Chapter 71

Emergency Nursing

Chapter 71

Emergency Nursing

QuestionIs the following statement True or False?TRUEThe emergency nurse has had specialized

education, training, experience, and expertise in assessing and identifying patients’ health care problems in crisis situations.

Scope and Practice of Emergency Nursing

• Emergency management– traditionally refers to urgent &critical care

needs– increasingly used for non-urgent –broadened to include concept that an

emergency is whatever the patient or family considers it to be.

Scope and Practice of Emergency Nursing

• Emergency nurse has special training, education, experience, and expertise in assessing and identifying health care problems in crisis situations.

• Nursing interventions are accomplished interdependently in consultation or under the direction of a physician or nurse practitioner.

• The emergency room staff works as a team.

Priority Emergency Measures for All Patients

• Safety is the first priority• Preplanning to assure security and a safe

environment• Close observatio• n of patient and family members in event that

they respond to stress with physical violence• Assessment of patient and family psychological

function

Priority Emergency Measures for All Patients

• Patient and family focused interventions– Actions to relieve anxiety and provide a sense of

security – Allow family to stay with patient, if possible, to

alleviate anxiety (they need to see that everything is being done to help the patient)

– Provide explanations and information (they need to know why your doing the things you are doing)

– Additional interventions are provided depending upon the stage of crisis

QuestionA basic and widely used triage system has

several categories. What does an emergent category for a patient mean?

A.Signifying potentially life-threatening injuries or illnesses requiring immediate treatment.

B.Episodic or minor injury or illness in which treatment may be delayed for several hours without increased morbidity.

C.Serious illness or injury that is not immediately life threatening.

D.Process of assessing patients to determine management priorities.

Answer

A

Emergent is signifying potentially life-threatening injuries or illnesses requiring immediate treatment. Non-urgent is episodic or minor injury or illness in which treatment may be delayed for several hours without increased morbidity. Urgent is serious illness or injury that is not immediately life threatening. Triage is the process of assessing patients to determine management priorities.

Triage• Sorts patients by hierarchy based on– severity of health problems– immediacy with which these problems must be treated.

• Triage nurse collects data & classifies illnesses & injuries to ensure that patients most in need of care do not needlessly wait.• Protocols may be initiated in triage area.• ED triages differs from disaster triage in that

patients who are the most critically ill receive the most resources, regardless of potential outcome.

• What is an expectant person?A person that is going to dye, so give morphine

and provide comfort measures, give support to family. These people will not get resources such as fluids and blood products etc.

• Triage nurse determines who is seen in what order

• Decapitation can also be known as a c1-c2 injury

Categories ***need to know***

• Emergent – highest priority, life threatening, must be seen immediately

• Urgent – serious conditions, not life threatening seen within 1 hour

• Non-urgent – episodic illnesses that can be addressed within a 24hour period

• Fast Track – simple first aid, still come to ED but could be dealt with in a Dr. office or a clinic

In what order do you see these patients? ***need to know***

• 45 year old, awake, alert, and oriented but short of breath-3

• Gunshot victim to the right arm-4• 32 year old with indigestion-1• 70 year old with severe back pain-2• Answer- indigestion can be a heart attack, severe

back pain can mean ruptured aortic aneurism. • If back pain ALWAYS THINK RUPTURED

ANEURISM!!!! Back pain could mean aneurism is going to pop

Management of Patients with Intra-Abdominal Injuries pg 2165

• Blunt trauma or penetrating injuries• Abdominal trauma can cause massive life-

threatening blood loss into abdominal cavity• Assessment – Obtain history (what happened? So you know what to

expect)– Abdominal assessment and assess other body systems

(such as lungs and heart) for injuries that frequently accompany abdominal injuries

– Assess for referred pain which may indicate spleen, liver, or intra-peritoneal injury

– Laboratory studies, CT scan, abdominal ultrasound (FAST), diagnostic peritoneal lavage

– Stab wound—sinography– If liver laceration you will have a lot of bleeding and

surgery

FAST Exam

• Introduction• Ultrasound Physics• Technique• Indications for FAST exam• Performing a FAST exam• Limitations• Questions

What is the FAST exam? Pg 2166 look under internal bleeding

O FFocused AAssessment by SSonography in TTraumaO Focused exam using ultrasound to diagnose hemorrhage

in a trauma settingO Ideally takes < 3 minO 4 primary views

ORUQOLUQOSubxiphoidOSuprapubic

Technique don’t need to know for test

• Goal: to identify blood in body cavities where it is not supposed to be– Unclotted blood appears black

on US– Clotted blood appears gray

• Abdominal probe with small footprint (between 1- 3 cm) with range of frequency between 2.0 Hz and 5.0 Hz

• Scan 4 areas– RUQ– Subxiphoid– LUQ– Suprapubic

• Unclotted blood allows passage of transmission of ultrasound waves without echoes. Clotted blood creates echoes and thus appears gray.

• Foot print is the area of skin that the probe covers. Good to have small probe b/c you can look b/n ribs if you need to. Generally you can use 3.5 hz. You can use higher frequencies in thinner patients. Lower frequencies will give better resolution in heavier patients.

• 1) subxiphoid - to visualize the heart, • 2) RUQ - to visualize Morrison's pouch and paracolic gutter, • 3) LUQ - to visualize the spleeno-renal recess and paracolic gutter, • 4) suprapubic - to visualize Douglas' pouch.

• Many people start in RUQ b/c this is where fluid is most likely to be. Some start subxiphoid in order to early see pericardium/tamponade also allows for adjustment of the gain.

• - fluid most likely to be in RUQ due to anatomical and gravitational considerations. People are generally supine. Organs in pelvis relatively well protected. Abdominal organs usually injured. Blood flows into Morrison’s pouch (space b/n liver and kidney)

• Generally, if hemorrhage is below the bony pelvis it will flow caudad and above it will flow cephalad.

Indications

• Blunt thoracoabdominal trauma• Penetrating thoracoabdominal trauma• Suspected pericardial tamponade• Trauma patient with hypotension on unknown

etiology• Thoracoabdominal trauma in a pregnant

patient

Right Upper Quadrant• Sagittal view obtained by placing

probe either in the midclavicular line on the lower rib cage or below the right costal margin

• May have to move probe laterally to avoid gas in hepatic flexure

• Air-filled lung creates reflection artifact in which lung appears to be composed of liver parenchyma

• Scan for black fluid in potential spaces

• Usually only do below right costal margin in patients able to take deep breaths.

• Lung is filled with air which is highly reflective leading to artifact. Abscense of this artifact suggests hemothorax.

• Some sonographers as they gain experience will scan solid organs for areas of abnormal echogenicity which would suggest parenchymal injury. This is not part of FAST exam.

Normal RUQ

Abnormal RUQ

This means there’s injury to the kidney

Subxiphoid• Probe placed under

xiphoid almost parallel with skin surface directed towards patient’s left shoulder

• Parasternal view may be used when supxiphoid unable to be obtained

• Consider pnuemothorax when unable to obtain images of heart and no apparent reason

Subxiphoid may be impossible due to patient’s body habitus or physical injuries.

Normal Subxiphoid

Abnormal Subxiphoid

Left Upper Quadrant

• Most technically difficult to obtain

• Probe placed parallel with ribs in posterior axillary line

• Scan potential spaces between diaphragm and spleen and spleen and kidney for free fluid

LUQ• When having trouble getting this view, it is

usually because the probe is not posterior enough or superior enough.

• In both the LUQ and RUQ, it is usually necessary to get multiple images in order to identify all of the required structures.Getting them all in a single image The features of the LUQ view are very similar to those of the RUQ, with the normal pleural space appearing as if there were spleen both above and below the diaphragm.

Normal LUQ

Abnormal LUQ

This is a spleen tear

they will have to

remove the spleen most

probably

Mesenteric artery lac

Suprapubic• Entire pelvis should be

scanned from top to bottom with transducer in transverse place and them side to side with transducer in sagittal plane

• Pouch of Douglas is the most dependent site in peritoneal cavity

• First sign of blood is often two small black triangles on either side of rectum– “Bow tie sign”

• In a normal transverse suprapubic view, the pouch of Douglas is the most dependent site (standing or supine) in the entire pentoneal cavity The first sonographic sign of blood in the pelvis is often two small black triangles on either side of the rectum the so-called bow tie sign. The entire pelvis should be scanned from top to bottom with the transducer in the transverse plane, and then from side to side with the transducer held in a sagittal plane.

Normal Suprapubic

Abnormal Suprapubic

Limitations• Retroperitoneal bleeding• Inadequate volume of fluid• Not enough time elapsed since trauma to

demonstrate bleeding• Solid organ trauma with encapsulated bleeding• Image quality dependent on quality of US

machine and probe, body habitus of patient, physical injuries

• Scan and interpretation are operator dependent

Management of Patients with Intra-Abdominal Injuries

• Assure airway, breathing, and circulation• Immobilize cervical spine- and log roll pt.• Continually monitor the patient –you can lose pt.

quickly• Document all wounds-you could have multiple

injuries everywhere• If viscera are protruding cover with sterile, moist

saline dressing

Management of Patients with Intra-Abdominal Injuries

• Hold oral fluids• NG to aspirate stomach contents –to prevent

aspiration in surgery• Tetanus and antibiotic prophylaxis- assume

infection there• Rapid transport to surgery if indicated-

especially if fluids aren't working

Question

Is the following statement True or False?Use ABCs and reduce temperature to 39.6°C as

quickly as possible.

FALSE-Use ABCs and reduce temperature to 39°C, not 39.6°C, as quickly as possible (within the hour).

Answer

False

Use ABCs and reduce temperature to 39°C, not 39.6°C, as quickly as possible (within the hour).

Nice to know

• Wet Bulb temperature• Heat Categories: 5• Handout

Environmental Emergencies: Heat Stroke

• Elderly, very young, ill or debilitated, and persons on some medications are at high risk

• Can cause death• Manifestations: CNS dysfunction, elevated

temperature, hot dry skin, anhydrosis, tachypnea, hypotension, and tachycardia

Management of Patients with Heat Stroke

• Use ABCs and reduce temperature to 39°C as quickly as possible

• Cooling methods– Cool sheets, towels, or sponging with cool water– Ice to neck, groin, chest, and axillae– Cooling blankets– Iced lavage of the stomach or colon– Immersion in cold water bath

Management of Patients with Heat Stroke

• Monitor temperature, VS, ECG, CVP, LOC, urine output

• IVs to replace fluid losses

Note: hyperthermia may recur in 3–4 hours, avoid hypothermia

Environmental Emergencies: Frostbite• Trauma from freezing temperature and

actual freezing of fluid in the intracellular and intercellular spaces

• Manifestations– hard, cold, and insensitive to touch– may appear white or mottled– may turn red and painful as rewarmed

• extent of injury is not always initially known.

Categories

1st degree to 4th degree

Environmental Emergencies: Frostbite• Controlled but rapid rewarming; 37–40°C

circulating bath for 30–40 minute intervals

• Analgesics for pain • Once rewarmed protect from additional

injury– Do not massage or handle; if feet are

involved, do not walk – Whirlpool, Escharotomy, fashiotomy– Instruct patient to avoid alcohol, caffeine

and smoking

Environmental Emergencies: Hypothermia

• Internal core temperature is 35°C or less• Elderly, infants, persons with concurrent

illness, the homeless, and trauma victims are at risk

• Alcohol ingestion increases susceptibility• Hypothermia may be seen with frost bite

and treatment of hypothermia takes precedence

• Physiologic changes in all organ systems• Monitor continuously

Management of Patients with Hypothermia

• Use ABCs, remove wet clothing, and rewarm• Rewarming– Active core rewarming

• Cardiopulmonary bypass, warm fluid administration, warm humidified oxygen, warm peritoneal lavage

– Passive external rewarming• Warm blankets and over the bed heaters

Note: Cold blood returning from the extremities has high levels of lactic acid and can cause potential cardiac dysrhythmias and electrolyte disturbances

Trauma

• A intentional or an unintentional wound or injury inflicted upon the body from a mechanism that the body cannot protect itself against.

• 4th leading cause of death in children and in adults under age 44.– Alcohol and drug abuse

Forensic Evidence

• Potential legal and/or criminal evidence• All articles in possessions are possible

evidence including wounds• Suicide or homicide – coroners case• Documentation and/or photographs– Statements– Clothing– Hands/skin

Injury Prevention

• Education• Legislation – be involved• Automatic protection

Priorities of Care for the Patient with Multiple Trauma

• Requires a team approach• Determine extent of injuries and establish

priorities of treatment• Assume cervical spine injury• Injuries interfering with vital physiologic

function have highest priority• Evidence of trauma can be very visible or

absent• Always assume much more than you see• Know mechanism of injury

Priority Management

• Establish airway• Control hemorrhage• Prevent or treat hypovolemic shock• Assess for head and neck injuries• Look for other injuries• Splint fracture• Perform more detailed assessment– See table71-6 pg. 2166

Crush Injuries

• Occur when a person is caught between two opposing forces.– Hypovolemic shock– Paralysis– Erythema and blistering– Damaged body part– Renal failure• Myoglobinuria - muscle damage - acute tubular

necrosis - acute renal failure

Fractures

• Be first aware of overall condition• ABC’s• Immediate management – cut off clothing to

visualize – do not move unless in danger• Multiple fractures often accompany internal

injuries• Stabilize

Assessment

• Systematic Head – Toe• Lacerations• Deformities• Swelling• Angulation• ROM• Shortening• Rotation• Peripheral Pulses

Cont.

• Immobilization– Splinting– Prevents further injury– Relieves pain

After Splinting re-assess!!!

Near Drowning

• Survival for at least 24hrs that caused a respiratory arrest.

• 2nd most common cause of death in children <14• Metabolic rates slow – better chance for survival• Near drowning causes hypoxia, hypercapnia,

bradycardia and dysrhythmias• Complications after resuscitation include hypoxia

and acidosis

Management

• Therapeutic goals: Cerebral perfusion and oxygenation to prevent further damage

• Manage– Hypoxia– Acidosis – Hypothermia

Close monitoring – VS, ECG, Electrolytes, ABG’sNeuro status, I & O, chest x-rays

Decompression

• Results from formation of nitrogen bubbles that occur with rapid changes in air pressure

• S/S– MS pain– Numbness– Hypesthesia

• Can Cause– Air embolism – stroke, paralysis, and/or death

Insect stings

• Anaphylaxis• Urticarial• Itching• Table 71-8, Table 71-9

Animal bites

• Rabies• Report to Public Health• Rabies prophylaxis

Snake Bites

• Venomous bites cause 7000-8000 bites per year

• Be familiar with snakes in your area• S/S include edema. Ecchymosis, hemorrhagic

bullae leading to necrosis, N/V, numbness, metallic taste in mouth

• Lead to hypotension, parathesias, seizures and coma

Management

• Initial First aid• Report to ED• Circumstances• Document severity of symptoms• VS• Labs – CBC, Coags, urinalysis• Measure extremity• Antivenom

Spider Bites

• Black Widow– Pin prick, symptoms within 30 min. Abd. Rigidity,

N/V, hypertension, tachycardia, parethesias– Antivenom

• Brown Recluse– Painless, fever/chills, N/V, joint pain, wound

necrosis

Management of Patients with Poisoning • Poison is any substance that when ingested,

inhaled, absorbed, applied to the skin, or produced within the body in relativity small amounts injures the body by its chemical action.

• Treatment goals:– Remove or inactivate the poison before it is

absorbed– Provide supportive care in maintaining vital organs

systems– Administer specific antidotes– Implement treatment to hasten the elimination of

the poison

Management of Patients with Ingested Poisons—Assessment

• ABCs • Monitor VS, LOC, ECG, UO • Laboratory specimens • Determine what, when, and how

much substance was ingested

Management of Patients with Ingested Poisons—Assessment

• Signs and symptoms of poisoning and tissue damage

• Health history• Age and weight

Management of Patients with Ingested Poisons

• Measures to remove the toxin or decrease its absorption– Use of emetics– Gastric lavage– Activated charcoal– Cathartic when appropriate– Administration of specific antagonist as early as possible– Other measures may include diuresis, dialysis or hemoperfusion

• Corrosive agents such as acids and alkalines cause destruction of tissues by contact. Do not induce vomiting with corrosive agents.

Management Patients with Carbon Monoxide Poisoning

• Inhaled carbon monoxide binds to hemoglobin as carboxyhemoglobin. Carboxyhemoglobin does not transport oxygen.

• Manifestations—CNS symptoms predominate– Skin color is not a reliable sign and pulse oximetry is not

valid• Treatment

– Get to fresh air immediately– CPR as necessary– Administer oxygen; 100% or oxygen under hyperbaric

pressure • Monitor continuously

Management of Patients with Chemical Burns

• Severity of the injury depends upon the mechanism of action of the substance, the penetrating strength and concentration, and the amount of skin exposed to the agent.

• Immediately flush the skin with running water from a shower, hose or faucet.

Note: Lye or white phosphorus should be brushed off the skin dry.

Management of Patients with Chemical Burns

• Protect health care personnel from the substance.

• Determine the substance. • Some substances may require prolonged

flushing/irrigation.• Follow-up care includes reexamination of

the area at 24 hours, 72 hours, and 7 days.

Management of Patients with Food Poisoning

• A sudden illness due to the ingestion of contaminated food or drink

• ABCs and supportive measuresNote: Food poisoning, such as botulism or fish poisoning, may result in respiratory paralysis and death

• Determination of food poisoning• Treat fluid and electrolyte imbalances• Control nausea and vomiting• Clear liquid diet and progression of diet

after nausea and vomiting subside

Management of Patients with Substance Abuse

• Acute alcohol intoxication—a multisystem toxin – Alcohol poisoning may result in death– Maintain airway and observe for CNS depression and

hypotension– Rule out other potential causes of the behaviors

before it is assumed the patient is intoxicated– Use nonjudgmental, calm manner– May need sedation if noisy or belligerent– Examine for withdrawal delirium, injuries, and

evidence of other disorders

Crisis Intervention: Rape Victims• How the patient is received and treated

in the ED is important to his or her psychological well-being.

• Crisis intervention begins as soon as the patient enters the facility; the patient should be seen immediately

• Goals are to provide support, reduce emotional trauma, and gather evidence for possible legal proceedings

• Patient reaction; Rape trauma syndrome

Crisis Intervention: Rape Victims• History taking and documentation• Physical examination and collection of

forensic evidence• Role of the sexual assault nurse examiner

(SANE)– Spends time with police and family which aids

in investigation– Light-staining microscope – identifies mortile

and non-mortile sperm• PTSD• Provides support• Privacy and sensitivity must be respected

Psychiatric Emergencies• Overactive patients, violent behavior,

underactive or depressed patients and suicidal patients

• Management– Maintain the safety all persons and gain control

of the situation– Determine if the patient is at risk for injuring

himself or herself or others.– Maintain the person’s self-esteem while

providing care– Determine if the person has a psychiatric history

or is currently under care to contact that therapist

• Crisis intervention • Interventions specific to each of the

conditions

Suicide Patients

• Beware aware of high risk individuals• Communication and listening skills• History of suicide attempt• Family history• Loss of parent at an early age• Specific plan• A means to carry out the plan• Patients will be admitted to Psych or ICY for

constant supervision