emergency nursing

EMERGENCY EMERGENCY NURSING NURSING

AND AND DISASTER NURSINGDISASTER NURSING

GILBERT T. SALACUP RN,MSNGILBERT T. SALACUP RN,MSN

Emergency Action PrinciplesUse to get an accident situation under control quickly.

Survey the sceneCALL 911/ EMERGENCY RESPONSE TEAM

Do a primary survey A-- AIR WAYB-- BREATHINGC-- CIRCULATIOND-- DISABILITYE-- EXPOSUREH-- HEMORRHAGE S-- SPINALCORD INJURY

GILBERT T. SALACUP RN,MSN

AIRWAY: IS IT OPEN? MINIMIZE NECK MOVEMENTS MUCH AS

POSSIBLE; APPLY CERVICAL COLLAR IF AVAILABLE.

2 WAYS IN OPENING THE AIRWAY

**HEAD TILT – CHIN LIFT MANEUVER **JAW THRUST MANEUVER

BREATHING: IS THE VICTIM BREATHING? CHECK ( 3 – 5 SEC.) L ---- LOOK, L ---- LISTEN, F ---- FEEL.


CIRCULATIONIS THERE A PALPABLE CAROTID PULSE

FOR ADULT AND BRACHIAL PULSE FOR CHILD AND INFANT. CHECK ( 10 SEC. )

DISABILITY IS THERE INJURY TO THE NERVOUS AND MUSCULOSKELETAL SYSTEMS? STABILIZE

“C”- SPINE.


EXPOSURE: REMOVE VICTIM FROM OFFENDING ENVIRONMENT. IF NECESSARY, PLACE TENT OVER VICTIM.

HEMORRHAGE : LOOK FOR SEVERE BLOOD LOSS, CSF LEAK.

SPINALCORD INJURY : CHECK FOR THE SENSORY RESPONSE, AND OBVIOUS DEFORMITY ON THE SPINE.


TriageTriage Categories of severityCategories of severity

BlackBlack / / ExpectantExpectant –Last priority**Dead person

RedRed / / ImmediateImmediate

**first priority**"**first priority**"cannot wait"cannot wait"


YELLOW / OBSERVATION

**2ND PRIORITY**THEIR CONDITION IS STABLE FOR THE MOMENT

BUT REQUIRES WATCHING.

GREEN / WAIT (WALKING WOUNDED)**3RD PRIORITY**

REQUIRE A DOCTOR'S

WHITE / DISMISS (WALKING WOUNDED)*4RTH PRIORITY*

DOCTOR'S CARE IS NOT REQUIRED


RED A - irway Compromise, E - clampsiaI - mmediate Chest wounds,O - pen fractures, U –n Severe shock, 2-3 burns Ca - rdiac arrest, S - pine injury cervical, M -ultiple system trauma, A - ltered level of consciousness


YELLOW

S - table abdominal woundE - ye C - NS injuries

GREEN M - inor burnsM- inor fracturesM-inor bleeding

BLACK U - nresponsiveH - igh spinal cord injury

Shock is a critical physical condition due to failure of the circulatory

system to maintain adequate blood flow in the body and

ceases the delivery of oxygen and nutrients to vital organs.

BASIC CAUSES OF SHOCK

. Pump-failure Relative Hypovolemia . Hypovolemia

GILBERT T. SALACUP , RNGILBERT T. SALACUP , RN


THREE STAGES OF SHOCK THE COMPENSATORY STAGE OF SHOCK BP normal limits. shunted from the kidney, skin

and GIT to the vital organs- brain, liver. PROGRESSIVE STAGE OF SHOCK regulate blood pressure can no longer

compensate and the mean arterial The overworked heart becomes dysfunctional.

IRREVERSIBLE STAGE OF SHOCK there is severe organ damage that patients do not

respond anymore to treatment. Survival is almost impossible


TYPES OF SHOCK

1. CARDIOGENIC – HEART STOP TO PUMP DUE TO HEART DSE.

2. ANAPHYLACTIC --- SEVERE ALLERGIC REACTION

3. HYPOVOLEMIC --- SEVERE FLUID LOSS

4. PSYCHOGENIC --- CAUSE BY ANXIETY, FEARS, ALTERED ADAPTATION IN TRAUMATIC EXPERIENCE

5. NEUROGENIC --- CAUSE BY SPINAL FRACTURE OR DISLOCATION

6. METABOLIC --- LOSS OF BODY FLUIDS

7. RESPIRATORY ---- AIR WAY OBSTRUCTION AND HYPERVENTILATION

8. SEPTIC --- SEVERE BACTERIAL INFECTION


SIGNS AND SYMPTOMS

1.Early Stage: Pa- llor/cyanosis, Co- ld/clammy skin,Sha- llow and irregular breathing, Ra- pid and weak pulse,Dilated pupil.N - /V, Thirst,

2. Late Stage: V - acant eye, A - pathetic/unresponsive, De - creased blood pressure, De - creased temperature.MO - ttled appearance,


TRIAD SYMPTOMS OF SHOCK Hypo - tension; Tachy - cardia Tachy - pnea

Co - nsciousness Altered Nsg Dx: FLD VOLUME DEFICIT r/t dec in blood Vol.

Priority Intervention:

Fld replacement (D5Lr, NSS. Bld Trans – for jehova’s use plasma expander)


BODY RESPONSE TO SHOCK

Hyven - Hyper ventilation -> Respiratory alkalosisFlu - Fluid Shifts Intracellular to intracellularV - VasoconstrictionCT - TachycardiaIM - Impaired metabolism and organ

functionGILBERT T. SALACUP RN,MSN

DRUGS USED TO TREAT SHOCKC – Corticostiroids – use in septic shock protect cellmembranes and

decrease inflammatory response to stress

A – Antibiotics –infectious process related to septic shock

N - Norephineprine (levophed) improve cardiac contractility and cardiac output potent vasoconstrictor

D – Dopamine (Intropin) perfusion of kidneys &

urine output

D - Dobutamine (Dobutrex) increase myocardial contractility, vasodilator.

D - Digitalis preparation improve cardiac performance

I - Isoproterenol (Isuprel)increase myocardial contractility

S - Sodium Nitropusside Vasodilator, increase cardiac

output, use in cardiogenic shock, and hypertensive emergency.


EMERGENCY NURSING MANAGEMENT A - irway P - Promote restoration of blood volume;administer fluid and blood replacement as ordered A - Administer drugs as ordered M - Minimize factors contributing to shock.

Best Position

Modified trendelenburge


WOUND A BODILY INJURY

CAUSED BY PHYSICAL MEANS, WITH DISRUPTION

OF THE NORMAL CONTINUITY OF STRUCTURES.



CLOSED WOUND

Cause by a damage of a tissue with in the layer of the skins and to the layer of the skin without breaking the continuity of the skin.

Contusions (more commonly known as a bruise)

caused by blunt forc trauma that damages tissue under the skin.

Hematoma- (also called a blood tumor)

caused by damage to a blood vessel that in turn causes blood to collect under the skin.

Crushing Injuries caused by a great or extreme amount of force applied over

a long period of tissue


NURSING MANAGEMENT

I – ICE APPLICATION (10 – 15 MIN )

C -- COMPRESSION ( DIRECT PRESSURE )

E – ELEVATION ( ABOVE THE HEART )

OPEN WOUND IS A BREAKE IN THE CONTINUITY OF THE SKIN RESULTINGIN SHEDING OF BLOOD, AND CREATATING A PORTAL OF ENTRY FOR MICRO ORGANISM.


P – PUNCTURE * USE BY SHARP AND POINTED OBJECT

A – ABRAISION *( GRAZES) - A SUPERFICIAL WOUND IN WHICH THE TOPMOST LAYER OF THE SKIN (THE EPIDERMIS) IS SCRAPED OFF.

S – SUCKING WOUND * A PENETRATING WOUND OF THE CHEST THROUGH WHICH AIR IS DRAWN IN AND OUT.

A – AVULSION *THE FORCIBLE TEARING AWAY OF A BODY PART BY TRAUMA.

L – LACERATION *TISSUES ARE TORN. AN EVEN CUT.

I – ISCISION * ONE CAUSED BY A CUTTING INSTRUMENT. CLEAN CUT.


EMERGENCY CARE PROCEDURES:

Wash --wash the wound

Co – Control bleeding

co – Cover the wound

Lo – Look for drop BP and TEMP.

Co – Consult a doctor


BRUISES, STRAINS, SPRAINS, DISLOCATIONS.

1. Use rice.Amputation

1. Control Bleeding2. Find the severed part Seek Immediate medical attention.

Chest Injuries1. Check ABC2. Stabilize Chest using pillow, coat or blanket.3. Seek medical attention4. Do not remove impaled object.

Eye injuries1. Protect injured eye2. Patch unaffected eye3. Do not remove object stuck on the eyeDo not apply hard pressure


FRACTUREEMERGENCY CARE PROCEDURES:A -- Avoid putting pressure on he affected areaR – Rest ( 20-30 min q 2 – 3 hrs. in 1st 24 – 48 hrs )I – Ice application S – splint ( use to stabilize )

Head and Spinal Injury

EMERGENCY CARE PROCEDURES:

S - Stabilized the spineCo - Control bleedingAs - Asses for bladder distention and pineal erectionDo - Do not irrigate or clean the skull woundsDo - Do not stop the flow of blood or CSF from the ear or noseN - NPOCo - Consult a doctor


BURNS – INJURIES THAT INVOLVE THE SKIN, MUSCLE AND EVEN THE BONES.

CLASSIFICATIONFIRST DEGREE: “ SUPERFICIAL” ONLY INVOLVES EPITHELIAL LAYER. OFTEN VERY PAINFUL BUT RESOLVES WITH NO RESIDUAL SCARRING. SKIN IS RED AND PAINFUL BUT NO BLISTERS.

SECOND DEGREE:* PARTIAL THICKNESS* INVOLVES EPITHELIUM AND PART OF DERMIS. PAIN AND SCARRING VARY ACCORDING TO DEPTH OF BURN. WITH BLISTER FORMATION.

THIRD DEGREE : *FULL THICKNESS*. USUALLY PAINLESS. USUALLY DRY AND HAVE MILKY WHITE OR TANNED LEATHER APPEARANCE.


EMERGENCY CARE PROCEDURESSo -- Soak in cold water/ apply cold dressing ( w/o open wound or prick blister) 1st degree do not cover w/ dressing

SO -- Soak in cold water/ apply cold dressing Cover the wound w/ non sticky dry sterile dressing /clean cloth ( 2nd degree w/ open wound and)

CO -- Cover the wound w/ non sticky dry sterile dressing /clean cloth 3rd degree

A – a blister has formed,

Co -- Consult you Physician.


CHEMICAL BURNS

Wa – wash with water for 15 min.

Kee – Keep eye open, flush with water or milk immediately.

Fluid Replacement FormulaConsensus Formula

LRS: 2-4ml x kg wt x % tbsa½ 1st 8 hrs½ 16 hrs

Parkland Formula LRS: 4ml x kg wt x % tbsaDay 1. ½ 1st 8 hrs½ 16 hrs Day 2Colloid is added

SILVER SULFADIAZINE - (MOST bactericidal Agent) 1-3x/day Acticoat – for yeast and molds( againts gram + &

- )

Mafenide actate 5-10% - Easily absorb (against gram + & - ) 2x a day

Silver Nitrate- Anti bacterial does not penetrate escar fungicide, Cover dry gauze remoisten it q 2 hrs

•HEAT EMERGENCIES IN HUMANSUNEXPECTED CHANGES IN THE WEATHER

2 BASIC ENVIRONMENTAL EMERGENCIES2E

EXPOSURE TO HEAT EXPOSURE TO COLD

SIGNS AND SYMPTOMS ** RAPID, SHALLOW BREATHING ** COLD,

CLAMMY SKIN, **HEAVY PERSPIRATION **GENERAL

WEAKNESS, ** POSSIBLE LOSS OF CONSCIOUSNESS.

Heat CrampsCAUSE BY ELECTROLYTES IMBALANCE,

ARTICULARLY EXESIVE LOSS OF SALT.

EMERGENCY CARE PROCEDURES:Move - Move victim to a cool place.Give - Give fluids, preferably

with electrolytes.Massage - Massage affected muscles (firm

pressure massage).Apply - Apply moist towels to forehead and

cramped muscles.Call - Call for transportation to medical care

if symptoms persist.

HEAT SYNCOPERESULT FROM INTENSE SWEATING WHICH LEAD TO DEHYDRATION FOLLOWED BY PERRIPHERAL VASODILATION.

HEAT EXHAUSTIONHEAT EXHAUSTION IS A MORE SERIOUS RESULT OF

HEAT EXPOSURE.CAUSE BY ELECTROLYTES IMBALANCE,PARTICULARLY EXESIVE LOSS OF SALT.

HEAT STROKE

CAUSE BY A EXTREME BODY TEMP. THAT THE BODY WAS NOT ABLE TO REGULATE IT AND RELATED ALSO TO IMPAIRED SWEATING MECHANISM.

EMERGENCY CARE PROCEDURESActivate EMS system (call 911)

Move - Move victim to a cool place.

Rest - Rest victim.

Remove - Remove enough clothing to cool.

Give - Give fluids with electrolytes (to conscious victims only).Treat for shock.

Victim - Victim needs high concentration of oxygen.

Call - Call for transportation to definitive medical care.

HYPOTHERMIA

1. Get the victim out of the cold2. Replace wet cloths with dry warm

cloths.3. Keep flat and provide other source of

heat. NO. No. Things1. Do not give warm drinks2. Do not wrap with blanket unless with

out other source of heat.3. Do not engage with physical exertion.

STROKE **occurs when a blood vessel in the brain is

blocked or bursts. Without blood and the oxygen it carries, part of the brain starts to die.

S/S Numbness, weakness, or paralysis of the face,

arm, or leg, especially on one side of the body. Trouble seeing in one or both eyes. You may have

double vision, or things may look dim or blurry. Confusion or trouble understanding. Slurred or garbled speech. Trouble walking. You may feel unsteady, dizzy, or

clumsy. Severe headache.

Causes** thrombus/ ischemic/ clot**Risk factors1. Atrial fibrillation2. Hypertension3. DM4. Smoking

S/S of affected part of the Brain

Left hemisphereLeft hemisphere Right hemisphereRight hemisphere

Language problem/ Language problem/ aphasiaaphasia

Perceptual deficitPerceptual deficit

Pt is cautious Pt is cautious Impulsive behaviorImpulsive behavior

2 type of strokeischemic stroke develops when a blood clot

blocks a blood vessel in the brain.

hemorrhagic stroke develops when an artery in the brain leaks or

bursts. TIA – Acute neurogical deficit lasting for 24

hrs. S/S1. Pt is irritable2. Pt appears in a deist3. Disarchia4 Temporary blindness

EMERGENCY CARE PROCEDURES:** Check for ABSDEHS**** keep in side lying position****Seek immediately medical help.

SEIZURES due to uncontrolled electrical activity in the brain

causes involuntary muscle contraction.EMERGENCY CARE PROCEDURES:

1. Do not move/stimulate the victim2. Ensure safety “ remove all near by objects”3. after seizure ‘’ loosen tight clothing's turn

to side’’4. Consult a doctor

DIABETIC EMERGENCYEMERGENCY CARE PROCEDURES:** provide sugar (candy, soda,frit juice)

**Consult a doctor

ASTHMA

EMERGENCY CARE PROCEDURES:1. RELAXATION TECHNIQUES ‘pursed lip breathing’

2. SIT Up RIGTH

3.Assist the victim in his meds.

4. Consult a doctor

CARDIAC ARREST -- Occurs when the heart stop pump, or it pumps insufficient blood causing

deprivation of o2 to the vital organs.

THREE CONDITIONS OF CARDIAC ARREST1. CA -- CARDIO VASCULAR COLLAPSE2. VE -- VENTRICULAR FIBRILLATION3. CAR -- CARDIAC STANDSTILL

Myocardial InfarctionMyocardial Infarction Angina PectorisAngina Pectoris

Pain at restPain at rest Pain upon ExertionPain upon ExertionNot Relive by NitroglycerinNot Relive by Nitroglycerin Relive by NitroglycerinRelive by Nitroglycerin

Crushing painCrushing pain SameSame

SevereSevere MildMildNot Relive above 15 min. Not Relive above 15 min. Relive by rest 2 -3 min.Relive by rest 2 -3 min.

Severe chest painSevere chest pain Diaphoresis Diaphoresis

EMERGENCY CARE PROCEDURESL --Limit Stressful activityS -- Stop the victim from what his doingO -- Open the airway A -- Assist the victim in taking the his prescribe medsP -- Perform CPR If – P and – B (30:2)

Priority Nx diagnosis

Decrease cardiac outputCause of death in MI

1. Arrhythmias2. Ventricular fibrillationChokingEMERGENCY CARE PROCEDURESInfant – 5 Back blows and 5 chest ThrustAdult & Child – Heimlich maneuver, abdominal

and chest thrust.

PoisoningPoisoning

PoisoningPoisoning

PoisoningPoisoning

PoisoningPoisoning

PoisoningPoisoning

POISON ANY SUBSTANCE THAT CAUSING ILLNESS OR DEATH WHEN EATEN, DRUNK, OR ABSORBED EVEN IN RELATIVELY SMALL QUANTITIES.

INGESTED/ SWALLOWED – BY MOUTH

EMERGENCY CARE PROCEDURES:1. SYRUP OF IPECAC IS NOT A ROUTINE TREATMENT FOR POISONING. 2. ACTIVATED CHARCOAL IS NOT RECOMMENDED FOR HOME USE.3. GIVE MILK OR WATER IMMEDIATELY4.. POSITION THE VICTIM IN LEFT SIDE LYING.5. IDENTIFY THE POISON AND HOW MUCH AND WHEN TAKEN.6. CALL POISON CONTROL CENTER.

Inhaled – by breathing EMERGENCY CARE PROCEDURES 1. Remove the victim form the toxic environment

and into fresh air immediately.2. Give 100% of O2 3. Call poison control center.

Injected poisoning poison that enters the body through a bite,

sting, or syringe.EMERGENCY CARE PROCEDURES

1. Remove the stinger 2. Wash the wound3. cold compress

Absorbed poisoning

EMERGENCY CARE PROCEDURES1. Remove the cloth ( cut the cloth )2. Flash it w/ water away from the body part3. observe for allergic reaction.

VENOMOUS NON VENOMOUS

Movement Cortina, Semi cortinaor locomotion

Head Semi-triangular Round

Skin Rough Smooth

Manner Non-constrictor Constrictorof attack

Pupil Vertical sphere/Oblong

Body Semi-triangular Oblongated

Bite mark fang mark Horseshoe shapevisible

SNAKE BITE1. Keep the affected area lower than the heart

2. Clean w/ soap and water

3. Splint part to reduce movement

4. Limit annescerary movement

5. Call poison control center.

Motor Vehicle Accident1. Do not rush to get the victims out, contrary to opinion most

vehicle crashes do not involve fire

Internal bleeding1. Check ABC

2. Lie on side

3. Treat shock

4. Seek medical attention

External bleeding 1. Direct wound pressure

2. Elevate

3. Pressure points

4. Tourniquet

AIR WAY OBSTRUCTION1. Types a. Anatomical b. Mechanical

2. Classification

a. Mild b. Severe Management1. Head tilt chin lift 2. jaw thrust3. Heimlich 4. Chest and abdominal thrust

NOSE BLEEDINGEMERGENCY CARE PROCEDURES

Sit upright , head bent slightly forward, pinch the nostrils, breath trough our mouth.

Water rescue – “Reach, Throw, Row, Go”

The End?

Hindi pa !.


TEST TAKING TECHNIQUES1. Discern The Exam Concentrate on fundamentals Therapeutic Communication Aseptic Techniques Safety Nursing Priority Basic law touching the practice lot of Question from Community Ethical Practice select ans. Respecting

human Rights


2. Prepare your selfa. Get enough restb. Eat rightc. Drink your vit.d. Exercisee. Avoid negative talkf. Release anxiety to your friendsg. Seek help and verbalizeh. Relaxation techniques

3. Organize your study time. There maybe no two individuals who will have the

same way of studying. Some prefer studying at night while some, early in the morning or during the day. Some, may have so much work at home, they can only spare a few hours studying. Whatever is your circumstances is, there are the basic rules in organizing study time:


Make a checklist of all the things to review. Make a schedule of this checklist. Don’t overkill. Do not give so much time on one

area while forgetting the others. Don’t just use your favorite area, give equal time even on those that you feel are not coming out of exam.

Organize your study time by reviewing on the basic first, then at the last part of your schedule, make sure you test yourself by answering exam question.

Allow much flexible to accommodate your other important activities.

I always help to remove all distraction like cell phones and television. Boyfriends and girlfriends may schedule later.


4. let’s dissects the Monkey. Read the question carefully from the first word

to the last word. Remember not to miss out on key words that would lead you to what the question is really asking for.

look for hints…

-“most, first, best, initial”- indicate you must establish priorities.

-“further teaching is necessary”- answer will contain incorrect information.

-“understand the teaching”- answer will be correct information.

3. rephrase the question in your own words so that it can be answered w/a ”yes” or a “no”, or w/ a specific bit of information.

-“what”.”when”, “why”


Example: The nurse should teach the patient who

was cirrhosis of the liver to avoid w/c of the ff. food in the diet?

a. Baked chickenb. Apple piec. Macaronid. Spinach

Rephrase: what is the metabolic problem of the patient

w/ liver cirrhosis? Answer: he cannot digest fat What food is contraindicated for the patients w/ liver

cirrhosis Answer: fatty foods. Thus, among the

choices, baked chicken should not be given.


HOW TO SCORE POINTS

Step1. Read the question. Spend more time on reading the question. learn to rephrase. Underline the key words to increase tour understanding on the important aspect of the problem.

Step2: after reading the question, stop. Before looking at the options, think of an answer.

Step3: selection pass. In selecting the correct answer, read each option carefully and do this.

Step 3.1 cover all answer choices except one.


Step3.2 read answer choices 1. then repeat the REWORDED QUESTION after

reading answer choice. As yourself… “does this answer the REWORDED QUESTION.

If it does not – eliminate Not sure- leave the answer choice for consideration

Step 3.3 repeat the above process w/ each remaining answer choices.

Step 3.4 note w/c answer choice remain.

Step 3.5 reread the question to make sure you have correctly identified the REWORDED QUESTION


REWORDED QUESTION. STEP 3.6 ask yourself “ w/c answer choices

best answer the question?: THAT IS YOUR ANSWER!!! R E M E M B E R ! ! !1. eliminate only what you know is wrong.

Once choice has been eliminated.. PUT IT OUT OF YOUR MIND!!!

2. stay focus on the REWORDED QUESTION. Not on the back information!!! Don’t fall for distraction!!!

3. if your “ideal” answer choice is not there… well don’t sit and moan because it will get you nowhere… read the question again, rephrase, and select the best answer.


Look for Qualifiers“Never, always, all, none” Most often absolute terms, generalizations. Do not

choose these options.

Look for contrasting options.Usually contrasting option lead you to correct answer. 1 of this is the right answer.

Example.Mr. bean is suffering from gastric ulcer. As a nurse, you have to

prevent dumping syndrome. Which of the ff. preventive measures should noy be taken?

a. allow him to lie down after eating b. avoid giving fluids after meal. c. allow him to talk after eating. d. serve dry meals only.


Choices a & c are contrasting option, thus one of these may be the correct option, eliminating b& d. the question may be rephrase to” what is the best position after meals to prevent dumping syndrome?” the answer is… a. allow him to lie down after meal, but the question is asking for the measure that should not be advice, thus the answer is… c

3. PRIORITIES. The board exam is testing your ability to decide your priorities in patient care. The most common bases of prioritization are:

a. ABC’s – airway, breathing & circulationb. Safety and protection- decide what will cause the least

amount of harm. DO NO HARM!!! c. Rights of patient- will of the patient is the basis for action.

We are safeguards and advocates of the patient well being.d. Assessment comes before any intervention.e. The less invasive procedures first before invasive one.f. Remember MASLOW!!! Physiologic needs comes as a

priorityg. Patient first before equipment.


4. NORMALS-decide if the assessment data being presented in the question is within normal range. If the answer is yes, you just have to look for the option that will not need further intervention..

only continue monitoring or assessment. If the answer is otherwise ,then go ahead and rephrase the question…and follow the steps in answering a question. Familiarize yourself with the values will be much easier than memorizing. Post them on your walls where you see them everyday.


5. Always be therapeutic. Therapeutic simply means choosing the options that will

solicit information from the patients and make him/her express his feelings. Usually, we eliminate options that will:

6. It is your business not others Eliminate choices that what doctors midwife or social

workers do

7. Do every thing by the book.Every thing is taken from the books, based on

ideal settings.


emergency nursing

Education

salacup rn

rn shock

cardiogenic shock

stages of shock

irreversiblestage of

progressivestage of

types of shock

u n severe shock