emergency care

define triage 5 level sorting

• Classification system used to establish priorities of patient care according to the gravity of injuries, urgency of treatment, and need for care. Most critically ill first.

• Life threatening, Emergency Severity Index (ESI) 1: Cardiac Arrest/Pulselessness, intubated trauma, OD with bradypnea, severe respiratory distress, anaphylactic shock, hypoglycemia with change in mental status

• High risk, ESI 2: Chest pain from ischemia, multiple trauma unless responsive, suicidal, immunocompromised with fever, CVA

• Urgent, Priority ESI 3: Abdominal pain or Gyn disorder unless in severe distress, hip fx in older pt, vomiting, HTN. They have normal vitals.

• Mostly Urgent, Priority ESI 4: Closed extremity trauma, simple laceration, cystitis

• Non-urgent, ESI 5: Cold symptoms, minor burn, poison ivy, wound recheck, prescription refill

primary survey in ER: identify life threatening problems

• ABCDEFG (Table 21.3)

• Airway (obstruction) and Alertness (LOC). Cervical spine stabilization, if needed.

• Breathing

• Circulation and Control of Hemorrhage. Vital signs.

• Disability (Glasgow and Pupils)

• Exposure and Environment (Full body and Environmental assessment)

• Family presence

• Getting other monitoring devices and Comfort. Pain.

primary survey in ER: blood transfusions

• ABO System

• Universal Donor:  Type O

• Universal Recipient:  Type AB

• Blood type identified by antigens found in the RBC membrane

  • Type A has B antibodies; gets A & O

  • Type B has A antibodies; gets B & O

  • Type AB has No antibodies; gets A, B, & O

  • Type O has A & B antibodies; gets O

types of blood packs

• Packed Red Blood Cells:  used for symptomatic or severe anemia, acute blood loss-infuse slowly (2-4 hours)

• Platelets:  used for bleeding caused by thrombocytopenia; given at <10,000 -infuse quickly (30 mins) (6 units raises 10,000 each unit)

• Fresh Frozen Plasma:  used for bleeding caused by deficiency of clotting factors-infuse wide open

• Salt-poor albumin: concentrated human albumin solution with reduced sodium levels. Used to treat conditions like hypoalbuminemia, nephrotic syndrome, decompensated hepatic cirrhosis, and when there's salt and water overload (burns-massive edema, ascites).

blood transfusion administration

• Verify the client identification according to hospital policy

  • 2 RNs to identify patient & blood product match prior to start  (second person can also be LPN)

• Requires informed consent

• At least 20 gauge IV to prevent hemolysis

• NSS maintenance infusion, No D5W

• Vital signs prior to infusion start

• Slow infusion for first 15 minutes

• Vital signs at 15-minute mark and then every hour

• Vital signs at completion of transfusion

blood transfusion reactions

• 90% result from improper product to patient identification

• Range from mild to life threatening

• Febrile reaction is most common: Shivering; rigors

• Hemolytic reaction is most life threatening

how to treat blood transfusion reactions

• Stop the transfusion

• Maintain a patent IV with NSS

• Notify blood bank and HC Provider

• Monitor VS and Urine Output

• Send urinalysis to lab

• Treat symptoms as ordered

• Save bag and tubing for examination by blood bank personnel

secondary surveys

• Screening for Abuse: Adult, Domestic, Child

• RN ethically obligated to address concerns

• Forensic nurses specially trained

types of emergencies

• Heat-Related

• Cold-Related

• Submersion Injuries

• Stings

• Bites

• Poison

heat emergencies: heat stroke clinical manifestations

• Emergency!!

• Core temperature rises within 10 to 15 minutes; higher than 105.8° F (41° C). No oral temps.

• Altered mental status; confusion leading to coma

• Hypotension, Tachycardia, Tachypnea, Weakness

• Hot, dry skin; absence of perspiration. Thermoregulatory mechanisms (sweating) cannot compensate for exposure to higher ambient temperatures.

heat stroke treatment

• Stabilize ABCs

• Cool water immersion, ice packs to axilla and groin

• Fluid replacement

• Control shivering (shivering increases temp)…Meperidine

• Monitor for rhabdomyolysis (breaking down of RBC)

  • Skeletal muscle breakdown

  • Causes kidney damage (clog kidney vessels)

  • Monitor urine for color, amount, pH, and myoglobin

• Acetaminophen does NOT help to bring temperature down

cold emergencies

• deep frostbite

• hypothermia

deep frostbite clinical manifestations

• Frostbite starts with skin very red, yellow, then blue.  When skin turns white and hard, body part in deep frostbite.

• Initially numbness, tingling, burning. When skin is insensitive to touch, body part in deep frostbite.

• Mottling gradually progresses to gangrene

• Blistering occurs in 6 hours to days

• Involves muscle, bone, and tendon

deep frostbite treatment

• Never squeeze, massage, or scrub the injured tissue

• Swelling will occur with thawing

• Immerse in a temperature-controlled circulating water bath 99.0° to 102° F (37.2° to 38.9° C) until flushing occurs distal to injured area

• Elevate to decrease edema after rewarming

• IV analgesia. NSAIDs for analgesic and anti-inflammatory affects

• Anticoagulation

• Tetanus and ATB prophylaxis

hypothermia clinical manifestation

• Shivering

• Lethargy, Confusion

• Rigidity

• Bradycardia, Bradypnea, Hypotension

• Metabolic and respiratory acidosis

• Hypovolemia

• May see VF, pulseless electrical activity (PEA)

hypothermia treatment

• Place on an ECG monitor and treat dysrhythmias. Priority.

• Rewarm patient

  • Warm slowly and use cardiac monitor. Discontinue rewarming once core temperature is 90° to 95° F (32.2° to 35° C)

  • Do not rub patient’s skin or move patient, if possible

• Risks of rewarming

  • Afterdrop - further drop in core temperature. Occurs when cold peripheral blood returns to central circulation

  • Shock - hypotension and dysrhythmias

• Correct dehydration and acidosis

Submersion injury/near drowning clinical manifestations

• Person becomes hypoxic due to submersion in a liquid, usually water. Respiratory impairment after submersion in water or other fluid

• Hypertonic saltwater. Draws fluid from vascular space into alveoli causing hypoxia

• Crackles, Pink frothy sputum, Pulmonary edema

• Dysrhythmias, Tachycardia, Bradycardia if cold water submersion

• Cardiac arrest

• Cyanosis

• Hypothermia

Submersion injury/near drowning treatment

• Immediate CPR

• ABC

• Mechanical ventilation

• Cervical spine immobilization

• Tx pulmonary edema complication

Sting clinical manifestations

• Symptoms may begin immediately or be delayed up to 48 hours

• Death from Blood loss, Allergic reactions, Lethal toxins

• Stinging, Burning, Itching

• Swelling, Edema

• Headache, Fever, Syncope

• Nausea, Vomiting

• Wheezing, Bronchospasm, Laryngeal edema

• Hypotension

Sting treatment

• Elevation

• Cool compresses

• Antipruritic lotions

• Oral antihistamines (mild)

• IM or IV antihistamines (severe).

• Subcutaneous epinephrine (severe)

• Corticosteroids

• Antidote

• IV NSS

bite emergencies: tx

• High risk of infection

• TX:

  • Clean, irrigate, debride, close

  • Tetanus prophylaxis

  • Analgesics

  • Prophylactic antibiotics

  • Rabies prophylaxis essential in management of animal bites. Initial injection: rabies immune globulin, followed by series of injections

toxicologic emergencies

• Acute poisonings and intake of substances of abuse

• Severity depends on type, concentration, and route of exposure

• TX:

  • Decrease absorption, Enhance elimination, Implement toxin-specific interventions per poison control center

  • Emesis

  • Gastric Lavage with large bore NGT

  • Activated charcoal: binds to poisons in the stomach and intestines, preventing their absorption into the bloodstream

  • Cathartics (Sorbitol or magnesium citrate): accelerate the movement of substances through the digestive tract

  • May require intubation with mechanical ventilation

  • May require dialysis

  • Antidote, if available

  • Psych consult required for intentional poisoning/suicide attempt