ADVANCED MS- quiz 9 review

what is triage?

rapid process of determining patient acuity and prioritizing care so that the most critical patients are treated first

used in both: ED --> one patient at a time, resources available; and Mass casualty/disaster--> limited resources, focuses on the greatest good for the greatest number of people

mass casualty/disaster triage color tags:

RED--> immediate help (emergency)

YELLOW--> delayed but serious injuries (not immediately life-threatening)

GREEN--> minor injuries

BLACK--> deceased (no signs of life)

red tag examples:

-airway compromise but breathing after positioning

-severe respiratory distress

-uncontrolled breathing

-signs of shock (tachycardia/hypotension)

-decreased LOC

yellow tag examples:

-long-bone fractures with stable vitals

-significant wounds but controlled bleeding

-stable abdominal injury without shock

green tag examples:

-sprains or minor lacerations

-anxious by physiologically stable

black tag examples:

-pulseless

-massive head trauma with brain matter exposed

-agonal breathing with no chance of survival

if a patient can walk, they would be in the _______ color category in triage

green

if a patients respirations are over 30 bpm, they would be considered in the ______ color tag category

red

no radial pulse or capillary refill over 2? --> ________ tag category

red tag

triage scenario practice #1:

a 35-year old, walking around, crying, minor abrasions on arms, RR 22, HR 98, BP 128/78, follows commands. What tag?

green tag

(patient is ambulatory, has minor injuries, and stable vitals)

triage scenario #2:

60-year old, lying on ground, RR 8, weak radial pulse, confused, doesn't follow commands. What tag?

red tag

(RR under 10, altered mental status, weak perfusion= immediate threat to life)

triage scenario #3:

25-year old with open femur fracture, RR 24, capillary refill 1.5 seconds, follows commands, HR 110, BP 110/70. What tag?

yellow tag

(serious injury (fracture) but ABC's are stable and can safely delay)

triage scenario #4:

45-year old, not breathing. Can open airway but still not breathing. no pulse. What tag?

black tag

(no respirations even after opening airway, and no pulse)

Primary Survey (ABCDE)

(rapidly check for life-threatening problems 1st)

A- airway --> check for dyspnea, foreign body, difficulty speaking, or trauma to face/neck

B- breathing--> assess dyspnea, cyanosis, chest movement, breath sounds, tachycardia

C- circulation--> check pulses, BP/HR

D- disability (neuro)--> quick neuro assessment

E- exposure--> expose patient to check for hidden injuries/burns, remove exposure to chemicals etc.

airway interventions during the primary survey phase of triage:

-jaw thrust maneuver (especially with suspected C-spine injuries)

-suctioning

-oropharyngeal/nasopharyngeal airway placement

-endotracheal intubation

breathing interventions during the primary surgery phase of triage:

-oxygen

-bag-valve ventilation

-treat pneumothorax

-chest tubes

circulation interventions during the primary surgery phase of triage:

-check pulses

-control bleeding (direct pressure/tourniquet)

-insert two large bore IVs (16/18 gauge)

-start aggressive fluids (NS/LR's)

disability interventions during the primary survey phase of triage:

-neuro assessment

-AVPU: alert, Responds to Voice, responds to Pain, and Unresponsive

-GCS scale

-pupils (dilated or fixed?)

exposure/environmental control interventions for the primary survery phase of triage:

-completely expose patient to check for injuries

-prevent heat loss: warm blankets, warmed IV fluids

secondary survey begins once ____________

life threatening problems are addressed

this survery includes: head-to-toe full assessment, detailed hx of patient, complete vital signs, involve family at this time

priorities for multiple trauma patients:

-assume cervical spine injury until proven otherwise (immobilize head etc.)

-rapid primary survey (ABC's + stabilization)

-collect forensic evidence when needed (gunshot wounds, violence etc.)

-prevent secondary injury/shock

intra-abdominal injuries:

can result form blunt or penetrating trauma

major concern--> massive blood loss into abdominal cavity

Assessment:

-hx of mechanism

-distention, tenderness, guarding

-referred shoulder pain (Kehr's sign)

-fast ultrasound/CT

Interventions:

-if evisceration--> cover protruding organs with sterile/moist dressing

-NPO

-tetanus prophylaxis/ABX's

-prepare for surgery

heat exhaustion:

WHAT: prolonged exposure to heat --> dehydration and electrolyte loss

S/S: fatigue, light-headedness, N/V, diarrhea, feelings of impending doom, tachypnea, tachycardia, profuse sweating

INTERVENTIONS: move to cool area, remove excess clothing, oral/IV fluids, moist cool sheets

heat stroke:

WHAT: failure of thermoregulatory mechanisms; core temperature over 104

S/S: altered LOC, confusion/coma, hot/dry skin, tachycardia, hypotension

INTERVENTIONS: ABC's first, rapid cooling (remove clothes, wet sheets, ice packs to groin, cold water immersion, cool IV fluids)

Hypothermia:

WHAT: abnormally low body temperature (under 95 degrees)

S/S: shivering, lethargy, confusion, behavior changes, mild HR changes (mild); rigidity, bradycardia, bradypnea, hypotension, metabolic acidosis, hypovolemia

INTERVENTIONS: support ABC's, rewarm SLOWLY (rapid rewarming can cause dysrhythmias/shock), warmed IV fluids, warm humidified oxygen, treat dehydration/acidosis, and treat any dysrhythmias

frostbite:

WHAT: damage to the skin and tissues caused by extreme cold

S/S: skin hard/cold/white or mottled

INTERVENTIONS: controlled but rapid rewarming in a 37-40 degree circulating bath for 30-40 minutes, analgesics for severe pain, do NOT massage or handle roughly

management of near drowning:

-correct hypoxia first (oxygen, intubation if needed)

-CPAP or PEEP if pulmonary edema present

-correct acid-base and fluid imbalances

-rewarm if hypothermic

management of animal/human bites:

-immediate irrigation/debridement

-tetanus prophylaxis/analgesics

-prophylactic ABX's

-rabies prophylaxis

management for poisonings:

-identify the poison

-call poison control

-decrease absorption--> (gastric lavage/activated charcoal), enhance elimination (sorbitol, whole bowel irrigation, hemodialysis, antidotes), treat systemic effects, and correct fluids/electrolytes

gastric lavage for poisonings:

-can only be done within 2 hours of poisoning

-intubate first if poor gag reflex or decreased LOC

-do NOT use for caustics, sharp objects, or nontoxic substances

activated charcoal is best given within ______ hour(s) of ingestion

1

(absorbs many toxins)

-contraindications include diminished bowel sounds, paralytic ileum, substances poorly bound by charcoal

PPE levels

Level A--> highest protection, SCBA + vapor tight

Level B--> high-respiratory protection, less skin protection, chemical-resistant

Level C--> air-purifying respirator, hooded coverall, chemical-resistant gloves/boots

Level D --> regular work uniform (standard precautions)

terrorism biologic agents:

ex: anthrax, plague, tularemia (all treatable with antibiotics); smallpox (vaccine to prevent)

-nursing role--> early recognition of unusual clusters of illness, isolation, PPE, reporting to public health, education on prophylaxis and vaccination

phosphene gas

-colorless gas used in industry

-hgih-concentration exposure --> severe respiratory distress

-treatment = airway/pulmonary support

mustard gas

yellow-brown, garlic-like odor

-causes eye irritation, skin burns, and blisters

-do NOT irrigate with water or saline

sarin (nerve agent)

-extremely toxic nerve gas; can kill within minutes

-absorbed via eyes, skin, inhalation

-causes paralysis of respiratory muscles

-antidotes: atropine + pralidoxime chloride