Wk 12 (Sir Jabel Video) Emergency Nursing

Generalized Rxns from Stings and Bites

-Urticaria -Confluent red rash -Shortness of Breath, Wheezing -Edema in airway, tongue, uvula -Weakness, Syncope -Anxiety, confusion -Chest pain

Workup included in Foreign Body Obstruction?

Auscultation of Breath Sounds (which tends to be decreased or presents wheezing) and Chest Radiograph

ESI __ px's that do not need any resource

ESI 5

refers to the type of care that first-responders, healthcare providers and public safety professionals provide to anyone who is experiencing cardiac arrest, respiratory distress or an obstructed airway.

(BLS) Basic Life Support

Food poisoning Symptoms

-Abdominal Pain -Vomiting -Diarrhea -Headache -Fever -Stool changes -Reactive arthritis -Bloating

ACLS Drug Therapy

-Epinephrine 1mg IV/IO every 3 to 5 minutes -Amiodarone 300mg IV/IO initial dose (150mg second dose)

Stings and Bites - Emergency Department Care

-Epinephrine is the mainstay of treatment for anaphylaxis -H2 blockers + Diphenhydramine

ACLS H's (Reversible causes)

-Hypovolemia -Hypoxia -Hydrogen Ion (Acidosis) -Hypo/Hyperkalemia -Hypothermia

Local Rxns from stings and Bites

-Pain -Edema -Bleeding -Pruritus -Vasodilation -Nausea and Vomiting

Pre-hospital Stings and Bites

-Provide supplemental oxygen -Diphenhydramine limits the size of the local reaction -Clean wound and remove stinger if present -Apply ice or cool packs -Elevate the extremity to limit edema

ACLS CPR quality

-Push hard and fast, at least 2 inches (5cm) and 100-120 compressions per min -Allow complete chest recoil -Minimize interruptions in compressions -Avoid excessive ventilation -Rotate compressor every 2 minutes or if fatigued -Compression to ventilation ratio is 30:2 -Continuous compressions if advanced airway present

ACLS T's

-Tension pneumothorax -Tamponade (cardiac) -Toxins -Thrombosis (pulmonary) -Thrombosis (coronary)

ACLS Nonshockable Rhythm

. Initial tt of asystole/PEA is as ff: Continue CPR for 2 min Obtain IIV/IO access Consider advanced airway 2.Administer vasopressor (Epinephrine q 3-5 mins) 3.Check pulse and rhythm q 2 minutes as follows: -If nonshockable, see nonshockable rhythm algorithm -If shockable, See shockable rhythm algorithm and administer AMIODARONE after second defib attempt -Rotate chest compressors -Identify and treat reversible causes 4.If with ROSC, do Post Cardiac Arrest Care

Aspiration of foreign bodies produces 3 phases, what are they?

1. Initial Phase- chocking and gasping, coughing or airway obstruction at the time of aspiration 2. Asymptomatic Phase- Subsequent lodging of the object with relaxation of reflexes that often results in a reduction or cessation of symptoms lasting hours to weeks 3. Complications Phase - foreign body producing erosion or obstructions leading to pneumonia, atelectasis or abscess

ACLS Shockable Rhythm

1. Initial tt of VT/VF as ff: Defib immediately Continue CPR for 2 min Obtain IIV/IO access Consider advanced airway 2.Administer vasopressor (Epinephrine q 3-5 mins) 3.Check pulse and rhythm q 2 minutes as follows: -If nonshockable, see nonshockable rhythm algorithm -If shockable, See shockable rhythm algorithm and administer AMIODARONE after second defib attempt -Rotate chest compressors -Identify and treat reversible causes 4.If with ROSC, do Post Cardiac Arrest Care

ACLS Shock energy -Biphasic

200J

Urinary __H may help in the diagnosis of recurrent anaphylaxis

24H

MEDICAL EMERGENCIES Despite improvements in medical care and public awareness approximately _____ deaths occur each year from _________

3000, foreign body aspiration

ACLS Shock energy -Monophasic

360J

Oxygen in anaphylaxis treatment?

8-10L/minute via face mask

Steps in Primary Survey for Emergency Trauma

> Airway assessment and protection (maintain cervical spine stabilization when appropriate) > Breathing and ventilation assessment (maintain adequate oxygenation) > Circulation assessment (control hemorrhage and maintain adequate) >Disability assessment ([perform basic neurologic evaluation) >Exposure, with environmental control (undress patient and search everywhere for possible injury while preventing hypothermia) Diagnostic studies: >Portable Radiographs >Emergency CT Scan >ECG >Lab Tests

Four Decision Points in ESI

A. Does this patient require immediate life-saving intervention B. Is this a patient who shouldn't wait? C. How many resources will this patient need? D. What are the patient's vital signs?

Components of Primary Assessment

ABCDE (Airway, Breathing, Circulation, Disability and Exposure/Environment)

1. Initial Evaluation: -Activate emergency response team -Initiate adult basic life support algorithm 2.The Initial Intervention: -Start high quality CPR -Admin oxygen if hypoxemic -Attach monitor/defib -Monitor BP and oximetry, do not delay defib

ACLS Advanced Cardiovascular Life Support

What component of Primary Assessment? -airway noises -position of head -foreign body -fluid, secretions -oedema >> Open, Suction, Secure, O2 -> Goal: Patent Airway How? Head Tilt, Chin lift

Airway

Is an acute, potentially fatal, multiorgan system reaction caused by the release of chemical mediators from mast cells and basophils -a majority of adult patients have some combination of urticaria, erythema, pruritus or angioedema

Anaphylaxis

Pharmacotherapy for Poisoning

Antidiarrheals, Antibiotics

What component of Primary Assessment? - Look, listen, feel approach - Respiratory rate and effort - Breath and added sounds - Subcutaneous emphysema - Symmetry of chest movement - Tracheal deviation - Jugular vein distention - Cyanosis >> O2 according to SPO2, Pneumothorax therapy, Inhalation Therapy, Ventilation -> Goal: Sufficient oxygenation and Ventilation

Breathing

Location of foreign body where px presents with cough, unilateral wheezing and decreased breath sounds, but only 65% of patients present with this classic triad

Bronchial

Decision Point ___.>> How many resources are needed? The disposition of the patient cold either be: o Send the patient's home o Admit to the hospital o Transfer to another institution =stable px's

C

What component of Primary Assessment? - Heart Rate - Blood Pressure - Capillary Refill TIme - Bleeding - Skin color - Blood samples - Diuresis >> IV/IO access, Control of Bleeding, Massive haemorrhage protocol, Fluids, Drugs, Transfusion -> Goal: Stabilization of Circulation

Circulation

Decision Point ___.>> Is patient's Vital signs stable? If not, upgrade to ESI 2

D

A 60 year old healthy male who everted his ankle in the golf course presents with moderate swelling and pain upon palpation of the lateral malleolus ESI = _?_ How many ESI resources will this patient needed?

ESI 4 ESI 3 if given IV/IM pain medication, which is a resource so XRay+IM inj. = 2 resources ESI 2 if severe pain bec.of deformity at ankle =px must be seen within 10 min

What component of Primary Assessment? - AVPU(Alert, Verbal, Pain& Unresponsive) /GCS - Reactive and symmetry of pupils (PERRLA) - Blood glucose level - Basic neurological examination - Posture - Toxicological examination >> Glucose, Antidotes -> Goal: Evaluation of neurological state

Disability

-3rd leading cause of unintentional injury death, accounts to 7% of all injury related deaths -is a process result in primary respiratory impairment from submersion in a liquid medium

Drowning

Decision Point A.>> Does this patient require immediate life-saving intervention? o Yes = ESI ___ o No = proceed with Decision point B

ESI 1

ESI=___ o Does this patient have a patent airway? o Is the patient breathing? o Does the patient have a pulse? o Is the nurse concerned about the pulse rate, rhythm, and quality? o Was this patient intubated pre-hospital because of concerns about the patient's ability to maintain a patent airway, spontaneously breathe or maintain oxygen saturation o Is the nurse concerned about this patient's ability to deliver adequate oxygen to the tissues? o Does the patient require an immediate medication, or other hemodynamic intervention such as volume replacement or blood? o Does the patient meet any of the following criteria: already intubated, apneic, pulseless, severe respiratory distress, SPO2 <90%, acute mental status changes or unresponsive? *Questions to determine whether patient require an immediate life-saving intervention?

ESI 1

Example of ESI __ o Cardiac Arrest o Respiratory Arrest o Critically Injured trauma pc who presents unresponsive o Drug overdose with a respiratory rate of 6 o Severe respiratory distress with agonal respirations o Anaphylactic shock o Hypoglycemia with a change in mental status

ESI 1

A 22 year old female involved in a high-speed rollover motor vehicle collision and thrown from the vehicle, presents intubated, no response to pain, and hypotensive ESI = _?_ How many ESI resources will this patient needed?

ESI 1 , no need to determine no. of resources

ESI __ and __ no need to identify how many resources are needed kay ___ immediate life saving intvtn's and ____ px needs to be seen within 10 mins of arrival

ESI 1 and 2

Decision Point B.>> Should the patient wait? Guide Q's: -High Risk situation? -Confused/Lethargic/Disoriented? -Severe pain/distress? o Yes = ESI ___ o No = proceed with Decision point C

ESI 2

ESI __ patients are very ill and at high risk

ESI 2

ESI= ____ Is the patient confused, lethargic or disoriented? Example: new onset of confusion in an elderly client stroke patient? Concern is whether the px is demonstrating an acute change in LOC

ESI 2

ESI= ____ Is the patient in severe pain or distress? Example: self reported pain rating of 7 or higher on a scale of 0-10, combined with the nurse's clinical observation. Clinical Observation: o Distressed facial expression, grimacing, crying o Diaphoresis o Body posture o Change in VS (BP,HR,RR)

ESI 2

A 34 year old male presents to triage with right lower quadrant pain, 5/10, all day. Pain is associated with loss of appetite, nausea and vomiting Past Medical History: None. The patient appears in moderate discomfort, skin warm and dry, guarding abdomen. ESI = _?_

ESI 3

ESI __ px's that need two or more resources

ESI 3

ESI __ px's that need only one resource

ESI 4

Emergency Department care for Drowning

Early use of intubation and PEEP (oxygenation before intubation)

Non-Resources

Example: - History Taking - Physical Examination -Point of care testing (reflo, PEFR) -Prescription refills -Saline or heparin lock -PO medications -Simple wound care (check, dressing) -Crutches, splinting

Resources

Example: -Labs (blood,urine) -ECG -Imaging: X-rays, CT, MRI -IV fluids -Specialty Consultation Simple procedure = 1 (Simple T & S, foley catheter, STO) Complex procedure = 2 (Complicated T&S procedural sedation analgesia) *The concept of a "resource" in ESI means types of complex interventions or diagnostic tools, above and beyond physical examination. Examples of resources include X-ray, blood tests, sutures, and intravenous or intramuscular medications. Oral medications and prescriptions are specifically not considered resources by the ESI algorithm.

What component of Primary Assessment? - Head to toe examination - Medical History - Temperature - Injuries - Oedema - Scars - Signs of drug abuse - Skin changes - Signs of infection/sepsis >> Identified cause therapy, Thermomanagement, Trauma treatment, Insertion of NGT, IUC -> Goal: Revealing other symptoms and thermomanagement *provide privacy while examining wounds/injury *

Exposure/Environment

True/False PO meds or Oral Medications are considered a resource

False

True/False Most deaths occur post-hospital evaluation and treatment

False, pre-hospital

Management of Foreign Body Obstruction

Heimlich Maneuver Surgical Therapy

Kind of Sting -Bees -Wasps -Yellow Jackets -Hornet -Ants

Hymenoptera

Airway in Anaphylaxis: immediate intubation if evidence of impending airway obstruction from angioedema. Medication of choice? Placement?

IM epinephrine (1mg/m: prep): 0.3 to 0.5 mgIM (mid outer thigh), repeat every 5-15 mins as needed. -Recumbent position, elevate lower extremities

Surgical Therapy of Laryngeal FBO _______________ catheter through the nose with the tip in the hypopharynx to maintain anes and oxygenation Larygoscope is then placed at the vallecula for exposure, removed with appropriate forceps

Insufflation catheter

Resource

Interventions needed to be done above and beyond physical assessment/examination

Location of foreign body where px presents with airway obstruction and hoarseness or aphonia

Laryngeal

Foreign body aspiration usually lodged in the _______,.________,_________

Larynx, Trachea and Bronchus

General Findings Poisoning

Mild dehydration : Dry mouth, decreased axillary sweat, decreased urine More severe volume depletion: orthostasis, tachycardia, hypotension S. Typhi Infxn: Exudative Pharyngitis Vibro Vulnificus: Cellulitis, Otitis Media

Diagnostic Test: Chest X-ray, Abdominal X-ray Resource Assigned: ________________________

One resource (X-ray)

Diagnostic Test: CBC and Electrolyte Panel Resource Assigned: ______________________

One resource (lab test)

Diagnostic Test: CBC and UA Resource Assigned: ________________________

One resource (lab)

In anaphylaxis, patients often experience____ and ____. Other symptoms can evolve rapidly, such as the ff: > Dermatologic: flushing, urticaria, angioedema, conjunctival pruritus, warmth and swelling > Respiratory: nasal congestion, coryza, rhinorrhea, sneezing, throat tightness, shortness of breath, cough, hoarseness, dyspnea > cardiovascular: Dizziness, Weakness, Syncope, Chest pain, palpitations >GI: Dysphagia, Nausea, Vomiting, Diarrhea, Bloating, Cramps >Neuro: Headache, Dizziness, Blurred vision, and Seizure (rare and often associated with hypotension) >Other: Metallic taste, Feeling of Impending Doom

Pruritus and flushing

Supportive care for Poisoning

Rehydrationi

Prehospital care for Drowning

Rescue breathings Once out of water, begin CPR

Med for Anaphylaxis, for bronchospasm resistant to IM epinephrine

Salbutamol

Leading cause of death due to fires Produces injury through several mechanisms incldg. Thermal Injury to the upper airways, IRRITATION or CHEMICAL INJURY to the airways from Soot, ASPHYXATION and TOXICITY from carbon monoxide and other gases such as cyanide

Smoke Inhalation

Signs and Symptoms of _________________ o Facial burns, o Blistering or Edema of the oropharynx, o Hoarseness, o Strider o Upper airway, Mucosal lesions o Tachypnea, Dyspnea, Cough o Decreased breath sounds, Wheezing, Rales, Ronchi o Retractions Diagnostics included: o ABG o Lactate o Chest radiograph o ECG/Cardiac Enzymes (w/ chest pain) o Direct laryngoscopy and Fiberoptic Bronchoscopy Management: o IV access, cardiac monitoring and supplemental oxygen o Bronchospasm: use of bronchodilators o Steroid use o Hyperbaric oxygen therapy

Smoke Inhalation

Secondary Survey, SAMPLE means

Symptoms Allergies Medications Past medical history Last oral intake Events

first assessment in BLS and ACLS: Does the patient need help emergently? If they do not respond, they need help immediately. If they do respond, they still may need medical attention. Call for help - Yell for help, telling others to call 911 and to bring an AED.

The BLS Survey

Acuity

The measurement of the intensity of care that is required by a patient ex: ankle sprain

o Emergent o Urgent o Non-urgent

The most common triaging systems before utilizes

Urgent (Triaging)

o Requires prompt care but will not cause loss of life or limb if left untreated for hours - Abdominal pain - Multiple fractures

Priority in the P.E.. of Anaphylaxis

To assess the patient's airway, breathing, circulation and adequacy of mentation (alertness, orientation, coherence)

Location of foreign body where px presents similarly to laryngeal foreign bodies but without hoarseness or aphonia, can demonstrate wheezing similar to asthma

Tracheal

can range from minor isolated wounds to complex injuries involving multiple organ systems

Traumatic Injuries

True/False If the diagnosis is unclear, Serum Tryptase may help confirm diagnosis of Anaphylaxis

True

True/False In anaphylaxis, Lab studies are not usually required and are rarely helpful

True

Diagnostic Test: MRI of brain plain, Chest CT-scan Resource Assigned: ________________________

Two Resources (MRI and CT)

Diagnostic Test: CBC and chest X-ray Resource Assigned: _______________________

Two resources (lab, x-ray)

5-tier triage tool

based on patient's acuity and resources

Anaphylaxis: Normal saline rapid bolus: treat _______ with rapid infusion of 1-2 liters IV

hypotension

Food Poisoning

is defined as an illness caused by the consumption of food or water contaminated with bacteria, and/or their toxins, or with parasites, viruses, or chemicals

ESI Emergency Severity Index

o 1 most critical, 5 the least

AVPU = ? When determining whether the patient require immediate life-saving intervention, the triage nurse must also assess the patient's level of responsiveness

o Alert o Verbal o Pain o Unresponsive **Pain and Unresponsive usually meet the ESI 1 criteria**

ACLS Advanced Airway

o ETT (Endotracheal Tube) o SGA (Supraglottic airway) o Waveform Capnography to confirm and monitor ET tube placement o Ventilation every 6 secs asynch with compressions

When is admission advised for Smoke Inhalation?

o History of closed-spaced exposure for longer tahn 10 minutes o Metablolic aidosis o Arterial PO2 less than 60 mmHg o Carboxyhemoglobin levels above 15% o Bronchospasms o Odynophagia o Central Facial Burns

Non-urgent (Triaging)

o Is non-urgent and is not time-bound o Can wait 5-6 hours or more Example: - Sprains - Coughs and Colds

Triaging

o It involves the sorting of patients in emergency care settings according to their level of acuity o It also aims to ensure that all patients receive access to care in an organized, equitable, and timely manner based on the urgency of their clinical needs o Basically, we are trying to answer the question "Who do we see first?"

Emergent (Triaging)

o Life-threatening or possible loss of a limb o To be seen and treated now Example: - CP (Cardiopulmonary) arrest - Severe Respiratory Distress

Food poisoning, most common pathogens

o Norovirus o E. coli o Salmonella o Campylobacter o S. aureus

High risk patients

o are those whose condition could easily deteriorate or who presents with symptoms suggestive of a condition requiring time-sensitive treatment o Px needs to be seen within 10 mins upon arrival in ER o Examples of high-risk situations: - Active chest pain, sus for ACS but does not require an immediate life-saving intervention - Signs of stroke but does not meet ESI 1 criteria - A rule-out ectopic pregnancy, hemodynamically stable - A suicidal patient

Immediate _________ involvement in the care of the patient is a key difference between ESI 1 and ESI 2 patients

physician involvement

All trauma patients require a __________ to maximize outcomes and reduce risk of undiscovered injuries

systematic evaluation