emergency nursing

What determines an ESI triage level?

Severity of illness and anticipated treatment resources.

What is the difference between ESI 1 and ESI 2?

ESI 1: Immediate life-saving intervention. ESI 2: High-risk emergency.

What ESI level is suspected MI with stable vital signs?

ESI 2 — high-risk condition despite stable vital signs.

What are three major emergency nursing responsibilities? -

Rapid assessment, life-saving stabilization, and communication/advocacy.

What does ABCDE stand for?

Airway, Breathing, Circulation, Disability, Exposure.

What airway maneuver is preferred with suspected cervical spine injury? -

Jaw-thrust maneuver with spinal precautions.

What does AVPU stand for? -

Alert, Verbal response, Pain response, Unresponsive.

What does LMNOP stand for?

• Labs, Monitor ECG, Nasogastric tube, Oxygenation, Pain.

What does SAMPLE stand for? -

Signs/symptoms, Allergies, Medications, Past history, Last meal, Events.

What most commonly causes pediatric cardiac arrest?

• Progressive respiratory failure or shock.

What are the three components of the Pediatric Assessment Triangle?

• Appearance, Work of breathing, Circulation to skin.

What do slow, irregular respirations in a critically ill child indicate?

• Impending respiratory arrest.

Why is pediatric hypotension a late warning sign?

-Children compensate for shock until decompensation occurs; indicates cardiopulmonary arrest

When should chest compressions begin for pediatric bradycardia? -

HR <60 with poor perfusion despite effective oxygenation and ventilation.

Why are critically ill children prone to hypoglycemia?

• Limited glycogen stores become rapidly depleted during stress.

• mimics signs of hypoxemia, poor perfusion, hypotension and cardiac arrest

• *for infants and children with hypoglycemia, administer D25 slowly IV or IO (its too shocking to system if its too fast)

Why is head CT required before considering stroke thrombolysis?

• To exclude hemorrhagic stroke, a contraindication to tpa.

What emergency causes unilateral absent breath sounds and hypotension? -

Tension pneumothorax; requires emergency decompression.

What is the hallmark finding of flail chest?

Paradoxical chest wall movement.

What is the priority concern with facial burns and hoarseness? -

Inhalation injury and progressive airway edema. MECH VENT

What medications are first-line for prolonged convulsive seizures?

• Benzodiazepines: lorazepam, midazolam, or diazepam. keppra is gold standard

What is Cullen sign?

bruising within 2 inches of belly button (GI BLEED)

How does heat stroke differ from heat exhaustion?

• Heat stroke causes severe hyperthermia with CNS dysfunction.

Why may severe frostbite initially be painless?

-Decreased blood flow and cold-induced nerve dysfunction.

What are EMTALA's three major requirements? -

Medical screening, stabilization, and appropriate transfer when indicated.

peds airway/breathing signs to look out for

• head bobbing

• tripod position

• grunting

• tachypnea or bradypnea —- INTUBATE

sunken fontanelles

brain swelling → inc ICP → seizures

exposure red flags

• petechiae : shaken, repeated exposure

• purpura : constant trauma and bleeding

hyperglycemia

it causes osmotic diuresis and is associated with brain ischemia and cellular injury. may occur with head trauma