curative and rehabilitative nursing care management of clients in acute biologic crisis

Bio-Crisis – Ms. Lina Navarro

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Curative and Rehabilitative Nursing Care Management of Clients in Acute Biologic Crisis

Lina B. Navarro, RN

4 Days

Grading System

Q – 50% T – 40% P – 10% Course Content

Basic Concepts of Emergency First Aid

Intensive/Critical Care Nursing

Specific Biologic Crisis Situations

Disasters

Basic Concepts of Emergency First Aid Nursing

Definition of Terms

o Emergency – a situation which poses an immediate risk to life, heath, property or environment

o Emergency Care – care given to clients with urgent or critical needs

o Emergency Nursing – a nursing specialty in which nurses care for patients in the emergency or critical phase

of their illness of injury

o Paramedics – health care professional specializing in emergency medicine

o Emergency Medical Service (EMS) – a service providing out of hospital acute care and transport to definitive

care

Characteristics of Emergency Nurses

o Skilled at dealing with clients in the phase when a diagnosis has not yet been made and the cause of the

problem is not known

o Specialize in rapid assessment and treatment when every second counts

o Tackle diverse tasks with professionalism efficiency, and above all – caring

o Possess both general and specific knowledge about health care

o Ready to treat a wide variety of illnesses or injury situation, ranging from a sore throat to a heart attack

First Aid

o Immediate and temporary care given to a person who is injured or who suddenly becomes ill before

professional medical care is available

o Goals: 3 P’s

Preserve life

Prevent further injury

Promote recovery


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Characteristics of a Good First Aider

o Gentle

o Resourceful

o Observant

o Tactful

o Empathic

o Respectable

Contents of a First Aid Kit

o Hemorrhagic Control

- Tourniquet

- Gauze

- Bandage

- Clamps

o Spinal Immobilization

- Backboard

- Cervical collar

o Extremity Immobilization

- Splint

- Bandage

- Slings

o Labor and Delivery

- Clamps

- Scissors

- Suction

- Linen

- Gauze

o Resuscitation

- Ambu bag

- Bag Valve Mask Device

- O2 tank (mask and cannula)

o Emergency Drugs

- Epi

- AtSo4

- Dopamine

o Wound Care

- Betadine

- Gauze

- Alcohol

- PNSS


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Ethical, Legal and Medical Issues in Nursing

Ethical Principles

o Autonomy – pertains to the right to make one’s own choices

o Beneficence – the duty of health care providers to be a benefit to the patient as well as to take positive

steps to prevent and to remove harm from the patient

o Non-maleficence – is the principle of doing no harm

o Justice – an equal distribution of risks and benefits. It is usually defined as a form of fairness.

o Veracity – is the ethical principles of honesty

o Fidelity – being true to our commitments and obligations to others

Ethical Responsibility

o Makes the physical/emotional needs of the patient a priority

o Practice/maintain skills to the point of mastery

o Critically review performances – self critical

o Attend continuing education/refreshes/programs

o Be honest in reporting – documentation

Duty to Act

o Legal obligation to provide patient care

1. When employment requires

2. When a pre-existing responsibility exists

3. When first aid has begun

Good Samaritan Acts

o Immunity from civil liability when providing assistance at the scene of an emergency; unless you did

something negligent

1. Do not leave the scene until the injured person leaves or another qualified person takes over

(Abandonment)

2. Limit actions to those considered first aid, if possible

3. Offer assistance, but don’t insist

4. Have someone call or go for additional help

5. Do not accept any compensation

Privacy and Confidentiality

o Sharing of confidential information by the nurse about a patient’s condition is legal when:

- Information is shared with other members of the health care team

- With client’s consent (signs a written release)

Negligence – failure to provide care what another prudent person would allow do under the same circumstances

Malpractice – “professional negligence”


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Elements of Malpractice

1. Duty

2. Breach of Duty

3. Damages

4. Causation

Terms

o Abandonment

o Assault and Battery

- Assault – verbal threat

- Battery –threats into action; procedure without explaining

o Consent

- Informed (client is aware or told of procedure)

- Implied

- Minors (can’t sign consent except those who are married, pregnant, parents, emancipated,

military)

- Mentally-ill (they can sign consent)

o Refusal of treatment

o Restraints – needs doctor’s order

o Advance Directives – written statement that specifies medical treatment desired, if px is unable to make

decisions

o Do Not Resuscitate (DNR) Orders

o Organ Donors (save particular organ)

o Medical Identification Devices

o Special reporting requirements

- Abuse of children, elderly, and spouse

- Drug-related injury

- Childbirth

- Infections disease exposure

- Crime scene

- Deceased

Emergency Action Principles

o Scene Size-up/Survey the Scene

- Scene safety/potential hazard

- Mechanism of injury – 4W’s and 1H

- Number of casualties – account for all

- Bystanders – observe bystanders that can help

- Body Substance Isolation (BSI)

o Primary Survey

- Rapid assessment of life threatening conditions

- Must be treated before the assessment continuous

A – Airways


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B – Breathing

C – Circulation

The Body’s Need for O2 Time is Critical 0-1 minutes: Cardiac irritability 0-4 minutes: brain damage not likely 4-6 minutes: brain damage possible 6-10 minutes: brain damage very likely More than 10 minutes: irreversible brain damage The Golden Hour Discovery of incidents and activation of EMS 20 minutes The Golden Ten Minutes Initial Assessment and Intervention EMS intervention EMS packaging and transport 10 minutes Initial Stabilization 20 minutes

o Medical Assistance

o Secondary Survey

Identifies non-life threatening problems

o Neurologic Assessment: GCS, LOC, Pupil reaction

o General Overview: baseline V/S

o Head-to-Toe Assessment: IPPA, DCAPBTLS

o History Information: OPQRST, SAMPLE

Glasgow Coma Scale

Generally, comas are classified as:

Severe, with GCS </= 8

Moderate GCS 9-12

Minor, GCS >/= 13

Eye opening

Spontaneous 4

To Voice 3

To Pain 2

None 1

Verbal response

Oriented 5

Confused 4

Inappropriate words 3

Incomprehensible words 2

None 1

Motor Response

Obeys Commands 6

Localizes Pain 5


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Withdraw 4

Flexion 3

Extension 2

None 1

Level of Consciousness

A-Alert

V-Response to Verbal stimulus

P-Responsive to Pain

U-Unresponsive

Golden Rule

Altered level of consciousness is characteristic of nervous system dysfunction and warrants

thorough examination to rule out all possible causes

Change in Pupil Size

- Unequal pupil size (anisocoria) may indicate increased pressure on one side of the brain

General Overview

- Respirations

- Pulse

- Blood pressure

- Temperature

- Pain scale

- Capillary refill

Used as a basis whether client’s conditions is improving or deteriorating

Head-to-Toes Assessment

- Inspections

- Palpation

- Percussion

- Auscultation

DCAPBTLS

- Deformities

- Contusions

- Abrasions/Penetrations

- Punctures

- Burns

- Tenderness

- Lacerations

- Swelling

History Information

- Onset

- Provoking factors


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- Quality of pain

- Radiation of pain

- Severity

- Time

SAMPLE

- Signs and Symptoms

- Allergies

- Medications

- Past medical history

- Last oral intake

- Events leading to the episode

Priority Setting/Triage

o “trier” which means to sort out or prioritize

o To assess and determine the severity or acuity of the presenting problem

o Not a static process

o Purpose:

- Rapidly identify patients with urgent, life-threatening conditions

- Initiate appropriate and immediate interventions

Triage and Acuity Scale Category

Level 1: Resuscitation

- Conditions that threatens life and limb

- Requires immediate and aggressive interventions

- Time to Physician: Immediate

Code/arrest

Major trauma

Shock state

Unconsciousness

Severe respi distress

Level 2: Emergent

- potential threat to life, limb or function, requiring rapid medical intervention

- Time to physician assessment/interview: 15minutes

Altered mental state/CVA

Head injury/severe trauma

Neonates

Chest pain/abdominal pain

Drug overdose

GI Bleed

Asthma/dyspnea

Chemotherapy


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Anaphylaxis

Vaginal bleeding/acute lower abdominal pain

Serious infections/fevers

Diabetes

Diarrhea and vomiting

Acute psychosis/drug withdrawal

Level 3: Urgent

- Potentially progress to a serious problem

- Time to physician: 30 minutes

Head injury/moderate trauma

Asthma/dyspnea, mild/moderate

Chest pain

GI bleed

Vaginal bleeding and pregnancy

Acute pain, moderate

Diarrhea and vomiting

Dialysis

Level 4: Less Urgent (Semi-urgent)

- Conditions related to patient age, distress, or potential for deterioration or complications that would

benefit from intervention or reassurance within 1-2 hours

- Time to physician: 1 hour

Head injury

Minor trauma

Abdominal pain

Chest pain

Head act/earache

Suicidal/depressed

Chronic back pain

URI symptoms

Diarrhea and

Vomiting with no signs of dehydration

Level 5: Non urgent

- Investigations or interventions could be delayed or even referred to other areas

- Time to physician: 2 hours

Minor trauma

Sore throat/URI

Vaginal Bleeding (scanty)

Vomiting alone, diarrhea alone

Psychiatric cases


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Triage Coding

Priority Treatment Color

1 Immediate Red

2 Urgent Yellow

3 Delayed Green

4 Expectant Blue

Dead Black

Deaths

1. Clinical – patient has stopped breathing

2. Biological – brain dead

3. Terminal – cancer patients; process of dying

4. Temporary – Death caused by general anesthesia

5. Sudden – reversible death; CP arrest

Causes of Sudden Death

o V-fib – most common in cardiac arrest

o Electrocution

o Drowning/near drowning

o Drug overdose

o Suffocation

o Insect bites

o Falls/trauma

o Stroke

o Respiratory arrest

- Cessation of breathing

- Occurs first followed by cardiac arrest

o Cardiac arrest

- Stoppage of circulation

o Give BLS

Basic Life Support

BLS

- emergency treatment, to a client/victim having respiratory or cardiac arrest, through cardiopulmonary

resuscitation and emergency cardiac care

- Save heart and brain

Goals

- Emergency oxygenation

- Maintain airway patency

- Support breathing

- Support circulation

- No equipment


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Cardio Pulmonary Resuscitation (CPR)

- Combination of rescue breathing (one person breathing into another person) and chest compression in

lifesaving procedure

- Performed when a person has stopped breathing or a person’s heart has stopped breathing

History of Basic Life Support

- Books of Kings II (4:34), wherein the Hebrew prophet Elisha warms a dead boy’s body and “places his

mouth over his”

- Peter Safar – father of CPR; wrote the book of ABC of Resuscitation in 1957

Basic Life Support

- D-Check for Danger

- R-Responsive? If not, shout for help

- A-open Airway

- B-check Breathing. If non, give 2 initial breath

- C-Circulation. If non, compression 30:2

- D-attach Defibrillator; continue CPR

Phone First

- Cardiac

- Adults

- Children at high risk for cardiac arrhythmias

Phone Fast (act now, call later)

- Respiratory

- Children

- Submersion

- Drowning

- Arrest associated with trauma

- Drug overdose

Steps in CPR

1. Check safety

2. Determine responsiveness

o Are you okay? 2x

o If he responds, no need for CPR; keep safe and reassess

o If no response:

Adults: call EMS immediately

Child/Infant: perform 30:2 x 5 cycles, then call EMS

Lay him face up on a firm, flat surface, moving his head and body simultaneously


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Assess for Breathing:

3. Open airway: head tilt, chin lift.

o If you see foreign object in his mouth or throat, remove them

4. Place your face close to his mouth and observe his chest

o Look – for chest movement

o Listen – at the mouth for breath sounds

o Feel – for airflow on your cheek

Within 5-10 seconds

2 Rescue Breaths

5. If breathing normally, turn to recovery position.

o If no breathing, give 2 rescue breaths at 1 second/breath. (Maintain an open airway. Pinch his nose

and give 2 blows into his lungs)

o The victim’s chest should rise with each blow

o If unsuccessful (no chest rise), reposition head and try again

AR Method

o Adult/Child

- Mouth to mouth, nose pinched

- Mouth to barrier device

- Mouth to nose

- Mouth to stoma

o Infant

- Mouth to mouth and nose

6. Next, feel for pulse at the carotid (neck area) up to 10 seconds

- If there is a pulse, perform artificial respiration at the rate of 12 times per minute, until natural

breathing is restored

- If there is no pulse, immediately begin CPR

- Precordial thumb

7. No Pulse: CPR

- Center the heal of one hand at the center of chest, between nipples, keeping your fingers off the

ribs

- Cover this hand with the heel of your other hand

- Arms straight and elbows locked; push down vertically about 4 to 5 cm and then release

- Compress 5 cycles of 30 compression and 2 full vent in 2 minutes (30:2 X 5 x 2 minutes)

- Do not lift your hands off the chest between compressions. Avoid interruptions

- Repeat pulse check after 2 minutes and every 5 cycles thereafter

Chest Compressions

o Infants

- Just below the nipple line within 2 fingers


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- 1/3 to ½ of the depth of the chest

o Child

- Lower half of the sternum, falling at the nipple line using 1 or 2 hands; 1/3 to ½ in depth

o Adults

- Center of the chest at the nipple line

- Both hands, 1 ½ to 2 inches in depth

8. The moment his pulse returns, immediately stop compression and check for breathing

No breathing, With Pulse

- If the victim is not breathing, perform rescue breathing at 12 times/minute (1 breath every 5

seconds) until victim’s natural breathing is restored

- If both pulse and breathing have returned, place victim in the recovery position and maintain an

open airway

- Continue to monitor for both breathing and pulse every few minutes until heap arrives

2 Rescuer CPR

o Adult: 30:2 x 5 cycles x 2min

o Child/Infant: 15:2 x 5 cycles x 2

Ways to Know if CPR is Effective

o Pupils are constricted

o Px has circulation

o Px has respi

o Px has regained consciousness

Problems During CPR

o Gastric Distention

o Lacerations of internal organs

o Punctured lungs

o Fractured ribs or sternum

When BLS Should not Be Started

o Rigor mortis or stiffening of the body

o Putrefaction of decomposition

o Evidence of non-survivable injury

o Existing DNR or no-CPR order

o Alive

When to Stop CPR

o S – patient Starts breathing and has pulse

o T – patient is Transferred to another person or a higher facility


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o O – you Out of strength (exhaustion)

o P – a Physician asks you to stop (beyond resuscitation)

Foreign Body Airway Obstruction

Causes of Foreign Body Obstruction

o Vomited stomach contents

o Blood clots, bone fragments, damaged tissue

o Foreign objectives

o Swelling caused by allergic reactions

o Relaxation of the tongue (during general anesthesia, mouth guard )

General Signs of Choking

o Attack occurs while eating

o Victim may clutch his neck

o 2 types of Choking

o Mild

o Severe

Mild/Partial Obstruction

Signs of mild airway obstruction:

“Are you choking?”

- Victim speaks and answers yes

- Victim is able to speak, cough and breath

o Encourage to continue coughing but do nothing else

o Administer 100% O2

o Continue to check for deterioration or relief of obstruction

Severe Airway Obstruction

“Are you choking?”

Response

o Unable to speak

o May respond by nodding

o Unable to breath

o Breathing sounds wheezy

o Attempts at coughing are silent

o Victim may be unconscious

Severe Airway Obstruction: Conscious Adult

o Abdominal thrust


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o “Heimlich Maneuver” are a series of under-the-diaphragm abdominal thrusts

o Lifts the diaphragm and force enough air from the lungs to create an artificial cough to move and expel the

foreign body.

Abdominal Thrust: Heimlich Maneuver

Step 1: Ask the choking person to stand if he or she is sitting

Step 2: Place yourself slightly behind the standing victim

Step 3: Reassure the victim that you know the Heimlich maneuver and you are willing to help

Step 4: Place your arms around the victim’s waist.

Step 5: Make a fist with one hand and place your thumb toward the victim, just above the umbilicus and below the

Xiphoid process

Step 6: Grab your fist with your other hand

Step 7: Deliver 5 inward and upward thrusts

Step 8: Repeat until the foreign body is expelled or until the victim becomes unconscious

Severe Airway Obstruction: Unconscious Adult

o Place the patient in a supine position

o Straddle the patient’s hips or legs

o Place the heel of one hand against the abdomen

o Press into the patient’s abdomen with quick inward and upward thrust

o Repeat 5 times

Finger Sweep

o Open the mouth with tongue-jaw lift

o Using the index finger, do a hooking action to dislodge the foreign body

o Done only in unconscious patients

o Done only when the foreign body is visible

o Blind finger sweep should not be performed

o Contraindicated with seizure

Advance Cardiac Life Support

Airway

- ET Intubation

- Give a source of air to be effective O2


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Confirm Placement of ET

- CXR

- Auscultate chest while ventilated by ambubag

- (+) Breaths sounds on both lung fields

- (+) chest wall rise

- Auscultate the stomach

Intubation Complication

- Intubating the right main stem bronchus

- Intubating the esophagus

- Aggravating spinal injuries

- Taking too long to ventilate

- Patient vomiting

- Soft tissue trauma

- Mechanical failure

- Patient intolerant of ETT

- Dec in HR

Airway Adjuncts

- Oropharyngeal airway – oral airway

- Guedel pattern airway

- Maintain a patent airway by preventing the tongue from covering the epiglottis

- Inserted upside down

Cricothyrotomy

Breathing

Respiration

- Spontaneous

- Rate, depth, and symmetry

- Breath sounds

- Bag, valve, mask device

- No breathing: Deliver 8-12 breaths/min

- Spontaneous breathing: together with chest rise

O2 Saturation

- Pulse oximetery

- 96-100% at room air

- No not suction when O2 Sat is below 95%

Bag-valve-mask – delivers more than 90% O2 use; 10-15lpm


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Circulation

- Pulses

- Cardiac rhythm and rate

- Blood pressure

- Capillary refill and skin color

- CPR; 100compresssion/min

- IV lines

Types of Solution

Hypotonic Isotonic Hypertonic

Hydrates Cells Stays Put Expands Volume

.45% NaCl, .33% NaCl D5W LR NSS D10W, D5NS, Albumin

Drugs

Cardiac Stimulants

Epinephrine – adrenergic agonist

- Restores electrical activity

- Bronchodilator

- Vasoconstrictor

- No C/I in cardiac arrest or anaphylactic shock

- Can be given via ET

Atropine SO4 – anticholinergic;

- Red hot, dry, blind, mad

Isoproterenol – bradycardia

Cardiac Stimulant

Drug Action Side Effects

AtSo4 IV, ET, PO, IM

Blocks vagal stimulation I: Bradycardia, organophosphate poisoning

Red, hot, dry, blind, mad

Isoproterenol (Isuprel) IV Enhances myocardial contractility I: Bradycardia

Tachycardia, Inc BP

Dopamine HCl – sympathetic agents

- Shock drug

- Enhances force (inotropic) of heart contractions

- Increase rate (chronotropic) of heart contractions

- Renal dose, cardiac dose, vasopressor dose


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Dobutamine

Norepinephrine

- Potent vasoconstrictor

Cardiac Glycosides (Digitalis)

Lanoxin, Digoxin

- CHF, atrial fibrillation

- Slows and strengthens heart beat

- Toxicity

Bradycardia and/or dysrhythmias

Anorexia, nausea and vomiting

Green and yellow vision

Check K levels, PR > 90

Antianginal Drugs:

Nitrates and Nitrites

- Isordil, NTG, Nitrostat

- Vasodilator

- Check for Hypotension and potency

Morphine SO4

- Narcotic analgesic

- Relieves pain, vasodilation

- N and V, hypotension, respiratory depression

- Antidote: Narcan

Drugs Used to Treat Ventricular Dysrhythmias:

Adenosine

Lidocaine HCl

- Watch out for toxicity

Procainamide (Pronestyl)

Amiodarone (Cordarone)

- Watch our for bradycardia, very potent


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Antihypertensives

Central Acting

- Clonidine (Catapres)

- Methyldopa (Aldomet)

Alpha Adrenergic Blockers – zosins

- Prazosin, Terazosin

B Adrenergic Blockers - olols

- Propanolol (Inderal), Atenolol

Ca Channel Blockers: Nifedipine, Verapamil, Diltiazem (Slows down conduction, vasodulating effect)

ACE inhibitors – Prils, Captopril, Enalapril, Fosipril

Other Drugs

Diuretics – inhibits sodium reabsorption

- Edema, CHF, mild hypertension

- Hypotension, MIO, weight, serum electrolytes

Anticoagulants – prevent further formation of blood clots

- Heparin, Coumadin, warfarin

- Bleeding

Thrombolytics – dissolve clots

- Alteplase (tPA), Streptokinase, Urokinase

Must be given within 6 hours of infarct

Followed by heparin therapy

- Bleeding

Antihistamines – blocks histamine effects in allergic reactions

- Sedative, inhibits motion sickness

- Diphenhydramine, chlorphenamine

Antidotes

- Naloxone, Flumazenil, AtSO4, activated charcoal

Steroids

- Anti-inflammatory, diminishes severity of allergic and inflammatory reactions


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Antacids

- NaHCO3

- Watch for extravasation

Bronchodilators – as nebulizers; Albuterol, Salbutamols

Electrocardiography

- Records the electrical conduction of the heart

- Does not assess the contractility of the heart

- 12 tracings I, II, III, aVR, aVL, aVF, V1, V2, V3, V4, V5, V6

Lead Placement

- May be placed in the shoulder or groin in case of amputation or cast

Limb Leads

Right Arms: Read Right Leg: Black Left Arm: Yellow Left Leg: Green

Precordial Leads

C1 – 4th ICS right sternal borders

C2 – 4th ICS left sternal border

C3 – midway between C2 and C4

C4 – 5th ICs MCL or below the nipple

C5 – in line with C4, anterior axillary line

C6 – in line with C4, mid axillary line

Nursing Responsibilities

- Explain the procedure

- Provide privacy and assist in draping hte client

- Remove all metals from the client’s body

- Attach the leads and apply conduction gel

- Operate the machine according to the manufacturer’s instructions

- Remove the lead and wipe off the gel

- Label the strip. Date, time, client’s name, age and sex

- Report the result immediately


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The Normal ECG

1. normal sinus rhythm 2. Atrial Flutter: the atria are contracting rapidly about 300 bpm, and the ventricles are responding to every

third or fourth impulse 3. Premature Ventricular Contraction 4. Ventricular Tachycardia – R wave, QRS wave 5. Ventricular Fibrillation 6. Ventricular Asystole (Standstill)

HR absent

Rhythm absent

P wave Absent or present

PR interval absent

Atrial Flutter

- The atria are contracting rapidly at about 300bpm, and the ventricles are responding every third or fourth

impulse

Premature Ventricular Contraction

Ventricular Tachycardia

Ventricular Fibrillation

Ventricular Asystole (P-wave may be present)


- Dysrhythmia in cardiac arrest

- Heart quivers and does not beat

- No cardiac output, no pulse

- Converts to Asystole in a few minutes

- Clinical death

Defibrillation

- Stop the fibrillation

- An asynchronous countershock used to stop pulseless V tack or VF

- Convert VF to an effective rhythm


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Rationale for Early Defibrillation

- Third link in the chain of survival

- Within 2 minutes

- Success probability decreases over time

- Precordial thump

Non-Shockable Rhythms

- Asystole

- PEA (Premature Electrical Activity)

Fibrillation Treatment

- Process in which an electronic devise gives an electric shock to the heart

- Helps re-establish normal contraction rhythms

Procedure

- Apply gel to hand-held paddles or used electrode pads

- Turn on machine and choose appropriate energy level

- Charge the capacitor

- Position paddles/electrodes

- Apply firm pressure (25lbs) to hand held devices

- Clear the area

Defibrillators

Monophasic

- The CPR algorithm recommends single socks started at and repeated at 360J

Biphasic

- The CPR attachment algorithm recommends shocks initially of 150-200J and subsequent shocks of 150-360J

Automated External Defibrillator (AED)

AEDs come in two forms

- Automated

- Semiautomated

A specialized computer recognizes heart rhythms that require defibrillator

W – no Water

I – no Internal pacemaker

P – Patches; removed


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E – Eight years and below, no defib

Cardioversion

- Organized rhythms

- Delivery of a therapeutic dose of electrical current to the heart at a specific moment in the cardiac cycle

- A synchronized countershock to convert an undesirable rhythm to a stable rhythm

- Lowe amount of energy is used

- Synchronized with the R-waves

- Informed consent is needed and client is sedated

What things should I do after Cardioversion/Defibrillation

- Monitor the patient carefully – ABCs, V/S, LOC

- Keep the patient well oxygenated

- Check up on your patient’s lab studies...K+, Magnesium, CPK, Troponin

- Get a 12 lead after the Cardioversion for documentation

- Assess the patient’s skin for evidence of burns

Advance Cardiac Life Support

Critical Care

Prolonged life support

Goal: Cerebral Resuscitation and post resuscitation intensive therapy (providing mechanical ventilation

G – Gauging: determine cause of the disease (specific biologic crisis)

H – Human mentation: cerebral resuscitation (brain damage)

I – Intensive Care: Multiple organ support

Intensive Care

- Provision of life support or organ support systems in patients who re critically ill and who usually require

intensive monitoring

- Condition is potentially reversible and who have a god chance of surviving with intensive are support

- System by system approach to treatment

CV, CNS,ENDO, GIT (and nutritional condition), hematology, microbiology (including sepsis

status), peripheries (and skin), renal (and metabolic), respiratory system

Critical Care Nursing

- Deals specifically with human responses to life-threatening problems

- Patient advocate

- CCU nurses are responsible for ensuring that acutely and critically ill patients and their families receive

optimal care

- Frequent assessment, monitoring, rapid intervention, access to technology


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Goals

- Pursue continuous optimal nursing care to patients in life threatening situations

- Remain alert to the physiologic, Psychologic and social needs of the patient as an integrated being

- intensive Care Unit (ICU) or critical care unit (CCU) - coronary care unit (CCU) for heart disease - medical intensive care unit (MICU) - Surgical intensive care unit (SICU) - Pediatric intensive care unit (NCCU)

Equipments and Systems

Patient monitoring equipment

- Acute care physiologic monitoring system

- Pulse oximeter

- Intracranial pressure monitor

- Apnea monitor

Life Support and Emergency resuscitative equipment

- Ventilator (also called a respirator)

- Infusion pump

- Crash cart

- Intra-aortic balloon pump

Diagnostic Devices

- Mobile x-ray units

- Point of care analyzers

Other ICU Equipment

- Urinary (Foley Catheters)

- Catheters used for arterial ad central venous lines

- Swan-Ganz catheters

- Chest and endotracheal tubes

- GI and NG feeding tubes

- Monitoring electrodes

Basic Trauma Life Support

A – Airway and C-Spine control

B – breathing; chest injury


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C – Circulation; no pulse, CPR; control hemorrhage, immobilize

D – Disability; neuro assessment: AVPU (LOC), GCS V/S

E – Expose, environment control

F – Foley Cath

Trauma Assessment DCAPBTLS

Bleeding

- Hemorrhage

- Average adult has 5L of circulating blood

- Body cannot tolerate greater than 20% blood loss

- Blood loss of 1l can be dangerous in adults; in children, loss of 100-200mL is serious

Safety

- Universal and standards precautions

- Wear gloves and eye protection in all situations

- Avoid direct contact with body fluids

- Thorough hand washing between patient is important

Controlling External Bleeding

- Direct pressure (10 minutes) and elevation

- Ice

- Pressure bandage

- Indirect pressure (pressure points)

- Pneumatic Anti-shock garment (PASG)

- Splints/air splint

- tourniquet

PASG

- An inflatable garment that surround the legs and torso and can generate up to around 100mmHg of

pressure

- Controls significant internal bleeding by placing pressure on the abdomen

- Controls massive soft-tissue bleeding of the lower extremities

- Increases blood flow to vital organs

- May effectively increase the blood pressure

Tourniquet Precautions

- Place as close to injury as possible, but not over the joint

- Never use a narrow material. Mark the area with a letter T

- Use wide padding under the tourniquet

- Never cover a tourniquet with a bandage


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- Do not loosen the tourniquet once applied

- Rotate the site every 2 hours

Open Wounds

- Control hemorrhage; immobilize injured area

- Check dressing every few minutes; if soaked with blood, do not remove, apply another dressing on top of it

and reapply pressure

- Irrigate the wound with scope and water or saline solution

- Impaled objects: do not remove; stabilize object with a bulky dressing

- Butterfly enclosures

- Sutures and ligation of bleeders

Controlling a Nosebleed

- Help the patient sit and lean forward

- Pinching the nostrils together

- Place a rolled gauze under the upper lip and gum; and press with your fingers

- Cold compress over the nose nad face

- Nasal packing with epinephrine

Internal Bleeding

- May not be readily apparent

- Causes

Blunt trauma

Penetrating trauma

Fractures

- Assess for:

Signs and symptoms

Mechanism of injury

S/Sx of Internal Bleeding

- Ecchymosis

- Hematoma

- Hemoptysis

- Hematemesis

- Hematochezia

- Melena

- Hematuria

- Pain, tenderness, bruising, or swelling

- Broken ribs; bruises over the lower chest; shallow rapid respiration

- Rigid, distended abdomen, guarding


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First Aid

- Prioritize

Chest cavity

Abdominal cavity

Pelvic cavity (2-8 units)

Femoral area (2-8 units)

- EMS

- ABCDs

- Treat for shock

Soft Tissue Injuries

- Close injuries

Soft tissue damage beneath the skin

- Open injuries

Break in the surface of the skin

- Burn

Soft tissue receives more energy than it can absorb

- Amputations

Contusion

- Results from blunt force striking the body

- Epidermis is intact, dermis damage and blood vessels are torn

Hematoma

- Pool of blood collected beneath the skin

- Tearing of large blood vessels

Abrasions

- Caused by rubbing, scraping or shearing

Laceration

- Smooth or jagged cut, irregular edges

Avulsion

- Tearing loos of a flap of skin

Penetrating Wound

- Penetration from a sharp pointed object


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Gunshot Wound

Crushing Open Wound

- May involve damage internal organs or broken wounds

Amputation

- Loss of a body part

Traumatic Emergencies

- Trauma assessment DCAPBTLS Mechanism of injury Loss of consciousness Vomiting Current symptoms Intake of drugs or alcohol

Tissue Perfusion

- The heart demands a constant supply of blood - The brain and spinal cord can survive for 4-6 minutes without perfusion - The kidneys may survive 45 - Skeletal muscles may last 2 hours

Normal Perfusion requires 3 intact mechanisms

1. A functioning PUMP: the heart 2. Adequate VOLUME: the blood and the plasma 3. An INTACT VASCULAR SYSTEM: blood vessels are able to constrict and dilate

Shock

- A state of collapse and failure of the CVS due to the inadequate tissue perfusion and less oxygenation Leads to inadequate circulation Without adequate blood flow, cells cannot get rid of metabolic wastes

- Not a disease in itself, but a secondary cause

“Death is a severe stage of shock, or shock is a pause in the act of dying”

Phases of Shock

I. Compensated shock - The preservation of vital organ function: body uses normal defense mechanism to maintain normal function

Signs and Symptoms

- Restlessness, agitation, confusion


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- Slightly increased respiratory rate - Slightly increase heart rate - Normal BP slightly decreased capillary refill - Oliguria - Pallor, cold, clammy, skin/warm and flushed

II. Uncompensated Shock - Vital organ function is impaired and clinical deterioration professes; blood is shunted away from extremities

and abdomen towards the heart, brain and lungs

Signs and Symptoms

- Decreasing LOC (Stuporous, unconscious) - Dilated sluggish pupils - Rapid breathing; shallow, irregular respirations - Rapid heart rate; weak, ready pulse - Hypotension - Anuria - Clod, clammy, cyanic - Metabolic acidosis

III. Irreversible Shock - Terminal, irreversible changes to vital organs - Blood is shunted from the liver and kidneys to heart and brain - Organs die - Death

Signs and Symptoms - Bradycardia - Bradypnea - Mottled skin - Coma

Classification of Shock

1. Hypovolemic Shock - An absolute reduction in circulating volume

2. Cardiogenic - Reduction in cardiac output secondary to pump failure

3. Distributive - An increase in the volume of the circulatory system (vasodilation)

Septic/Anaphylactic/Neurogenic 4. Obstructive

- Resistance to the flow (respi insufficiency) 5. Psychogenic –

- psychological 6. Metabolic

Management of Shock

- Maintain airway - Oxygen - Positioning – shock position


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- Control bleeding - Splint fractures - Keep warm - Keep safe - NPO - Monitor V/S - Monitor Output - Trendelenburg

Medical Mgt

- Establish proper airway - Hydration (IVF: NSS, PLR) - Drugs

Dopamine NaHCO3

- BT - Correct cause of shock - Foley catheter

Anaphylactic Shock

- Administer Epi, Diphenhydramine, corticosteroids - Provide all possible support

O2 Ventilatory assistance

Psychogenic Shock

- Usually self-resolving - Assess patient for injuries from fall - Anxiety attack

Eye Injuries

- Considered as an emergency - Foreign objects

Victim to blink several times Irrigates with saline

- Lacerations Never exert pressure on or manipulate eye Cover with protective metal eye shield

- Burns Flush for 20 minutes Remove contact lenses

Injuries to the Face

- Injuries about the face can lead to upper airway obstructions Bleeding, loose teeth

- Clear airway - Immobilize fracture - Control bleeding


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- Monitor airway constantly - Blunt trauma to the nose can result in fractures and soft-tissue injuries

Neck Injuries

- An open neck injury can be life threatening - Air can get into the vein and cause an air embolism

Cover the wound with an occlusive dressing Apply manual pressure

- Subcutaneous emphysema Protect airway

Chest Wounds

- A penetrating wound to the chest may cause air to enter the chest - Air enters through a hole causing the lungs to collapse in a few seconds or minutes - Sucking chest wound

Rib Fractures

- Rib fractures – may lacerate surface of the lungs; common in the elderly - Flail chest

Three or more fractured ribs Sternum in fractures along with several ribs Creates paradoxical movement Immobilize flail segment with a pad of dressing or a small pillow; secure with a wide tape Do not ever place anything completely around the chest!

Pneumothorax

- Spontaneous Pneumothorax Weak areas in the surface of the lungs and rupture spontaneously

- Tension pneumothorax Can occur from sealing all four sides of the dressing on a sucking chest wound Can also occur from a fractured rib puncturing the lung or bronchus Can also result from a spontaneous pneumothorax Let air escape by inserting a needle

Cardiac Tamponade

- Collection of blood or other fluids in the pericardium - Causes

Stab wounds Blunt chest trauma Recent cardiac catheterization

- S/Sx Rapid, thready pulse Hypotension JVD Muffled heart sounds

- Treatment Ensure open airway


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O2 IV line Pericardiocentesis CPR

Abdominal Wounds

- An open wound in the abdomen may expose organs - An organ protruding through the abdomen is a called an evisceration

Abdominal Wound Management

- Do not touch exposed organs - Cover organs with a most sterile dressing - Manage for shock - Prepare for surgery

Blunt Abdominal Wounds

- Severe bruises of the abdominal wall - Laceration of the liver and spleen - Rupture of the intestine - Tears in the mesentery - Rupture or tearing of the kidneys (hematuria) - Rupture of the bladder - Sever intra-abdominal hemorrhage - Peritonitis

Assessment

- Tenderness - Rebound tenderness - Guarding - Rigidity - Distention - Pain

Management

- Prevent shock - Control bleeding - Positioning - NPO

Injuries to the Genitalia

- Male Painful by not life-threatening Cut off zipper fastener and separate teeth Ice or cold compress

- Female Extreme pain, bleeding


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Straddle injuries, sexual assault, blows to the perineum or abortion attempt, childbirth, or when foreign objects are inserted into the vagina

Direct pressure, moist compress (bleeding) Ice packs or cold compress (pain, swelling) Sexual assault, preserve chain of evidence

Skull Fracture

- Indicates significant force - Signs

Obvious deformity Visible crack in the skull Raccoon eyes – Periorbital ecchymoses Battles sign – ecchymosis behind the ears Basal skull fracture

- Signs and Symptoms Lacerations, contusions, hematomas to scalp Soft areas or depression upon palpation Visible skull fractures or deformities Ecchymosis around eyes and behind the ear Clear or pink CSF leakage Unequal pupils Cerebral edema Period of unconsciousness, amnesia, seizures Numbness or tingling in the extremities Irregular respirations Dizziness Visual complaints Combative or abnormal behavior Nausea and vomiting

- Bleeding from Skull Fracture Do not attempt to stop the blood flow Loosely cover bleeding site with sterile gauze Leakage of clear fluid from ears or nose If cerebrospinal fluid is present, a target sign will be apparent

Head Injuries

- The most important sign in evaluating head injury is a changing state ofconsciousness - A head-injured patient has a cervical spine injury until proven otherwise - Shock means injury elsewhere

Cerebral Concussion

- Brain is jarred around the skull - Mild, diffuse brain injury transient dysfunction of the cerebral cortex - Resolved rapidly and spontaneously - No structural damage or permanent neuro impairment


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- S/Sx – transient confusion and disorientation (lasts several minutes), with or without loss of consciousness, retrograde amnesia or anterograde amnesia

Cerebral Contusion

- Brain tissue is bruised and damaged in a local area - Physical damage/injury to the brain causes greater neurologic deficits - Swelling of injured tissue leads to increase ICP

Coup-contrecoup

- Acceleration-deceleration injury - Head comes to a sudden stop, but brain continues to move back and forth inside the skull, resulting in

massive injury - Two sites of injury

Point of impact Point on the opposite side when the head hits the skull

Brain Injury

- Increase blood flow (vasodilation) - Leakage of blood and plasma to the affected area (bleeding)

Decreased brain perfusion CO2 build-up in brain tissue vasodilation

- Increase pressure in the skull - Brain tissues become compressed and stop functioning - Decreased blood flow to the brain as pressure increases - Brain stem is compressed due to swelling - Heart, breathing and blood pressure fails

Complications of Head Injuries

- Cerebral Edema - Convulsions and seizures - Vomiting - Leakage of CSF

***Check for increase ICP

Increased Intracranial Pressure

- Increased BP (Systolic) - Widening of pulse pressure - Decreased Pulse (bradycardia) - Abnormal respiration - Increased temp - Vomiting

Shock (Hemorrhage Elsewhere)

- Decreased BP - Narrowing of pulse pressure - Increased Pulse (tachycardia)


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- Increased Respiratory Rate

First Aid

- Immediate medical attention - Support victim until medical help arrives - Stabilize head and neck - ABCD - Prevent aspiration - Treat for shock - Do not elevate legs

Interventions

- Manage airway and breathing - Circulation - Medications

Dexamethasone Mannitol Furosemide

- Positioning - Do not allow patient to become overheated; keep cool - Craniotomy

Spinal Cord Injury

- Anything below the level of damage cord is affected - Suspect in

Vehicular trauma Falls from a height Diving accidents Cave-ins With head or facial injuries Lightning injuries Any unconscious victim of trauma

Complications

- Inadequate breathing Respiratory paralysis Chest wall muscles are paralyzed Diaphragm continues to function

- Paralysis Weakness, loss of sensation or paralysis below level of injury Paralysis of arms or legs – most reliable sign

S/Sx

- Pain and tenderness of spine - Deformity of spine - Numbness and paresthesias - Loss of sensations - Incontinence


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- Injuries to the head - Diaphragmatic breathing

Management

- Ensure open Airway (jaw thrust); suction - Assist breathing - Support circulation – stop bleeding, IV - Immobilization (cervical collar, backboard) - Keep warm - V/S, neurologic status

Types of Musculoskeletal Injuries

- Fractures – broken bone - Dislocation – disruption of a joint - Sprain – joint injury with tearing of ligaments - Strain – stretching or tearing of a muscle

Management of Fractures

- Assessment – ABC, DCAPBTLS - Immobilization by splinting or casting - Be alert compartment syndrome

Permanent damage in 6-8 hours - Check neurovascular status

Pulse Capillary refill Sensation Motor function

Common Medical Emergencies

Airway Problems

- Upper airway obstructions - COPD - Atelectasis - Consolidation - Fluid (Pulmonary Edema)

Management of Airway Problems

- Airway – maintain patency Assist ventilations with BVM Protect by endotracheal intubation Suction secretions Remove foreign bodies (Heimlich) tracheostomy

- Oxygen - Establish IV line - Drugs - Chest Tubes


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Acute Myocardial Infarction (AMI)

- Pain signals death of cells - Opening the coronary artery within the first hour can prevent damage

S/Sx

- Severe, crushing chest pain (Levine’s sign) - Cold, clammy skin - Feeling of impending doom - Apprehension anxiety - Sudden death - Pulmonary edema

Treatment

- Oxygen - IV line - Bed rest; semi fowlers - Cardiac monitor - I and O - Drugs – vasodilators, hemolytics (<6 hours), analgesics, anti-arrhythmics, anticoagulants, stool softeners

Cardiac Arrest


Aim: To convert to an effective rhythm

- Defibrillate - Intubation - Oxygen - IV line, fluids - Drugs – lidocaine

Asystole

Aim: To convert to an effective rhythm or to VF

- Start CPR - Intubation - Oxygen - IV line, fluids - Drugs – Epi, AtSO4 - Defibrillate if in V Fib

Cerebrovascular Accident (CVA or Stroke)

- Hemorrhagic – arterial rupture High blood pressure is a risk factor Rapid onset

- Ischemic – blockage, occlusion of blood supply Thrombosis Embolus


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- Stroke symptoms typically develop rapidly (seconds to minutes) - Symptoms are related to the anatomical location of the damage

Ischemic strokes: affect regional areas of the brain perfused by the blocked artery Hemorrhagic strokes: affect local areas, but often can also cause more global symptoms

due to bleeding and increased ICP - History, neurological examination, and presence of risk factors

General S/Sx of Stroke

- Sudden numbness or weakness of the face, arm or leg, especially on one side of the body. Sometimes weakness in the muscles of the face can cause drooling

- Sudden confusion or trouble speaking or understanding - Sudden trouble seeing in one or both eyes - Sudden trouble waking, dizziness, loss of balance or coordination - Sudden, severe headache with no known cause

Central Nervous System Pathways

- If the area of the brain affected contains of the three prominent CNS pathways – the spinothalamic tract, corticospinal tract, and dorsal column (medial lemniscus), symptoms may include:

Hemiplegia and muscle weakness of the face Numbness Reduction in sensory or vibratory sensation

Brain Stem

Brain Stem also consists of the 12 cranial nerves

- Altered smell, taste, hearing, or vision (total or partial) - Drooping of eyelid (ptosis) and weakness of ocular muscles - Decreased reflexes: gag, swallow, pupil reactivity to light - Decreased sensation and muscle weakness of the face - Balance problems and Nystagmus - Altered breathing and heart rate - Weakness in sternocleidomastoid muscle with inability to turn head to one side - Weakness in tongue in tongue (inability to protrude and/or move from side to side)

Cerebral Cortex

If the cerebral cortex is involved, the CNS pathways can again be affected, but also can produce the following symptoms

- Aphasia – inability to speak or understand spoken language (Broca’s) - Apraxia – altered voluntary movements - Visual field defect - Memory deficits (temporal lobe – memory) - Hemineglect - Disorganized thinking, confusion, hypersexual gestures - Anosognosia – persistent denial of the existence of a usually stroke related deficit

Cerebellum

- Trouble walking


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- Altered movement coordination - Vertigo and/or disequilibrium

Hemorrhagic Stroke (Inc ICP)

- Loss of consciousness - Headache - Vomiting

Emergency Care for Stroke

- Patent airway, O2 - IV line - Drugs

Treat within 3 hours for thrombolytic drugs Antiplatelet, anticoagulants Antihypertensives Osmotic diuretics

- Protect paralyzed extremities - CR Scan, MRI - Surgery to remove blood - Supportive care – physiotherapy, occupational therapy

Seizures

- Generalized (Grand Mal) - last 2-5 minutes - Petit mal seizure – blank state, few seconds - Status Epilepticus – sing seizure more than 5 minutes or series of seizures without regaining consciousness

Brain deprived of oxygen - Goal: support victim, prevent injury

Emergency Care

- Airway (turn to side) - O2 - Assess for duration - Do not restrain - NPO - IV line - Drugs: Diazepam, phenytoin, phenobarbital

Diabetes Mellitus

Hyperglycemia – diabetic coma

- Lack of insulin causes glucose to build-up in blood in extremely high levels - Diabetic ketoacidosis (DKA)

Hyperglycemia – insulin shock

- Excess insulin


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First Aid

- When in doubt, give sugar - Look for medical alert tag - Hyperglycemia

EMS ABC Rule out other emergencies

- Hypoglycemia – death in a few minutes EMS Administer sugar if responsive ABC, NPO, and lateral recumbent if unresponsive

Common Environmental Emergencies

- Normal body temperature is 98.6F - Body cools itself by sweating (evaporation) and dilatation of blood vessels - High temperature and humidity decrease effectiveness of cooling mechanisms

Heat Stroke

***Sweating mechanisms fails; body overheats; profound emergency

***Peripheral vasodilation; Neurogenic shock

- No cramping - Headache, dizziness, impaired thinking; stupor, coma, seizure - Hot flushed skin - Hyperthermia - Rapid, bounding pulse - Hypertension, early stage, then drops

Care for Heat Stroke

- Move patient out of the hot environment - ABCD, O2 - Keep the patient cool

Remove the patient’s clothing Provide air conditioning at a high setting Apply cold packs to the patient’s neck, armpits, and groin Cover the patients with wet towels or sheets Aggressively fan the patient

- IV line KVO - Cardiac monitor - Treat seizures

Hypothermia

- Lowering of the body temperature below 95F (35C) - Elderly persons and infants are at higher risk - People with other disabilities with other illnesses and injuries are susceptible to hypothermia


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S/Sx

Mild

- Conscious, apathetic, lethargic - Shivering - Rapid pulse and respirations - Pale, cyanotic skin, cold to touch - May have acetone odor to breath

Severe

- Unconscious or stuporous - Shivering stops - Weak or absent V/S - Muscular activity decreases - Fine muscle activity ceases - Eventually, all muscle activity tops - Pupils unreactive

Hypothermic Patient is Not Dead, until he is Warm and Dead

Frost Bite

- Freezing of a body part; ears, nose hands and feet

Emergency Care

- Remove patient from cold environment - Remove wet clothing, cover with blankets - Passive rewarming

Immerse the frostbitten extremity at 37.7-40.6G. Gently Dry - Recumbent position, do not elevate legs - Very gentle handling – VF - Give warm, humidified oxygen; assist ventilations prn - Sugar and sweets, warm fluid - Assess pulse for 30-45 seconds before considering CPR

Frostbite Don’ts

1. Don’t rub snow in a frostbitten part 2. Don’t massage or rub the area 3. Don’t use dry or radiant heat for rewarming 4. Don’t rupture blisters 5. Don’t apply ointments to frostbitten skin 6. Don’t apply tight bandages 7. Don’t allow a thawed extremity to refreeze 8. Don’t handle a frostbitten extremity roughly 9. Don’t allow the patient to smoke, eat, or use any stimulants

Drowning and Near Drowning

- Drowning Death as a result of suffocation after submersion in water


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- Near Drowning Survival, at least temporarily, after suffocation in water

***Freshwater

***Saltwater

Emergency Medical Care

- Do not enter the water to save a drowning victim if you are not a qualified swimmer - Begin rescue breathing as soon as possible, even before victim is removed from the water - Continue AR and remove victim from water - Maintain cervical spine stabilization - If air does not enter the patient’s lungs, treat for obstructed airway - Check pulse and start CPR if needed; intubate and administer O2 - IV line, drugs (bicarbonate)

Poisoning

- Ingested – treat for shock - Inhaled – move to fresh air immediately - Absorbed – remove from patient as rapidly as possible - Injected – impossible to remove or dilute once injected

Stings or bite

Ingested Position

- Poison Control Center – PGH, IDH - EMS - ABCDs - Left side-lying - NPO (except acid or alkali) - Never induce vomiting until told to do so - Send samples - Kerosene ingestion – pneumonitis

Identifying Patient and the Poison

If you suspect poisoning, ask the patient the following poison

- What substance did you take? - When did you take it or (become exposed to i)? - How much did you get? - What actions have been taken? - How much do you weigh?

Food Poisoning

- Ingestion of food that contains bacteria, toxins or chemicals - Salmonella bacterium causes severe GI symptoms within 72 hours - Staphylococcus is a common bacteria that grows in foods kept too long - Botulism often results from improperly canned foods - Dehydration, shock. Rehydrate


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Drugs and Alcohol

- Aspirin – acid N/V, hyperventilation, tinnitus, confusion, seizures, coma, fever, sweating Induce vomiting; inactivated charcoal; NaHCO3

- Acetaminophen Generally not very toxic Liver failure might not be apparent after a full week

- CNS depressants – alcohols, narcotics Main concern is respiratory depression Airway clearance and ventilatory support

- Stimulants – cocaine, metamphetamines Cardiac arrhythmias, seizures Violent, burn out and crash

Inhaled Poisons

- Carbon monoxide – tasteless, colorless, odourless; mild drowsiness to coma Formed by incomplete combustion of gasoline, coal, kerosene, plastic, wood and natural

gas - Freons – cardiotoxic - Glue – similar to alcohol intoxications

First Aid

- Move to fresh air immediately (150ft) - ABCD’s

Absorbed-Cholinergic Agents

- Nerve agents for warfare - Overstimulates parasympathetic nervous system - Me be treated as a HazMat incident - Ingested – wild mushrooms, organophosphate insecticides - Inhaled – sarin gas

First Aid

- Avoid exposure; wear gloves - Decontaminate - Decrease the secretions in the mouth and trachea - Provide airway support - Atropine sulfate

Insect Bites and Stings

- Anaphylactic reactions to stings Histamine is a potent arterial dilator

- Death from insect stings outnumber those from snakebites - Venom is injected through stinging organ - Some insects and ants can sting repeatedly


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Assess

- Respiratory system Bronchospasm and wheezing, dyspnea Chest tightness and coughing

- Circulatory system Hypotension

- Mental status Anxiety

- Skin Swelling of the lips and tongue Itching and burning Widespread urticaria

- Muscle Spasms, cramps

General First Aid

- Standard airway procedures - Give oxygen - History of allergies - Baseline vital signs - Epinephrine, steroids

Snake Bites

- Minimize all activity. Do not let the victim walk - Clean wound with soap and water; splint - Maintain extremity at heart level, do not elevate - Apply cool compresses, not ice - Australian wrap - Transport - Oxygen, monitor, IV - Watch, constrictive bands, bandages, splints, are carefully for vascular compromise secondary to edema

Snakebite Management

Do NOT

- Apply ice - Apply arterial tourniquet - Cut and suck - Use electrical shock - Actively attempt to locate a venomous snake - Bring a live venomous snake to the hospital

Spiders

- Neurotoxin (muscle spasms) - Local necrosis

Bee Stings

- Anaphylactic reactions in some


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- Remove stinger by scraping it out - Cold compress or ice - Diphenhydramine, H2 Blockers, Epi - Research has shown that the best course of action is to pull the stinger out as soon as possible with your

fingers - The remaining venom in the sac of the stinger does not increase the reaction should you inadvertently push

more venom into your wound

Scorpion Stings

- Allergic reactions same with bees - “the bigger, the better, the small ones, don’t keep it to yourself” - Ice at the bite site and elevation - Muscles spasms may occur in severe cases - Calcium Gluconate, bed rest and NPO for the first 24 hours - Anti-venom is available for severe reaction but rarely needed. Do not skin test

Coelenterate

- Nematocysts – venom glands - Functions even when separated - Sea water, vinegar, baking soda deactivates the toxin - Irrigate with hot water/soak for 30 minutes

Emergency Care for Severe Burns

- Move the patient away from the burning area - ABCDs, O2 - Immerse the affected area in cool sterile water or saline solution for 10minutes - Gently remove any rings, watches, belts or constricting clothing from the injured area before it starts to

swell - Cover with a cool, wet dressing - Prevent body heat loss - Rapidly estimate burn severity - Check for traumatic injuries - Cover the injured area with clean, preferably sterile, non-fluffy material - A burnt face may be covered with a gauze mask, with holes cut into it to assist the victims in breathing - Do not break blisters or remove anything that is sticking to a burn - Do not apply lotions, ointments or fat to the injured area - Call EMS for severe burns - Treat the patient for shock, IVF - Silver nitrate, flammazine - Tetanus

curative and rehabilitative nursing care management of clients in acute biologic crisis

Documents

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