury, pneumonia). A drug history is obtained to elicit information that may facilitate adjustment of any sedative requirements. Baseline blood pressure is determined, because the patient's subsequent treatment may depend on blood pressure changes. Usually, the patient is sedated as directed with a sufficient dosage of benzodiazepines to establish and maintain sedation, which reduces agitation, prevents exhaustion, prevents seizures, and promotes sleep. The patient should be calm, able to respond, and able to maintain an airway safely on their own. A variety of medications and combinations of medications are used (e.g., chlordiazepoxide [Librium], lorazepam [Ativan], and clonidine [Catapres]). Haloperidol (Haldol), esmolol (Brevibloc), or midazolam (Versed) may be given for severe acute alcohol withdrawal syndrome. Dosages are adjusted according to the patient's symptoms (agitation, anxiety) and blood pressure response. The patient is placed in a calm, nonstressful environment (usually a private room) and observed closely. The room remains lighted to minimize the potential for illusions (visual misrepresentations) and hallucinations. Homicidal or suicidal responses may result from hallucinations. Closet and bathroom doors are closed to eliminate shadows. Someone is designated to stay with the patient as much as possible. The presence of another person has a reassuring and calming effect, which helps the patient maintain contact with reality. To orient the patient to reality, any illusions are explained. Fluid losses may result from gastrointestinal losses (vomiting), profuse perspiration, and hyperventilation. In addition, the patient may be dehydrated as a result of alcohol's effect of decreasing antidiuretic hormone. The oral or IV route is used to restore fluid and electrolyte balance. Temperature, pulse, respiration, and blood pressure are recorded frequently (every 30 minutes in severe forms of delirium) to monitor for peripheral circulatory collapse or hyperthermia (the two most serious complications). Frequently seen complications include infections (e.g., pneumonia), trauma, hepatic failure, hypoglycemia, and cardiovascular problems. Hypoglycemia may accompany alcohol withdrawal, because alcohol depletes liver glycogen stores and impairs gluconeogenesis; many patients with alcoholism also are malnourished. Parenteral dextrose may be prescribed if the liver glycogen level is depleted. Orange juice, sports drinks, or other sources of carbohydrates are given to stabilize the blood glucose level and counteract tremulousness. Supplemental vitamin therapy and a high-protein diet are provided as prescribed to counteract nutritional deficits. The patient should be referred to an alcoholic treatment center for follow-up care and rehabilitation. Restraints are used as prescribed, if necessary, if the patient is aggressive or violent, but only when other alternatives have been unsuccessful. The least restrictive device that will prevent the patient from injuring him- or herself or others is used. Caution is taken to ensure that restraints are applied properly and that they are not impairing circulation to any part of the body or interfering with respirations. Restraints should be used in tandem with verbal intervention to calm the patient and promote adherence. Restraints must be released according to protocol. Physical observation (e.g., skin integrity, circulatory status, respiratory status) is ongoing, and the patient's response is documented.

Snakebites Clinical Manifestations

Snake venom consists primarily of proteins and has a broad range of physiologic effects. It may affect multiple organ systems, especially the neurologic, cardiovascular, and respiratory systems. Classic clinical signs of envenomation are edema, ecchymosis, and hemorrhagic bullae, leading to necrosis at the site of envenomation. Symptoms include lymph node tenderness, nausea, vomiting, numbness, and a metallic taste in the mouth. Without decisive treatment, these clinical manifestations may progress to include fasciculations, hypotension, paresthesias, seizures, and coma.

Lyme Disease Stages

Stage I may present with a classic "bull's-eye" rash (i.e., erythema migrans) that typically can be found in the axilla, groin, or thigh area and that appears within 4 weeks after the tick bite, with a peak manifestation time of 7 days after the bite. Classically, this rash is at least 5 cm in diameter with bright red borders. It is accompanied by flulike signs and symptoms that may include chills, fever, myalgia, fatigue, and headache. Without treatment, the rash subsides within 3 to 4 weeks. However, the rash and flulike manifestations can be significantly reduced within days if prompt treatment with antibiotic agents (e.g., doxycycline [Vibramycin]) is initiated. If antibiotics are not given, stage II Lyme disease may present within 4 to 10 weeks following the tick bite and may manifest with joint pain, memory loss, poor motor coordination, adenopathy, and cardiac abnormalities. Facial nerve palsy is the most common manifestation of stage II Lyme disease. Stage III can begin anywhere from weeks to more than a year after the bite and has serious long-term chronic sequelae, including arthritis, neuropathy, myalgia, and myocarditis. Even after appropriate treatment with antibiotics, 10% to 20% of patients may experience long-term effects including fatigue and arthralgias; some experience neurologic symptoms that may persist for over 10 years.

Hemorrhage

Stopping bleeding is essential to the care and survival of patients in an emergency or disaster situation. Hemorrhage that results in the reduction of circulating blood volume is a main cause of shock. Minor bleeding, which is usually venous, generally stops spontaneously unless the patient has a bleeding disorder or has been taking anticoagulant agents. Internal hemorrhage can hide in many anatomic spaces and compartments, resulting in shock without external evidence of hemorrhage. The internal spaces and compartments that are capable of housing large amounts of blood include the retroperitoneum, pelvis, chest, and thighs. The patient is assessed for signs and symptoms of shock: cool, moist skin (resulting from poor peripheral perfusion), decreasing blood pressure, increasing heart rate, delayed capillary refill, and decreasing urine volume (see Chapter 14). The goals of emergency management are to control the bleeding, maintain adequate circulating blood volume for tissue oxygenation, and prevent shock. Patients who hemorrhage are at risk for cardiac arrest caused by hypovolemia with secondary anoxia. Nursing interventions are carried out collaboratively with other members of the emergency health care team.

Gerontologic Considerations

The ED is a common point of entry into the health care system for patients 65 years and older. As age increases, the percentage of admissions increases. Of these admissions, 29% were related to trauma, primarily falls. Older adult patients typically arrive with one or more presenting conditions. Nonspecific symptoms, such as weakness and fatigue, episodes of falling, incontinence, and change in mental status, may be manifestations of acute, potentially life-threatening illness in the older person. Emergencies in this age group may be more difficult to manage because older adult patients may have an atypical presentation, an altered response to treatment, a greater risk of developing complications, or a combination of these factors. The older adult patient may perceive the emergency as a crisis signaling the end of an independent lifestyle or even resulting in death. The nurse should give attention to the patient's feelings of anxiety and fear. The older patient may have limited sources of social and financial support during these times of crises. The nurse should assess the psychosocial resources of the patient (and of the caregiver, if necessary) and anticipate discharge needs. Referrals for support services (e.g., to the social service department or a gerontologic nurse specialist) may be necessary.

Intraperitoneal Injury

The abdomen is assessed for tenderness, rebound tenderness, guarding, rigidity, spasm, increasing distention, and pain. Referred pain is a significant finding because it suggests intraperitoneal injury. To determine if there is intraperitoneal injury and bleeding, the patient is usually prepared for diagnostic procedures, such as peritoneal lavage, abdominal ultrasonography, or abdominal CT scanning. Diagnostic peritoneal lavage (DPL), although no longer the standard diagnostic study used to evaluate a traumatized abdomen, remains a backup procedure that is easily performed and is very useful during mass casualty situations when CT scanners may not be readily available. DPL involves the instillation of 1 L of warmed lactated Ringer's or normal saline solution into the abdominal cavity. After a minimum of 400 mL has been returned, a fluid specimen is sent to the laboratory for analysis. Positive laboratory findings include a red blood cell count greater than 100,000/mm3; a WBC count greater than 500/mm3; or the presence of bile, feces, or food. In patients with stab wounds, sinography may be performed to detect peritoneal penetration; a purse-string suture is placed around the wound and a small catheter is introduced through the wound. A contrast agent is then introduced through the catheter, and x-rays are taken to identify any peritoneal penetration.

Violence, Abuse, and Neglect Management

The aims of IPV screening include earlier identification of patients who have been abused and prevention of continued abusive events, including homicide. Whenever abuse, maltreatment, or neglect is suspected, the health care provider's main concern should be the safety and welfare of the patient. Treatment focuses on the consequences of the abuse, violence, or neglect and on prevention of further injury. Protocols of most EDs require that a multidisciplinary approach be used. Nurses, physicians, social workers, and community agencies work collaboratively to develop and implement a plan for meeting the patient's needs. If the patient is in immediate danger, he or she should be separated from the person who is abusive or neglectful whenever possible. Referral to a shelter may be the most appropriate action, but many shelters are inaccessible to people with mobility limitations. When abuse or neglect is the result of stress experienced by a caregiver who is no longer able to cope with the burden of caring for an older adult or a person with chronic disease or a disability, respite services may be necessary. Support groups may be helpful to these caregivers. When mental illness of the person who is abusive or neglectful is responsible for the situation, alternative living arrangements may be required. Nurses must be mindful that competent adults are free to accept or refuse the help that is offered to them. Some patients insist on remaining in the home environment where the abuse or neglect is occurring. The wishes of patients who are competent and not cognitively impaired should be respected. However, all possible alternatives, available resources, and safety plans should be explored with the patient.

Airway Obstruction Pathophysiology

The airway may be partially or completely occluded. Partial obstruction of the airway can lead to progressive hypoxia, hypercarbia, and respiratory and cardiac arrest. If the airway is completely obstructed, permanent brain injury or death will occur within 3 to 5 minutes secondary to hypoxia. Air movement is absent in the presence of complete airway obstruction. Oxygen saturation of the blood decreases rapidly because obstruction of the airway prevents entry of air into the lungs. Oxygen deficit occurs in the brain, resulting in unconsciousness, with death following rapidly. Upper airway obstruction has a number of causes, including aspiration of foreign bodies, anaphylaxis, viral or bacterial infection, trauma, and inhalation or chemical burns. For older adult patients, especially those in extended care facilities, sedative and hypnotic medications, diseases affecting motor coordination (e.g., Parkinson disease), and mental dysfunction (e.g., dementia, intellectual disability) are risk factors for asphyxiation by food. As patients age, atrophy of the posterior pharynx occurs, resulting in aspiration or difficulty swallowing. In adults, aspiration of a bolus of meat is the most common cause of airway obstruction. Peritonsillar abscesses, epiglottitis, and other acute infectious processes of the posterior pharynx can also result in airway obstruction. The most common causes of airway obstruction are from an allergic reaction (i.e., causing laryngospasm), infection, or angioedema.

Collection of Forensic Evidence

The basics of care management for patients with traumatic injury include an understanding that trauma in any patient (living or dead) has potential legal or forensic science implications if criminal activity is suspected. When clothing is removed from the patient who has experienced trauma, the nurse must be careful not to cut through or disrupt any tears, holes, blood stains, or dirt present on the clothing if criminal activity is suspected. Each piece of clothing should be placed in an individual paper bag. Plastic bags are not used because they retain moisture; moisture may promote mold and mildew formation, which can destroy evidence. If the clothing is wet, it should be hung to dry. Clothing should not be given to families. Valuables should be inventoried and either placed in the hospital safe or clearly documented to which family member they were given. If a police officer is present to collect clothing or any other items from the patient, each item is labeled and the transfer of custody to the officer, the officer's name, the date, and the time are documented. Evidence cannot be left unattended in the room; a formal chain of custody must be maintained for the evidence to be valid and useful for legal purposes. All deaths of patients who experienced trauma are reported to the medical examiner. If suicide or homicide is suspected in a patient who experienced trauma, the medical examiner examines the body on site or has the body moved to the coroner's office for autopsy. All tubes and lines must remain in place. The patient's hands must be covered with paper bags to protect evidence on the hands or under the fingernails. In the patient who has survived trauma, tissue specimens may be swabbed from the hands and nails as potential evidence. Photographs of wounds or clothing are essential and should include a reference ruler in one photo and another without the ruler. Documentation should also include any statements made by the patient in the patient's own words and surrounded by quotation marks. A chain of evidence is essential. If the patient's case is reviewed in a court of law in the future, clear documentation assists the judicial process and helps to identify the activities that occurred in the ED.

Primary Closure

The decision to suture a wound depends on the nature of the wound, the time since the injury was sustained, the degree of contamination, and the vascularity of tissues. If primary closure is indicated, the wound is sutured or stapled, usually by the physician, with the patient receiving either local anesthesia or moderate sedation. Wound closure begins when subcutaneous fat is brought together loosely with a few sutures to close off the dead space. The subcuticular layer is then closed, and finally the epidermis is closed. Sutures are placed near the wound edge, with the skin edges leveled carefully to promote optimal healing. Instead of sutures, sterile strips of reinforced microporous tape or a bonding agent (skin glue) may be used to close clean, superficial wounds.

Family-Focused Interventions

The family is kept informed about where the patient is, how he or she is doing, and the care that is being given. Encouraging family members to stay with the patient, when possible, also helps allay their anxieties. In many facilities, family presence during resuscitation is permitted to assist the family to cope through this difficult time. Many family members respond very well to this approach. One study found that families view emergency professionals favorably when a family member was resuscitated. They view their role as supportive and protective of the patient. Allowing family presence in the critical care areas of the hospital enhances the family role and builds trust in the caregivers. Posttraumatic stress disorder (PTSD) is less likely to occur if the family member is present during resuscitation. The presence of a family facilitator, who is trained to provide support to family members, is vital to the success of a family presence program. Additional interventions are based on the assessment of the stage of crisis that the family is experiencing.

Frostbite Management

The goal of management is to restore normal body temperature. Constrictive clothing and jewelry that could impair circulation are removed. Wet clothing is removed as rapidly as possible. If the lower extremities are involved, the patient should not be allowed to ambulate. Controlled yet rapid rewarming is instituted. Frozen extremities are usually placed in a 37°C to 40°C (98.6°F to 104°F) circulating bath for 30- to 40-minute spans. This treatment is repeated until circulation is effectively restored. Early rewarming appears to decrease the amount of ultimate tissue loss. During rewarming, an analgesic for pain is given as prescribed, because the rewarming process may be very painful. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated. Once rewarmed, the part is protected from further injury and is elevated to help control swelling. Sterile gauze or cotton is placed between affected fingers or toes to prevent maceration, and a bulky dressing is placed on the extremity. A foot cradle may be used to prevent contact with bedclothes if the feet are involved. Hemorrhagic blebs, which may develop 1 hour to a few days after rewarming, are left intact and not ruptured. Nonhemorrhagic blisters are débrided to decrease the inflammatory mediators found in the blister fluid. A physical assessment is conducted with rewarming to observe for concomitant injury, such as soft tissue injury, dehydration, alcohol intoxication, or fat embolism. Problems such as hyperkalemia (e.g., from release of potassium in the damaged cells) and hypovolemia, which occur frequently in people with frostbite, are corrected. Risk of infection is also great; therefore, aseptic technique is used during dressing changes, and tetanus prophylaxis is given as indicated. Nonsteroidal anti-inflammatory drugs (NSAIDs) are prescribed for their anti-inflammatory effects and to control pain. Additional measures that may be carried out when appropriate after emergency stabilization measures have been instituted include the following: Whirlpool bath for the affected body parts to aid circulation and débridement of necrotic tissue to help prevent infection Escharotomy (incision through the eschar) to prevent further tissue damage, to allow for normal circulation, and to permit joint motion Fasciotomy to treat compartment syndrome After rewarming, hourly active motion of any affected digits is encouraged to promote maximal restoration of function and to prevent contractures. Discharge instructions also include encouraging the patient to avoid tobacco, alcohol, and caffeine because of their vasoconstrictive effects, which further reduce the already deficient blood supply to injured tissues.

Obesity Considerations

The growing rate of obesity in the United States has implications for treating patients with obesity within the ED, in terms of stocking appropriately sized equipment, gowns, and stretchers; ensuring that equipment (e.g., computed tomography [CT] scanners) is able to handle a greater weight capacity; and recognizing specific disorders and complications that may occur in these patients. For instance, research suggests that increased mortality is associated with the degree of obesity. Other considerations in ED management of patients with obesity include an understanding that it is generally more challenging to insert IV lines and airways. Ventilation also can be a challenge from the increased weight of the chest wall and the increased incidence of hypoventilation and sleep apnea among patients with obesity. Special consideration must be taken with lipophilic medications, as they take longer to clear from the larger volume of adipose tissue. Weight-based medications must be calculated carefully using ideal body mass. X-rays may be difficult to visualize because of poor penetration. Complications that patients with obesity are more prone to experience during hospitalization include respiratory failure, acute kidney injury, pneumonia, deep vein thrombosis, and pressure ulcers. Patients with severe obesity who have femur fractures have a significantly higher risk of death, as well as a higher risk of acute respiratory distress syndrome (ARDS) and sepsis than patients of normal weight. Although many of these complications do not occur until later in the hospital stay, some preventive measures (e.g., encouraging turning, coughing, and deep-breathing exercises to prevent atelectasis) may be initiated in the ED. Functional recovery time is extended in patients with obesity, resulting in longer lengths of stay and increased hospital costs. Initiating prevention measures in the ED, such as early backboard removal and providing early preventive respiratory care, are targeted to improve recovery time. Arranging transfers of patients with obesity must also take into consideration the availability of appropriately sized equipment.

Patients Who are Overactive

The immediate goal is to gain control of the situation. If the patient is potentially violent, security or police should be nearby. Restraints are used as a last resort and only as prescribed. Approaching the patient with a composed, confident, and firm manner is therapeutic and has a calming effect. Helpful interventions include the following: Introduce yourself by name. Tell the patient, "I am here to help you." Repeat the patient's name from time to time. Speak in one-thought sentences, and be consistent. Give the patient space and time to slow down. Show interest in, listen to, and encourage the patient to talk about personal thoughts and feelings. Offer appropriate and honest explanations. A psychotropic agent (e.g., one that exerts an effect on the mind) may be prescribed for emergency management of functional psychosis. However, a patient with a personality disorder should not be treated with psychotropic medications, and psychotropic medications should not be used if the patient's behavior results from the use of hallucinogens (e.g., lysergic acid diethylamide [LSD]). Agents such as chlorpromazine and haloperidol act specifically against psychotic symptoms of thought fragmentation and perceptual and behavioral aberrations. The initial dose depends on the patient's body weight and the severity of the symptoms. After administration of the initial dose, the patient is observed closely to determine the degree of change in psychotic behavior. Subsequent doses depend on the patient's response. Typically, after stabilization, the patient is transferred to an inpatient psychiatric unit, or psychiatric outpatient treatment is arranged.

Wounds

The main goal of treatment is to restore the physical integrity and function of the injured tissue while minimizing scarring and preventing infection. Proper documentation of the characteristics of the wound, using precise descriptions and correct terminology, is essential. Such information may be needed in the future for forensic evidence. Photographs are helpful because they provide an accurate, visible depiction of the wound. Photographs also become important for exigent wounds (i.e., wounds that will eventually heal). Patients involved in domestic violence or trauma may need the photographs later to visually describe the extent of injury. Determining when and how the wound occurred is important because a treatment delay increases infection risk. Using aseptic technique, the clinician inspects the wound to determine the extent of damage to underlying structures or the presence of a foreign body. Sensory, motor, and vascular function is evaluated for changes that might indicate complications.

Sexual Assault

The manner in which the patient is received and treated in the ED is important to their future psychological well-being. Crisis intervention should begin when the patient enters the health care facility. The patient should be seen immediately. Most hospitals have a written protocol that addresses the patient's physical and emotional needs as well as collection of forensic evidence. In many states, the emergency nurse has the opportunity to become trained as a sexual assault nurse examiner (SANE). Preparing for this role requires specific training in forensic evidence collection, history taking, documentation, and ways to approach the patient and family. Specialized training also includes learning proper photographic methods and the use of colposcopy. Colposcopy facilitates assessment by magnifying tissues and looking for evidence of microtrauma. Evidence is collected through photography, videography, and analysis of specimens. Another tool useful to the SANE is the light-staining microscope, which enables the examiner to identify motile and nonmotile sperm and infectious organisms. This tool saves time and also enhances assessment. The SANE complements the ED staff and can spend more time with both the patient and police officers investigating the incident.

Facts About Emergency Department Visits

The most common reasons for ED visits were abdominal pain, chest pain, cough, and fever. Most patients had health insurance, with only 15.1% of patients without insurance Approximately 14.5% of patients arrived at the ED by ambulance. 12.2 million visits resulted in admission (9.3%); of these, 1.5 million required admission to an intensive care unit (ICU). Injuries and poisonings accounted for 21.4% of all ED visits. The leading causes of injuries were unintentional, totaling 71.4% of injury admissions, with falls and motor vehicle collisions making up 34.8% of these. Nearly 30% of patients were seen by a provider in less than 15 minutes after arrival to the ED.

Heat-Induced Illnesses

The most serious of these—heat stroke—is an acute medical emergency caused by failure of the heat-regulating mechanisms of the body. It is the inability to maintain cardiac output in the face of moderately high body temperatures and is associated with dehydration. The most common cause of heat stroke is nonexertional, prolonged exposure to an environmental temperature of greater than 39.2°C (102.5°F), although a heat index of greater than 35°C (95°F) is associated with increased mortality. It usually occurs during extended heat waves, especially when they are accompanied by high humidity. Exertional heat stroke is caused by strenuous physical activity that occurs in a hot environment. Less severe forms of heat-induced illnesses include heat exhaustion and heat cramps or heat illness. The causes of heat exhaustion are the same as for heat stroke. Heat illness is caused by a loss of electrolytes, typically during strenuous physical activity in a hot environment.

Helping Family Members Deal with Sudden Death

The nurse takes the following actions: Take the family to a private place. Talk to the family together so that they can grieve together and hear the information given together. Reassure the family that everything possible was done; inform them of the treatment rendered. Avoid using euphemisms such as "passed on." Show the family that you care by touching, offering coffee, water, and the services of a chaplain. Encourage family members to support each other and to express emotions freely (grief, loss, anger, helplessness, tears, disbelief). Avoid giving sedation to family members; this may mask or delay the grieving process, which is necessary to achieve emotional equilibrium and to prevent prolonged depression. Encourage the family to view the body if they wish; this action helps to integrate the loss. Cover disfigured and injured areas before the family sees the body. Go with the family and do not leave them alone. Show acceptance by touching the body to give the family "permission" to touch. Spend time with the family, listening to them and identifying any needs that they may have for which the nursing staff can be helpful. Allow family members to talk about the deceased and what he or she meant to them; this permits ventilation of feelings of loss. Encourage the family to talk about events preceding admission to the emergency department. Do not challenge initial feelings of anger or denial. Avoid volunteering unnecessary information (e.g., the patient was drinking).

Cricothyroidotomy

The opening of the cricothyroid membrane to establish an airway. This procedure is used in emergency situations in which endotracheal intubation is either not possible or contraindicated, as in airway obstruction from extensive maxillofacial trauma, cervical spine injuries, laryngospasm, laryngeal edema (after an allergic reaction or extubation), hemorrhage into neck tissue, or obstruction of the larynx. A cricothyroidotomy is replaced with a formal tracheostomy when the patient is able to tolerate this procedure.

Crush Injuries Assessment and Diagnosis

The patient is observed for the following: Hypovolemic shock resulting from extravasation of blood and plasma into injured tissues after compression has been released Spinal cord injury Erythema and blistering of skin Fractures (usually an extremity) Acute kidney injury (acute tubular necrosis [ATN])

Nonfatal Drowning Management

Therapeutic goals include maintaining cerebral perfusion and adequate oxygenation to prevent further damage to vital organs. Cardiopulmonary resuscitation is the factor with the greatest influence on survival. The most important priority in resuscitation is to manage the hypoxia, acidosis, and hypothermia. Prevention and management of hypoxia are accomplished by ensuring an adequate airway and respiration, thus improving ventilation (which helps correct respiratory acidosis) and oxygenation. Arterial blood gases are monitored to evaluate oxygen, carbon dioxide, bicarbonate levels, and pH. These parameters determine the type of ventilatory support needed. The use of endotracheal intubation with PEEP improves oxygenation, prevents aspiration, and corrects intrapulmonary shunting and ventilation-perfusion abnormalities (caused by aspiration of water). If the patient is breathing spontaneously, supplemental oxygen may be given by mask. Because of submersion, the patient is usually hypothermic. A rectal probe or other core measurement device is used to determine the degree of hypothermia. Prescribed rewarming procedures (e.g., extracorporeal warming, warmed peritoneal dialysis, inhalation of warm aerosolized oxygen, torso warming) are started during resuscitation. The choice of warming method is determined by the severity and duration of hypothermia and available resources. Intravascular volume expansion and inotropic agents are used to treat hypotension and impaired tissue perfusion. ECG monitoring is initiated, because dysrhythmias frequently occur. An indwelling urinary catheter is inserted to measure urine output. Hypothermia and accompanying metabolic acidosis may compromise kidney function. Nasogastric intubation is used to decompress the stomach and to prevent the patient from aspirating gastric contents. Even if the patient appears healthy, close monitoring continues with serial vital signs, serial arterial blood gas values, ECG monitoring, intracranial pressure assessments, serum electrolyte levels, intake and output, and serial chest x-rays. After a nonfatal drowning, the patient is at risk for complications such as hypoxic or ischemic cerebral injury, ARDS, and life-threatening cardiac arrest. The patient is also at heightened risk for aspiration; vomiting frequently occurs in patients requiring rescue breathing and in up to 86% of patients requiring CPR.

Spider Bites

There are two venomous spiders found in the United States that may interact with humans: the brown recluse and the black widow. Both are usually found in dark places such as closets, woodpiles, and attics, as well as in shoes. Brown recluse spider bites are painless. Systemic effects such as fever and chills, nausea and vomiting, malaise, and joint pain develop within 24 to 72 hours. The site of the bite may appear reddish to purple in color within 2 to 8 hours after the bite. Necrosis occurs in the next 2 to 4 days in approximately 10% of cases. The center of the bite may become necrotic, and surgical débridement may be necessary. Wound care consists of cleansing with soap and water, and hyperbaric oxygen treatments may be helpful. Most wounds heal within 2 to 3 months. Black widow spider bites feel like pinpricks. Systemic effects usually occur within 30 minutes—much more rapidly than with brown recluse spider bites. Signs and symptoms include abdominal rigidity, nausea and vomiting, hypertension, tachycardia, and paresthesias. Severe pain also develops within 60 minutes and increases over 1 to 2 days. Treatment involves application of ice to the site to decrease swelling and discomfort, along with elevation and assessment of tetanus immunization status. Analgesic agents and benzodiazepines may relieve muscle spasms. Cardiopulmonary monitoring is essential. Antivenin is effective for severe black widow spider bites. This antivenin is horse serum based; therefore, testing for sensitivity must be performed prior to administration.

Trauma

Trauma (an unintentional or intentional wound or injury inflicted on the body from a mechanism against which the body cannot protect itself) is the fourth leading cause of death in the United States. Trauma is the leading cause of death in children and in adults younger than 44 years. The incidence is increasing in adults older than 44 years. Alcohol and drug abuse are often implicated as factors in both blunt and penetrating trauma.

Frostbite

Trauma from exposure to freezing temperatures and freezing of the intracellular fluid and fluids in the intercellular spaces. It results in cellular and vascular damage. Frostbite can result in venous stasis and thrombosis. Body parts most frequently affected by frostbite include the feet, hands, nose, and ears. Frostbite ranges from first degree (redness and erythema) to fourth degree (full-depth tissue destruction).

Airway Obstruction Clinical Manifestations

Typically, a person with a foreign-body airway obstruction cannot speak, breathe, or cough. The patient may clutch the neck between the thumb and fingers (i.e., universal distress signal). Other common signs and symptoms include choking, apprehensive appearance, refusing to lie flat, inspiratory and expiratory stridor, labored breathing, the use of accessory muscles (suprasternal and intercostal retraction), flaring nostrils, increasing anxiety, restlessness, and confusion. Cyanosis and loss of consciousness, which develop as hypoxia worsens, are late signs. Action must be taken before these manifestations develop, if possible, or immediately if the patient has already exhibited these signs.

Hemorrhage Fluid Replacement

Typically, two large-gauge IV catheters are inserted, preferably in an uninjured extremity, to provide a means for fluid and blood replacement. Blood samples are obtained for analysis, typing, and cross-matching. Replacement fluids are given as prescribed, depending on clinical estimates of the type and volume of fluid lost. Replacement fluids may include isotonic electrolyte solutions (e.g., lactated Ringer's, normal saline), colloids, and blood component therapy. Packed red blood cells are infused when there is massive blood loss, which may also necessitate transfusion of other blood components, including platelets and clotting factors. The infusion rate is determined by the severity of the blood loss and the clinical evidence of hypovolemia. Any blood replacement therapy should be given via warmer when possible, because administration of large amounts of blood that has been refrigerated has a core cooling effect that may lead to cardiac arrest and coagulopathy.

Tick Bites

Usually occur in grassy or wooded areas. It is important to learn the place where the bite occurred as well as the location of the bite on the body. The tick bite itself is not usually the problem; rather, it is the pathogen transmitted by the tick that can cause serious disease. Ticks can carry diseases such as Rocky Mountain spotted fever, tularemia, west Nile virus, and Lyme disease. Ticks transmit pathogens through their saliva; therefore, the earlier the tick is removed, the better the prognosis. The tick should be removed with tweezers using a straight upward pull, and the patient should be informed of the signs and symptoms of diseases carried by ticks, especially if the patient lives in or has visited an area endemic for tick-related diseases (e.g., Lyme disease).

Providing Holistic Care

When confronted with trauma, severe disfigurement, severe illness, or sudden death, the family experiences several stages of crisis. The stages begin with anxiety and progress through denial, remorse and guilt, anger, grief, and reconciliation. The initial goal for the patient and family is anxiety reduction, a prerequisite to effective and appropriate coping. During this stressful time, safety is of prime importance. Close observation and preplanning are essential and security personnel are stationed nearby in the event that a patient or family member responds to stress with physical violence. Assessment of the patient and family's psychological function includes evaluating emotional expression, degree of anxiety, and cognitive functioning. Possible nursing diagnoses include: Anxiety or death anxiety related to uncertain potential outcomes of the illness or trauma Ineffective coping related to acute situational crisis Possible nursing diagnoses for the family include: Grieving Interrupted family processes Compromised or disabled family coping related to acute situational crises

Family Violence, Abuse, and Neglect Clinical Manifestations

When people who have been abused seek treatment, they may present with physical injuries or health problems such as anxiety, insomnia, or gastrointestinal symptoms related to stress. The possibility of abuse should be investigated whenever a person presents with multiple injuries that are in various stages of healing, when injuries are unexplained, and when the explanation does not fit the physical picture. The possibility of neglect should be investigated whenever a person who is dependent shows evidence of inattention to hygiene, to nutrition, or to know medical needs (e.g., unfilled medication prescriptions, missed appointments with health care providers). In the ED, the most common physical injuries seen are unexplained bruises, lacerations, abrasions, head injuries, or fractures. The most common clinical manifestations of neglect are malnutrition and dehydration.

Intra-Abdominal Injury Management

With blunt trauma, the patient is kept on a stretcher to immobilize the spine. If the patient has been placed on a backboard, it should be removed as early as possible to prevent skin breakdown. Cervical spine immobilization is maintained until cervical x-rays have been obtained and cervical spine injury has been ruled out. Likewise, once the backboard is removed, logrolling can be used to protect the spine until x-rays are obtained and confirm that there is no evidence of injuries. Knowing the mechanism of injury (e.g., penetrating force from a gunshot or knife, blunt force from a blow) is essential to determining the type of management needed. All wounds are located, counted, and documented. If abdominal viscera protrude, the area is covered with sterile, moist saline dressings to keep the viscera from drying. Typically, oral fluids are withheld in anticipation of surgery, and the stomach contents are aspirated with an orogastric tube to reduce the risk of aspiration and to decompress the stomach in preparation for diagnostic procedures. Trauma predisposes the patient to infection by disruption of mechanical barriers, exposure to exogenous bacteria from the environment at the time of injury, aspiration of vomitus, and diagnostic and therapeutic procedures (hospital-acquired infection). Tetanus prophylaxis and broad-spectrum antibiotics are given as prescribed. Throughout the stay in the ED, the patient's condition is continuously monitored for changes. If there is continuing evidence of shock, blood loss, free air under the diaphragm, evisceration, hematuria, severe head injury, musculoskeletal injury, or suspected or known abdominal injury, the patient is rapidly transported to surgery. In most cases, blunt liver and spleen injuries are managed nonsurgically. The goal for the management of all patients who have experienced trauma is to minimize the length of stay in the ED. The patient should be moved to the definitive destination quickly so that care and rehabilitation can continue.

Hypothermia

a condition in which the core temperature is 35°C (95°F) or less as a result of exposure to cold or an inability to maintain body temperature in the absence of low ambient temperatures. Urban hypothermia (extreme exposure to cold in an urban setting) is associated with a high mortality rate; older adults, infants, people with concurrent illnesses, and those who are homeless are particularly susceptible. Alcohol ingestion increases susceptibility because it causes systemic vasodilation. Some medications (e.g., phenothiazines) or medical conditions (e.g., hypothyroidism, spinal cord injury) decrease the ability to shiver, hampering the body's innate ability to generate body heat. Fatigue and sleep deprivation are also associated with the development of hypothermia. Wet clothing accelerates heat loss, and immersion in cold water increases heat loss. Victims of trauma are also at risk for hypothermia resulting from treatment with cold fluids, unwarmed oxygen, and exposure during examination. The patient may also have frostbite, but hypothermia takes precedence in treatment.

Drugs Producing Sedation, Intoxication, or Psychological and Physical Dependence (nonbarbiturate sedatives)

diazepam (Valium) chlordiazepoxide (Librium) oxazepam (Serax) lorazepam (Ativan) midazolam (Versed) flunitrazepam (Rohypnol, "roofies," "date rape drug") Clinical Manifestations: Seizures, coma, circulatory collapse, death Acute intoxication: Respiratory depression Decreasing mental alertness Confusion Slurred speech, decreased blood pressure Ataxia Pulmonary edema Coma, death Flunitrazepam: Disinhibition with antegrade amnesia Weakness and unsteadiness with impaired judgment Powerlessness Therapeutic Management: Endotracheal tube is inserted as a precaution; use assisted ventilation to stabilize and correct respiratory depression. Observe for sudden apnea and laryngeal spasm. Assess for hypotension.Insert indwelling urinary catheter for patient who is comatose; decreased urinary volume is an index of reduced renal flow associated with reduced intravascular volume or vascular collapse.Start volume expansion with saline or dextrose as prescribed. Evacuate stomach contents; lavage (if within 1 hour of ingestion); activated charcoal. Start ECG monitoring. Observe for dysrhythmias. Administer flumazenil (Romazicon), a benzodiazepine antagonist (reversal agent). Refer patient for psychiatric evaluation (potential suicide intent).

Selective Serotonin Reuptake Inhibitors and Other Antidepressants

trazodone (Desyrel) fluoxetine (Prozac) paroxetine (Paxil) sertraline (Zoloft) venlafaxine (Effexor) escitalopram (Lexapro) bupropion (Wellbutrin) Clinical Manifestations: Decreased level of consciousness, confusion Respiratory depression Increased heart rate Serotonin syndrome may occur if the SSRI was taken in conjunction with dextromethorphan or meperidine Agitation, seizures Hyperthermia, diaphoresis Hypertension, headache, shivering, "goose flesh," cardiac dysrhythmias, loss of consciousness Therapeutic Management: Administer activated charcoal with possibly whole bowel irrigation if a sustained-release medication was taken. Use seizure precautions and administer benzodiazepines (e.g., diazepam) as prescribed.