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Is a specialized education, training and
experience to gain expertise in assessingand identifying patients health care
problems in crisis situations.
ER NURSING
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Emergency nurse establish priorities,
monitors and continuously assesses
acutely ill and injured patients,supports and attends to families,
supervise allied health personnel and
teaches the patient and families within
a time limited, high pressured careenvironment.
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Issues in Emergency Nursing Care
Documentation of consent.
Limiting exposure to health risk. Providing holistic care
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Care given to clients with urgent and critical
needs
Care must be rendered without delay
Diversified situations
Consent (unless unconscious and without S.O.)
Common clients (elderly, stomach pain, chest
pain, fever, drug related, wound) Disaster Nursing (terrorism)
Principle: TRIAGE
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Triage
- a process use in sorting victims into
categories of priority for care and transport
based on severity of injuries and medicalemergencies.
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TRIAGE
French word trier to sort
Sorting of clients based on the severity of
health problems Hierarchy based on the potential for life
loss
Advanced skills
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TRIAGE
3 categories ofTRIAGE (Berners)
1. Emergent
2. Urgent3. Non-urgent
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TRIAGE
I Emergent
Highest priority
Life threatening conditions, limbs Must be treated immediately
Airway compromise
Cardiac arrest
Shock
Stroke
Major Burns
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TRIAGE
II Urgent
Threatening conditions
Not immediate Must be seen within 1 hour
Fever
Minor Burns Lacerations
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TRIAGE
III Non-urgent
Can be addressed within 24 hours
Chronic conditions Dental problems
Missed Menses
4th category
Fast track simple first aid
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TRIAGE
Assess and Intervene (Primary survey)
A airway
B breathing C circulation
D disability
E expose
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QUICK ASSESSMENT
HEAD
MOUTH , LIPS & TEETH
EYES NOSE & EARS
FACE
SPINE & TRUNK LIMBS
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GLASCOW COMASCALE
Eye opening response
spontaneous 4To voice 3
To pain 2
None 1
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Verbal response
oriented 5
Confused 4Inappropriate words 3
Incomprehensible 2
None 1
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Motor response
Obeys commands 6
Localized pain 5 Withdraw 4
Flexion 3
Extension 2 None 1
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Secondary Survey
done after the priorities has been addressed.
a. Complete History and PE
b. Diagnostic and laboratory testing
c. ECG, Arterial lines, urinary catheters
d. Splinting of suspected fractures
e. Cleaning and dressing of wounds
f. other necessary interventions
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WOUNDS
Laceration skin tearwith irregular edges
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Avulsion tearing
away from
supporting structure
Abrasion denuded
skin
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Ecchymosis/contusi
on blood trapped
Hematoma tumorlike
under the skin massof blood trapped
under the skin
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Stab incision with
well defined edges
Stab wound with
evisceration
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Gun shot wound
Entry
Exit
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Management:
wound cleansing
wound closure primary closure
delayed primary closure
Tetanus prophylaxis antibiotics
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Hemorrhage
Stopping bleeding is essential to the care andsurvival
Primary cause of shock Signs & Symptoms ofShock:
Cool moist skin
Falling blood pressure
Increasing heart rate Delayed capillary refill
Decreasing urine volume
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Management:
fluid replacement
control of external bleeding control of internal bleeding
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Management:
Fluid replacement & Blood replacement
Control of external hemorrhage:
Direct pressure
Temporal
Facial
Carotid
Subclavian
Brachial
Radial & Ulnar
Femoral
Pressure dressing
Tourniquets (last resort)
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Control ofInternal Bleeding
Signs & Symptoms:
tachycardia
Falling blood pressure
Thirst
Apprehension
Cool & moist skin
Delayed capillary refill
Packed Red Blood Cell transfusion Surgery
Pharmacologic therapy
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SHOCK
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SHOCK
a condition of profound hemodynamic
and metabolic disturbance due to
inadequate blood flow and oxygen
delivery to the capillaries and tissues ofthe body.
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1. Hypovolemic
Results from loss of circulating volume.
This ma be due to excessive blood loss,loss of body fluids or third spacing fluids,hemorrhage, dehydration, burns andtrauma.
2. Cardiogenic
Results from impaired or compromisedcardiac output.
Pump failure, decreased venous return(myocardial infarction, cardiac tamponade,dysrhythmias)
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3. Vasogenic
Results from profound and massive
vasodilation thatleads to disproportionbetween the size of vascular space and the
amount of blood contained in it.
Head injury, general anesthesia, drug
overdose
4. Septic
Results from severe and profoundcondition of generalized vascular collapse
secondary to a systemic infection.
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5. Anaphylactic
Profound peripheral vascular
collapsed induced by severe allergic
reaction mediated by histamine,
bradykinin, leukotrienes, and
prostaglandins.
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Signs and Symptoms
Early stage Restless, confusion
increase pulse rate, RR
cold, moist skin
decreased pulse pressure
pallor
thirst, dry mucous membrane diaphoresis
oliguria
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Late stage shallow respiration
Dec. BP
Oliguria, anuria
Cool, clammy skin ( hypovolemic, cardiogenic,
septic)
Cool, mottled skin ( neurogenic, vasogenic)
Lethargy
Cyanosis
Dilated pupils
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Nursing problems: altered tissue perfusion related to failing
circulation
impaired gas exchange related to ventilation-perfusion imbalance
decreased cardiac output related to decreased
circulating blood volume
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Management:
1. Promoting fluid balance and cardiac
output whole blood and blood products
colloid solutions (albumin, plasma)
plasma expanders
crystalloids solution
Isotonic solutions plain LR
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2. Assisting cardiac support modified trendelenburg position
3.Assisting with respiratory supports
oxygen therapy
mechanical ventilation
suctioning
deep breathing,coughing exercise
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4. Assisting with renal support monitor urine output
BUN, Creatinine
5. Assisting GI support histamine blockers, antacids
NGT
6. Promoting safety restraints
strict asepsis technique
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Drug Therapy in Shock:
1. Vasoconstrictors (with Chronotropic and
Inotropic effects)
a. Epinephrine, Dopamine, Dobutamine
2. Vasodilatorsa. Nitroprusside
b. Nitroglycerine, Isosorbide
3. Sodium Bicarbonate to reverse acidosis
4. Antibiotics to control sepsis.5. Heparin to treat DIC
6. Steroids to produce antiinflammatory effect
7. Glucagon to increase blood sugar
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8. Cimetidine to prevent Stress Ulcer.
9. Glucose 50% to meet increased demand
for energy during shock.10. Naloxone (Narcan) to block Endorphin-
mediated hypotension.
11. Diphenhydramine (Benadryl) forAnaphylaxis
12. Narcotic to relieve pain.
13. Cardiotonic Medications:
a. To treat Dysrhythmias-Lidocaine,
Bretylium, Quinidine
b. To treat Bradycardia-Isoproterenol,
Atropine SO4
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Trauma
Unintentional or intentional wound or injury
4th leading cause of death in the US
Leading cause of death in children & youngadults < 44 years of age
Injury prevention ( only way to reduce incidenceof trauma)
Education
Legislation
Automatic protection
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TRAUMA
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Stab Wound
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1. Intra-abdominal injuries:
Penetrating abdominal injuries
Gunshot wound, Stab wounds
Serious & requires surgery
Liver ( most frequently injured solid organ)
All abdominal gunshot wounds require
surgical exploration Stab wounds may be managed non-operatively
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Blunt Trauma
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Blunt Abdominal Injury
Result from motor vehicle crashes, falls,
blows or explosions Injuries may be hidden or difficult to
detect
Involves the liver, kidneys, spleen, blood
vessel
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Assessment & Diagnostic Findings
History & PE
Lab studies: Urinalysis
serial Hct. level
WBC count
Serum amylase analysis
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Internal Bleeding Inspection ( front of the body, flanks & back)
Bluish discoloration, asymmetry, abrasion,
contusion Abdominal CT Scan
Abdominal Ultrasound
Left shoulder pain ( ruptured spleen)
Right shoulder pain (liver laceration)
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Intraperitoneal Injury
Assess for tenderness, rebound tenderness,
guarding, rigidity,
spasm, increasing distention & pain
Referred pain ( intraperitoneal injury)
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Diagnosis: abdominal ultrasound
abdominal CT scan
Diagnostic peritoneal lavage 1 L LRS/ NSS
400 ml return
RBC > 100,000/mm3
WBC ct > 500/mm3
Bile, feces, food
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Sinography ( detection of peritoneal
penetration)
Purse string
Small catheter
Contrast agent
X-ray
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Genitourinary Injury
Rectal/vaginal
examination
pelvis Bladder
Intestinal wall
Indwelling catheter
inserted after rectal
exam
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Intraabdominal Injury Management:
Resuscitation procedure
Occlusion of chest wound
Direct pressure
Intravenous fluid replacement
Immobilization of the spine
Cervical spine immobilization
Tetanus prophylaxis
Broad spectrum antibiotics
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Crush Injuries
Caught between
objects
Run over by movingvehicle
Compressed by
machinery
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Management:
ABC
Fasciotomy
Wound debridement & fracture repair
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Multiple Injuries
Requires a team approach
Affects every body system
Assessment & Diagnostic
Depends on the body part involved
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MVA
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MVA
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MVA
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MVA
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MVA
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Management:
Determine the extent of injury
Establish priority of treatment
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Fracture
A break in the continuity of the bone and is
defined according to its type and extent
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Fracture
Severe mechanical Stress to bone
bone fracture
Direct Blows
Crushing forces
Sudden twisting motion
Extreme muscle contraction
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Fracture
TYPES OF FRACTURE
1. Complete fracture
Involves a break across the entire cross-
section
2. Incomplete fracture
The break occurs through only a part of the
cross-section
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Fracture
TYPES OF FRACTURE
1. Closed fracture
The fracture that does not cause a break in
the skin
2. Open fracture
The fracture that involves a break in the skin
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Fracture
TYPES OF FRACTURE
1. Comminuted fracture
A fracture that involves production of several
bone fragments
2. Simple fracture
A fracture that involves break of bone into two
parts or one
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Fracture
ASSESSMENT FINDINGS
1. Pain or tenderness over the involved area
2. Loss of function
3. Deformity
4. Shortening
5. Crepitus
6. Swelling and discoloration
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Fracture
ASSESSMENT FINDINGS
1. Pain
Continuous and increases in severity Muscles spasm accompanies the fracture
is a reaction of the body to immobilize the
fractured bone
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Fracture
ASSESSMENT FINDINGS
2. Loss of function
Abnormal movement and pain can resultto this manifestation
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Fracture
ASSESSMENT FINDINGS
3. Deformity
Displacement, angulations or rotation ofthe fragments Causes deformity
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Fracture
ASSESSMENT FINDINGS
4. Crepitus
A grating sensation produced when thebone fragments rub each other
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Fracture
DIAGNOSTIC TEST
X-ray
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Fracture
EMERGENCY MANAGEMENT OF FRACTURE
1. Immobilize any suspected fracture
2. Support the extremity above and below
when moving the affected part from a vehicle
3. Suggested temporary splints- hard board,
stick, rolled sheets
4. Apply sling if forearm fracture is suspectedor the suspected fractured arm maybe
bandaged to the chest
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Fracture
EMERGENCY MANAGEMENT OF
FRACTURE
5. Open fracture is managed by covering a
clean/sterile gauze to prevent
contamination
6. DO NOT attempt to reduce the facture
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Fracture
MEDICAL MANAGEMENT
1. Reduction of fracture either open or
closed, Immobilization and Restoration of
function
2. Antibiotics, Muscle relaxants such as
METHOCARBAMOL and Pain
medications
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Fracture
General Nursing MANAGEMENT
For CLOSED FRACTURE
1. Assist in reduction and immobilization
2. Administer pain medication and muscle
relaxants
3. teach patient to care for the cast
4. Teach patient about potential complicationof fracture and to report infection, poor
alignment and continuous pain
Fracture
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Fracture
General Nursing MANAGEMENTFor OPEN FRACTURE
1. Prevent wound and bone infection
Administer prescribed antibiotics Administer tetanus prophylaxis
Assist in serial wound debridement
2. Elevate the extremity to prevent edemaformation
3. Administer care of traction and cast
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Fracture
FRACTURE COMPLICATIONS Early
1. Shock
2. Fat embolism 3. Compartment syndrome
4. Infection
5. DVT
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Fracture
FRACTURE COMPLICATIONS Late
1. Delayed union
2. Avascular necrosis 3. Delayed reaction to fixation devices
4. Complex regional syndrome
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Fracture
FRACTURE COMPLICATIONS: FatEmbolism
Occurs usually in fractures of the longbones
Fat globules may move into the bloodstream because the marrow pressure isgreater than capillary pressure
Fat globules occlude the small bloodvessels of the lungs, brain kidneys andother organs
Fracture
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Fracture FRACTURE COMPLICATIONS: Fat
Embolism Onset is rapid, within 24-72 hours
ASSESSMENT FINDINGS
1. Sudden dyspnea and respiratorydistress
2. tachycardia
3. Chest pain 4. Crackles, wheezes and cough
5. Petechial rashes over the chest, axillaand hard palate
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Fracture
FRACTURE COMPLICATIONS: FatEmbolism
Nursing Management
1. Support the respiratory function
Respiratory failure is the most commoncause of death
Administer O2 in high concentration
Prepare for possible intubation andventilator support
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Fracture
FRACTURE COMPLICATIONS: FatEmbolism
Nursing Management
1. Support the respiratory function
Respiratory failure is the most commoncause of death
Administer O2 in high concentration
Prepare for possible intubation andventilator support
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Fracture
FRACTURE COMPLICATIONS: Fat Embolism Nursing Management
3. Institute preventive measures
Immediate immobilization of fracture
Minimal fracture manipulation
Adequate support for fractured bone during
turning and positioning
Maintain adequate hydration and electrolytebalance
Fracture
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Early complication: Compartment
syndrome A complication that develops when
tissue perfusion in the muscles is less
than required for tissue viability
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Fracture
Early complication: Compartment syndrome
ASSESSMENT FINDINGS
1. Pain- Deep, throbbing and UNRELIEVED
pain by opiods Pain is due to reduction in the size of the
muscle compartment by tight cast
Pain is due to increased mass in thecompartment by edema, swelling orhemorrhage
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Fracture
Early complication: Compartment syndrome
ASSESSMENT FINDINGS
2. Paresthesia- burning or tingling sensation 3. Numbness
4. Motor weakness
5.P
ulselessness, impaired capillary refilltime and cyanotic skin
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Fracture
Early complication: Compartmentsyndrome
Medical and Nursing management
1. Assess frequently the neurovascularstatus of the casted extremity
2. Elevate the extremity above the
level of the heart 3. Assist in cast removal and
FASCIOTOMY
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Fracture (open)
Strains
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Strains
Excessive stretching of a muscle or
tendon
Nursing management 1. Immobilize affected part
2. Apply cold packs initially, then heat
packs
3. Limit joint activity
4. Administer NSAIDs and muscle
relaxants
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Sprains
Excessive stretching of the LIGAMENTS
Nursing management
1. Immobilize extremity and advise rest 2. Apply cold packs initially then heat packs
3. Compression bandage may be applied to
relieve edema
4. Assist in cast application
5. Administer NSAIDS
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Head Injury
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Eye Injuries
FLAIL CHEST
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1. A blunt chest trauma from a steering wheel Injury.
2. Occurs when three or more adjacent ribs(multiple
contiguous ribs) are fractured at two or more sites,
free-floating segments.
3. During inspiration, the flail segment moves in
paradoxical manner (pendelluft movement), in that
it is pulled inward during inspiration
4. Results in hypoxemia, retained airway secretions,atelectasis, hypotension, inadequate tissue
perfusion, metabolic acidosis.
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Management:
a. Supportive
1. Provide ventilatory support
2. Clearing secretions from the lung
3. Controlling pain4. Positioning
5. Coughing
6. Deep breathing
7. Suctioning8. Endotracheal intubation
9. Mechanical ventilation
HEAD INJURIES
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HEAD INJURIES
May be an injury to the scalp, skull or
brain
It as the most common cause of death
from trauma in the US
Traumatic brain Injury- most serious
form of head injury
C f T ti B i I j
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Causes of Traumatic Brain Injury:
1. Motor vehicle crashes
2. Violence
3. Falls
Age group at risk:15 to 24 years, Males
The best approach to head injury
prevention
Two forms of brain damage from traumatic Injury:
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g j y
a. Primary Injury
1. Initial damage to the brain that results from
traumatic events
2. Contusions, lacerations, torn blood vessel
from impact, Acceleration/deceleration,
foreign object penetration
b. Secondary Injury
1. Ensuing hours and days after initial injury
2. Due to brain brain swelling or on-ongoing
bleeding, increasing ICP, ischemia,
infarction, irreversible brain damage &
brain death
1 Scalp injury
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1.Scalp injury
A minor head injury, bleeds profuselywhen injured
May result in abrasion, contusion,laceration or hematoma
Diagnosis is based on PE, inspection,palpation
2 Sk ll F t
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2. Skull Fracture
Break in the continuity of the skull
caused by forceful trauma
May occur with or without brain
damage
May be linear, comminuted, depressed,
basilar, open or closed
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Clinical Manifestations:
Persistent localized pain in the affected
area
X-rayBattles sign
CSF otorrhea
CSF RhinorrheaHalo sign
Assessment & diagnostic findings
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Assessment & diagnostic findings
CT Scan
MRICerebral angiography
Medical Management:Close obsevation
Surgery
Antibiotic treatmentBlood therapy
3. Brain Injury
Most important consideration In any head
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Most important consideration In any head
injury
Two types of Brain Injury:
1. Closed brain injury- occurs when the
head accelerates and rapidlydecelerates or collides with another
object, brain damage
2. Open Brain Injury - occurs when an
object penetrates the skull, enters the
brain, & damages the soft brain tissue
Clinical manifestations of brain injury:
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Clinical manifestations of brain injury:
1. Altered level of consciousness
2. Confusion
3. Pupillary abnormalities
4. Altered or absent gag reflex
5. Absent corneal reflex
6. Sudden onset of neurological deficits7. Changes in vital signs
8 Vision & hearing impairment
9. Sensory dysfunction
10. Spasticity
11. Headache12. Vertigo
13. Movement disorder
14. Seizure
Concussion
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Results in temporary loss of neurologic function with no
apparent structural damage.
Involves a period of unconsciousness from a few
seconds to a few Minutes.
Pt may be hospitalized overnight for observation
Signs & Symptoms:
1. Difficulty in awakening
2. Difficulty in speaking
3. Confusion
4. Severe headache
5. Vomiting
6. Weakness of the one side of the body
Contusion
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A more severe injury in which the brain is bruised
and hemorrhaged
Pt is unconscious for more than a few seconds or
minutes.
Clinical signs & symptoms depends on the size of
the contusion & amount of cerebral edema.
Poor prognosis
Abnormal motor functions, abnormal eye
movement, elevated ICP, brain damage, disability
or death.
Diffuse Axonal Injury
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Diffuse Axonal Injury
Involves a widespread damage to axons in thecerebral hemisphere,corpus callosum and
Brainstem.
May result in axonal swelling & dislocation.Immediate coma, decorticate & decerebrate
posturing and global cerebral edema.
Diagnosis: CT scan & MRI
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Intracranial Hemorrhage
Hematoma that develop within the
cranial vault.
Most serious brain injury.
May be epidural, subdural orintracerebral.
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Management of Brain Injury:
Initial PE & neurologic exam
CT Scan & MRIPET scan
All therapy is directed toward preserving
brain homeostasis & preventing
secondary brain Injury.
Spinal Cord Injury (SCI)
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Occurs 4 times common in males aged
16-30
Motor vehicle crashes (most common
cause of SCI)
Risk factors: age, gender, alcohol & Drugabuse
CS, C6, C7, T12, L1 (most frequently
involved vertebrae)Damage ranges from concussion to
contusion, laceration, compression of
the cord to complete transaction.
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Two categories:
1. Primary injury - initial insult or trauma,
usually Permanent.
2. Secondary Injury- contusion or tear injury,in which the nerve fibers begins to swell &
disintegrate, ischemia, hypoxia, edema,
hemorrhage, destruction of myelin &
axons. May be reversible 4-6 hoursafter injury.
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Clinical Manifestations depend on the type & level of
Injury:
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Central cord syndrome
Cause injury or edema of the central cord,
usually cervicalCharacteristics: motor deficit, sensory loss
varies, bowel/bladder dysfunction
variable or function maybe completely
preserved.
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Anterior Cord Syndrome
Cause acute disc herniation or hyperflexion
injuries associated with Fracture-
dislocation of vertebra, injury toAnterior spinal artery;
Characteristic loss of pain, temperature and
motor function; light touch, position& vibration senses intact.
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Brown-Sequard Syndrome (Lateral cord syndrome)
Cause Transverse hemisection of the cord from a knife
or missile injury, fracture dislocation
from a unilateral articular process or
an acute ruptured disc.
Characteristics: Ipsilateral paralysis or paresis,
ipsilateral loss of touch, position
and vibration senses intact,contralateral loss of pain &
temperature.
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Types of Injury:
1. Incomplete Spinal Cord Lesion - according to
area of spinal cord damaged: central, lateral,anterior, peripheral
2. Complete Spinal Cord Lesion - may result in
paraplegia & quadriplegia
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Assessment & DiagnosticFindings:
1. Detailed neurologic exam2. Diagnostic X-ray
3. CT
4. MRI
ASIA Impairment Scale
A l ( f i i d i
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A = complete ( no motor, sensory function is preserved in
the sacral segments S4,S5)
B = incomplete (sensory but not motor function is
preserved below the neurologic level, includes
S4,S5)
C = motor function is preserved below the neurologic level,
more than half of key muscles have a grade less
than 3)
D = incomplete motor function is preserved, half of keymuscle have a grade more than 3.
E = motor & sensory functions are normal
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Emergency Management:
o Rapid assessment
o Immobilization
o Extricationo Stabilization or control of life threatening
injuries.
o Transportation to appropriate medical facilities.
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Management of SCI (Acute Phase)
o Resuscitation
o Oxygenation
o Cardiovascular stability
o Pharmacologic therapy (high dose steroidsat 6 weeks, 6 mos., & 1 yr)
o Respiratory Therapy -
o Skeletal fracture reduction & fraction
o Surgical management:Laminectomy
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Complications:
O Spinal shock and Neurogenic shock.
O Deep vein thrombosisO Autonomic Dysreflexia
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Heat Stroke An acute medical emergency
Failure of the heat regulating mechanisms of thebody
Occurs during extended heat waves People at risk: Not acclimatized to heat
Elderly & very young
Unable to care for themselves
With chronic & debilitating diseases
Taking certain medications Causes thermal injury at the cellular level ( heart, liver, kidney,
blood coagulation)
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Assessment:
Exposure to elevated temperature
Excessive exercise during extreme heat
Signs & Symptoms:
Confusion, delirium, bizarre behavior, coma
Elevated body temperature ( 40.6 C or
higher)
Hot, dry skin
Anhydrosis
Tachynea, hypotension, tachycardia
Management:
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To reduce hightemperatureASAP
cool sheets & towels,TSB
Ice pack
Cooling blankets
Iced Saline Lavage Immersion in cold water
bath
Massage ( promotecirculation)
Pt monitoring ( VS,ECG, CVP)
Oxygenation (100%)
IV infusion therapy
Monitor urine output
Patient education
HEAT CRAMPS
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HEAT CRAMPS
Heat Cramps
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HeatCramps
- a muscular pain and spasm due largely
to loss of salt from the body in sweating or
too inadequate intake of salt.
Signs and Symptoms:
Muscle cramps, often in the abdomen or
legs.
Heavy perspiration.
Lightheadedness; weakness.
First Aid Management
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First Aid Management
Have the victim rest with his/her feet.
Cool the victim. Do not use an alcohol
rub. Give the victim electrolyte beverages to
sip or make salted drink.
To relieve muscle cramps massage theaffected muscles gently but firmly untilthey relax.
Heat Exhaustion
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HeatExhaustion
- response to a heat characterized by fatigue, weakness, andcollapse due to inadequate intake of water to compensate for loss offluids through sweating.
Signs and Symptoms
Cool, pale or red, moist skin.
Dilated pupils. Headache.
Extreme thirst.
Nausea, vomiting.
Irrational behavior.
Weakness; dizziness Unconsciousness.
First Aid Management
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First Aid Management
Have the victim rest with his/her feet elevated.
Cool the victim.
Give the victim electroyte beverages to sip or
make a salted drink. Monitor the victim for signs of shock.
If the victim starts having seizures, protecthim/her from injury and give first aid for
convulsions. If the victim loses consciousness, give first aid
for unconsciousness.
Frostbite
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Trauma from
exposure to freezing
temperature
Actual freezing oftissue fluids
Results in cellular &
vascular damage
Feet, hand, nose,ears
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Assessment:
History of exposure to
cold
Frozen extremity,hard, cold ,
insensitive to touch
Management:R t l
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Restore normal
body
temperature
Circulating back
of 37 40 C
Sterile gauze or
cotton inbetween fingers
& toes
Massage is
contraindicated Whirlpool bath
Escharotomy
Fasciotomy
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Hypothermia
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The core (internal)
temperature is 35 C orless
Assessment and
Findings:
Progressive deterioration
Apathy
Poor judgement
Ataxia
Dysarthria
Drowsiness
Pulmonary edema
Coagulopathy
Management:
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Management:
Monitoring VS, CVP, UO, ABG, Bloodchem., ECG, Chest X-ray
Rewarming
a. core rewarming method, CP bypass,warm fluid, warm
humidified oxygen, warm peritoneal lavage
b. Passive external rewarming, warmblankets over the bed heaters
Supportive Care
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Near Drowning
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g
Survival for at least 24 hours after
submersion
Hypoxemia ( most common
consequence)
Leading cause of unintentional death in
children younger than 14 years old
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Factors:
Alcohol ingestion
Inability to swim
Diving injuries Hypothermia
Exhaustion
Fresh water aspiration (loss of surfactant) Salt water aspiration (pulmonary edema)
Management:
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Maintain cerebralperfusion
Adequate oxygenation
Immediate CPR
Monitor temperature by
rectal probe
Rewarming procedures
ECG monitoring
Indwelling urinary
catheter
NGT
. Decompression Sickness (DCS)
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Also called The Bends
Diving, high altitude flying or flying in commercial
aircraft within 24 hours after diving
Results from nitrogen bubbles trapped in thebody
Musculoskeletal pain, numbness/hypesthesia
Nitrogen bubbles become air emboli, stroke,
paralysis, death
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Assessment &
Diagnosis:
Detailed history
Rapid ascent, loss of
air in the tank, buddy
breathing, recent
alcohol intake, lack of
sleep or flight within 24
hours
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Management:
Patent airway
Adequate ventilation
Oxygenation (100%)Hyperbaric chamber
Anaphylactic Reaction
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p y
Acute systemic
hypersensitivity
reaction
Occurs withinseconds or minutes
after exposure to
certain foreign
substances Medications
Insect stings
Foods
Immunoglobulin E (IgE)
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Diagnosis:
Respiratory symptoms
DOB
Stridor secondary to laryngeal edema
Fainting, itching, swelling of mucus
membrane
Sudden drop in BP
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Management:
Patent airway & ventilation
ET intubation
Aqueous epinephrine
Crichothyroidotomy
Antihistamines
Aminophylines
Albuterol inhalers Isoproterenol or Dopamine
IV Benzodiazepines
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Latex Allergy
Affects healthcare
providers who uses
this product Management: Latex
free products
. Injected Poisons: Stinging Insects
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Venoms of the
hymenoptera (bees,
hornets, yellow
jackets, fire ants,
wasps)
Venom allergy ( IgE
mediated reaction)
Stinging
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ClinicalManifestations:
Generalized urticaria
Itching
Malaise
Anxiety
Bronchospasm
Shock Death
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Management:
Stinger removal
Wound care with
soap & water
Ice application
Oral Antihistamines
& analgesic
Aqueous
epinephrine SQ
Desensitization
therapy
Snake Bites
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Affects ages 1- 9 years
Pit vipers (most frequent poisonous snake in the
US) Cobra ( Philippines)
Upper extremity (most common site)
Envenomation (injection of a poisonous material
by sting, spine, bite)
Medical emergency
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Management:
Have victim lie down
Remove constrictive items
Provide warmth Cleanse & cover the wound
Immobilize the injured part below the level of
the heart Ice & tourniquet is contraindicated
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Corticosteroids are contraindicated in the first6-8 hours after bite
Observe for at least 6 hours
Administration of antivenin within 12 hoursafter the bite
Children requires more antivenin than adults
Skin or eye test to detect allergy to antivenin
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Measurement of circumference of theaffected part
before administration of antivenin and every 15minutes thereafter
After symptoms decrease, every 30-60 minutes forthe next 48 hours
Done to detect compartment syndrome (swelling,loss of pulse, increase pain, paresthesia)
Diphenhydramine & Cemetidine
Too rapid infusion ( most common caused ofallergic reaction)
Poisoning
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Any substance ingested, inhaled,
absorbed, applied to the skin or produced
within the body injures the body bychemical reaction
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Ingested orSwallowed Poisons(Corrosive)
Alkaline or acid agents caused tissue
destruction after in contact with mucusmembrane
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Management:
Airway, ventilation, oxygenation
Water or milk to drink for dilution
Syrup of Ipecac, Gastric lavage, Activated charcoal
and Catharsis are all Contraindicated.
Antidote as early as possible
Monitor VS, CVP, Fluid & Electrolytes
Psychiatric consultation
Inhaled Poisons : Carbon Monoxide
Poisoning
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Result of industrial or householdincidence or attempted suicide
Carbon monoxide exerts its toxic effect
by binding to circulating hemoglobin
thereby reducing O2 carrying capacity
of the blood
Carboxyhemoglobin does not transport oxygen
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Signs & Symptoms :
Headache
Muscle weakness
Palpitation
Dizziness
Confusion
Cyanosis
Coma
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Management:
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Reverse cerebral & myocardialhypoxia
Hasten elimination of carbon
monoxide
Oxygenation (100%) at atmospheric
or hyperbaric pressure
Substance Abuse
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Misused of specific
substances to alter
mood or behavior
Drug & alcohol
Acute Alcohol Intoxication
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Affects young adults or people older than 60years of age
Alcohol or ethanol is a direct multisystem toxin &
CNS depressant:
Drowsiness
Incoordination
Slurring of speech
Sudden mood changes, Aggression, belligerence,grandiosity
Uninhibited behavior
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Management:
Detoxification of
the acute
poisoning,
recovery,rehabilitation
Denial &
defensiveness
Alcohol Withdrawal
Syndrome/Delirium Tremens
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y
Acute toxic state that occurs as a result as a cessation ofalcohol intake
Signs & symptoms: Anxiety
Uncontrollable fear
Tremor
Irritability
Agitation
Insomnia
Incontinence
Visual, tactile, auditory, olfactory hallucination
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Management:
Adequate sedation & support
Allow pt to rest and recover
Place pt in a calm, nonstressful environment
Alcohol free environment
Refer pt to self help groups such as AA
Negative conditioning with
Disulfiram(Antabuse)
Naltrexone HCL (antidote)
Violence, Abuse, Neglect
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Family Violence, Abuse & Neglect
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Domestic violence is the leading cause ofdeath for young African American Women
Men & persons with disabilities are also
victims of domestic violence Elder abuse results physical,
psychological abuse, neglect, vilations of
personal rights & financial abuse
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Clinical Manifestation:
Unexplained bruises, laceration, abrasion,
head injuries & fractures
Malnutrition & Dehydration (most common inneglect)
Assessment:
Early detection & Intervention
Careful history
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Management:
Primary concern safety & welfare of
the pt.
Separation of the pt with the abuserMandatory reporting laws
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Sexual Assault
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Rape is force sexualact
Victims may either be
male or female
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Crisis Intervention: Assessment & diagnostic findings
rape trauma syndrome
phases of psychological reaction acute disorganization phase ( shock, disbelief,
fear, guilt, humiliation, anger)
Denial Phase: (anxiety, fear, flash backs, sleep
disturbances, hyperalertness & psychosomatic
reactions)
Phase ofReorganization: (Recovery)
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Management: Give sympathetic support
Reduce emotional trauma
Gather available evidence Goal: have pt. regain control over her/his life
. Violence in the Emergency Department
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Pts & families waiting for assistance at theED are sometimes dissatisfied resulting in
violence
Management: Safety is the first priority
Psychiatric Emergencies
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Is an urgent, serious disturbance ofbehavior, affect, or thought that makes the
pt. unable to cope with life situations &interpersonal relationships
Concern: Determining whether pt is at riskfor injuring self or others
Aim: Maintain pt self esteem whileproviding care
. Overactive Patients
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Display disturbed, uncooperative & paranoidbehavior
Management:
Reliable history about mental illness, hospitalization,
injuries, illnesses, use of alcohol or drugs
Immediate goal: Gain control of the situation
Restraint is used as the last resort
Psychotropic agent : Chlorpromazine, (Thorazine),
Haloperidol (Haldol)
Violent Behavior
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Usually episodic Means of expressing feelings of anger,
fear, or hopelessness
Management: Goal : bring the violence under control
Use calm & noncritical approach
Crisis intervention
Sedative
Restraint
Post Traumatic Stress Disorder (PTSD)
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. Development of characteristic symptomsafter a psychologically stressful event
Symptoms include intrusive thoughts &
dreams, phobic avoidance reaction,heightened vigilance, exaggerated startle
reaction, generalized anxiety, societal
withdrawal
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Assessment: Evaluation of the pts pretrauma history, the
trauma itself & post trauma functioning
Management: Crisis intervention
Establish a trusting & sharing relationship
Education of the pt and family
Underactive or Depressed
Patient
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Depression may be
masked by anxiety &
somatic complaints
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Clinical manifestations: Sadness
Apathy
Feeling of worthlessness
Self-blame
Suicidal thoughts
Anorexia, Weight loss
Decrease interest in sex Sleeplessness
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Management:
Ventilating personal feelings
Suicidal precaution
Antidepressant & antianxiety agentsPsychiatric consultation
Suicidal Patients
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.Attempted suicide is an act that stemsfrom depression
Viewed as a cry for help or intervention
Weight loss
Sleep disturbances
Somatic complaints
Suicidal preoccupation
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Management: Treat the consequences of suicidal attempt &
prevent further self injury
Crisis intervention
TOXICOLOGY
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POISONING & DRUG OVERDOSE
A. General Guidelines:
1. Maintain adequate airway, breathing and cardiac support.
2. If with mental status abnormalities (i.e. coma, stupor,
drowsy), give 50 ml ampule of 50% (1-2 mI/kg)
dextrose, followed by Naloxone (Narcan) 2 mg IV, or
endotracheally, and administer Thiamine 100 mg IV or
IM. Naloxone may be repeated in boluses of 1-2mg up
to 4mg IV. Obtain an immediate glucose level and
administer glucose if the glucose is
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4. Contact local poison center: Philippine General Hospital Poison CenterTelephone No. 524-1078, 521-8450 local 2311 or East Avenue Medical Center
Toxicology Center Telephone No. 928-0611 local 336 or 928-6233.
5. Consider possibility of suicide attempt or intentional poisoning in suspicious
overdoses.
6. All female patients with intentional ingestion should ideally have a pregnancy test
(check last menstrual period) following informed consent. And if found
positive, pregnancy outcome must be followed up.
7. Suicidal precautions should be instituted as needed: Always have a 24-hour
responsible watcher. There should be no access to sharp objects such asknives, razors, ropes, or belts inside the room. Always keep windows and
balcony locked. Never leave medications bedside. Limit visitors to prevent
possible supply of illicit substance.
B. Principles of Decontamination:
1. External Decontamination
a. Remove clothes.
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b. Wash skin with soap and water. Note also contamination ofhair and fingernails.
c. Keep warm; use blankets.
2. Gastric Lavage (Nasogastric tube)
a.Contraindications include ingestions of strong acids, alkalis,
petroleum distillates (unless volume is large because it may volatilizeand cause chemical pneumonitis).
b. Airway must be protected with endotracheal tube unless
patient is awake, alert and has a gag reflex. Place
patient in the Trendelenburg and left lateral decubitus position. Positionhead to one side to minimize aspiration. If patient has respiratory
difficulty, consider placing a cuffed endotracheal tube. Begin
mechanical ventilation and oxygenation if indicated.
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c. Perform gastric lavage unless overdose wasparenteral or distant in time. Lavage may be
useful if performed within 2 hours of drug
ingestion (unless dealing with a delayed
release preparation) and longer ifanticholinergic drugs (tricyclic
antidepressants) of other drugs that delay
gastric emptying were ingested.
3. Activated Charcoal
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a. Single dose activated charcoal: Always consider
giving charcoal after emesis or lavage unless
specifically contraindicated, such as if oral
antidote will be used or if endoscopy is
planned. For example, activated charcoal may
be detrimental in Paracetamol ingestion since it
binds to N-acetylcysteine. Adult dose of
activated charcoal is 50-1 00 grams (1 gram/kg
body weight) in 200 ml of tap water in a thickslurry. Instill slurry by lavage tube or have
patient ingest slurry.
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b. Multiple doses of charcoal: Giving activated charcoal 0.5 gram/kg/body
weight q 4-6 hours may be indicated for metamphetamine,
phenothiazines, digoxin, theophylline, phenobarbital and
organochlorine pesticides ingestion, because these substances
have enterohepatic recirculation kinetics. Note that activatedcharcoal may cause constipation or fecal impaction.
c. Activated charcoal is not effective for alkalis, cyanide, mineral acids,
ferrous sulfate and petroleum ingestion.
4. Cathartics (Sodium sulfate)
a. Contraindicated in infants, acid and alkali
ingestion patients who will receive an oral
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ingestion, patients who will receive an oral
antidote, adynamic ileus, severe diarrhea,abdominal trauma, surgery, suspected intestinal
obstruction, severe electrolyte loss or
dehydration.Magnesium sulfate cathartics are
contraindicated in renal failure. Sodium sulfate
is contraindicated in hypertension and heart
failure.
b. Sodium sulfate 15-30 grams (or 250 mg/kg)
in 100 ml water given 30 minutes after the
activated charcoal. If still without bowel
movement within one hour, may repeat
procedure.
5. a. Forced Diuresis:
Maintain urinary flow rate of 5-7
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Maintain urinary flow rate of 5 7
ml/kg/hr by infusing normal
saline and intermittent boluses
of Furosemide 20 mg N doses.Alternatively, use mannitol 20-
100gm IV, maximum 300 gm.
Monitor electrolytes and state of
hydration.
b. Forced Alkaline Diuresis:
May be useful for phenobarbital,
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mephobarbital, primidone, salicylates,lithium, isoniazid. Adult dose: Sodium
bicarbonate 1-2 amp N, followed by
continuous N infusion of 1-2 ampules (50-100
mEq) of sodium bicarbonate in 1 liter of 0.25-0.45 and normal saline at 25 0-500 mI/hr the
first 1-2 hours.
Maintain the urine pH of 7.3-9.0. Addadditional 0.45% normal saline and intermittent
doses of Furosemide 20 mg N. Increase urine
output to 2-3 mi/kg/hour.
6. Miscellaneous Antidotes
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a. Extrapyramidal reaction to Phenothiazines orMetoclopromide Diphenhydramine 25- 50mg IV
or IM q 6 hours X 4 doses; followed by 25-50
mg IV or P0 q 6 hours for 24-72 hours PRN.
b. Benzodiazepine overdose (e.g. Diazepam,
Midazolam, Lorazepam) Flumazenil 0.5 mg/S ml
ampule: 0.2mg IV q 5-15 minutes until the patient
wakes up or until 1 mg is reached. Consider gastricemptying, activatedcharcoal. Administer cathartic
and conservative supportive therapy.
C. Guidelines for Nurses:
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1. When antidotes are ordered, it is
meant to be given immediately or at
least reasonably within the hour insome cases. They are not given
when it is the next convenient
dosing period for the nurses (i.e.TID, q 6 hours).
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2. Always check with the Pharmacy for the
available antidote or the Poison Center
before asking the patient to purchase these at
outside pharmacy outlets becausethese special drugs may not be commercially
available. Inform the doctor at
once when it is known that these drugs are not
available.
ACiD INGESTION
Admit to:Diet: NPO
Nursing: Monitor BP HR and abdomen for guarding & tenderness
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Nursing: Monitor BP, HR and abdomen for guarding & tenderness
Diagnostics: Serial CBC, Cross-matching, Esophago-
gastroscopy, Upright CXR & Abdominal films (check for
pneumothorax &
pneumoperitoneum)
Therapeutics:I. Provide airway control, ventilation, circulatory
support, & fluid resuscitation.
Wash the oral cavity copiously with cold water
(controversial).
2. Induction of emesis, lavage, or charcoaladministration is contraindicated, and
passage of nasogastric tube should not be performed in
most patients. Steroids have no proven benefit.
ALKALI INGESTION
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ALKALI INGESTION
Diet: NPO Nursing: Monitor BP, HR;
abdomen for guarding & tenderness
Diagnostics: Serial CBC,
Crossmatching; Monitor electrolytes
Upright CXR & Abdominal films (check
for perforation, pneumoperitoneum)
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Therapeutics:
1. Immediately rinse the oral cavity
copiously with cold water. Protect
airway, and administer oxygen andfluids if appropriate; antibiotics if
evidence of esophageal injury is
present.
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2. Esophagoscopy and gastroscopy should be
performed immediately if there is drooling,
stridor or painful swallowing; otherwise it may
be deferred for 12-24 hours. Hydrocortisonedose 1V is recommended for deep or
circumferential burns with tapering of dose
over three weeks.
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3. Emesis, neutralizing agents, gastric
lavage, cathartics and charcoal are allcontraindicated.
HYDROCARBON/ KEROSENE INGESTION
Diagnostics: CBC, ABG, CXR PA-L
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Treatment Considerations:
1. Respiratory support: Provide supplemental oxygen; ensure
adequate airway protection.
2. Treatment is not required in the absence of symptoms.
3. Gastric emptying: Gastric lavage is indicated for ingestion ofa compound containing pesticides, organophosphates, heavy metals
(including lead in gasoline) or other toxics.
4. Skin decontamination: Remove contaminated clothing and
wash affected skin with soap and water. Once patient has
defecated, wash the perianal area to prevent chemical burns.
5. For Seizures: Diazepam or Phenytoin6. Watch out for cardiac arrhythmias, since hydrocarbon is also
a stimulant.
ISONIAZID OVERDOSE
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Nursing: I & 0; Insert foley catheter
IVF: D5NM 1 liter x 8 hours
Diagnostics: CBC, WBC (Leukocytosis)ABG (Metabolic acidosis)
K (Hypokalemia)
RBS (Hypoglycemia); Toxicology Screen
CPK-Total (Rhabdomyolysis)
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Therapeutics:
1. Place NGT and do gastric lavage till clean. Administer
Activated charcoal.
2. Antidote: Pyridoxine HCI (Vit B6) I gm/10 ml given gram per
gram basis
Example: Ingestion of 10 tabs INH 400mg requires 4graIns of Pyridoxine HCl IV
3. Seizures: Diazepam 5 mg N for active seizure
4. Metabolic acidosis: If pH < 7.15-7.20, administer sodium
bicarbonate IV infusion to correct acidosis early.
5. Consider Mannitol 20% 100 ml now then 75 ml q 6 hours
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ORGANOPHOSPHATE POISONiNG(Insecticides / Pesticides)
Nursing: NPO; I & 0; Insert foley catheter
Diagnostics: CBC, Na, K, RBS, BUN, Creatinine, CBG q 12
hours SGOT, SGPT, Amylase, PT, AEG
RBC Cholinesterase
Urinalysis (if urine output is reddish check for
Myoglobin)CXR, ECG
Therapeutics:
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1. Decontaminationa. External decontamination:
Have the patient rinse gently with
alkaline soap or baking soda (10 gm
in100 ml water). Change clothes and wash
patient with soap using gloves.
b. Internal decontamination:
Insert NGT and do gastric lavage with
activated charcoal 100gm in 200-500 ml water
2. Activated charcoal 1 gm/kg P0 then sodium
sulfate 15-30 grams in water after 30 minutes.
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g
Repeat sodium sulfate after one hour if still nobowel movement.
3. Antidote: Atropine Sulfate 0.01-0.05 mg/kg IV q 5
minutes or 1mg IV usually Maintain the following
parameters: Dry mucosa, HR> 60 bpm (target
HR of around 100 bpm), hypoactive bowel
sounds, pupils >4 mm; watch Out for Atropine
toxicity such as temperature> 39 C, absence of
sweating, psychosis and restlessness.
4. Seizures: Diazepam 5 mg IV q 8 hours
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Consider Phenytoin IV5. D50-50 glucose 1 ampule q 6 hours
6. Mannitol at I ml/kg IV in 10 minutes as test dose
If with good urine output, give 2.5-5 mI/kg q 6 hours x
8 doses
7. If with arrhythmia, do not give beta-blockers or Lidocine;may give calcium-channel antagonists or Phenytoin
instead.
8. Avoid the following drugs: Furosemide, beta-blockers,
sulfa-containing drugs and aminoglycosides.9. Correct acidosis with sodium bicarbonate
PARACETAMOL OVERDOSAGE
Diet: NPO during initial treatment of gastric lavage, then may
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resume diet if patient is conscious and coherent.VS: Neuro vital signs q 1 hour
Nursing: I & 0; Aspiration and seizure precautions; Place
NGT then lavage with wate
Diagnostics: CBC with plateletRBS, BUN, Creatinine, SGPT, SGOT, PT, PiT,
Amylase
Alkaline Phosphatase (daily for at least 3 days),
UrinalysisSerum Paracetamol Concentration (Note time of
blood extraction and time
of Paracetamol ingestion)
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Therapeutics:
1. Nasogastric tube
2. Activated Charcoal 30-100 gram doses,
remove via NGT suction prior tooral acetylcysteine antidote.
3. Sodium sulfate
4. IV Antidote: N-acetylcysteine (Hidonac)200 mg/mI injection
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SALICYLATE OVERDOSE(ASPIRIN)
Diagnostics: CBC, Blood culture and sensitivity, PT, PTT
(48 hours post-ingestion) SGPT, SGOT, Alkaline
Phosphatase (48 hours post-ingestion)
RBS, Na, K, Cl, BUN, Creatinine, ABG
Urinalysis, Stool exam with occult blood
ECG, CXR
Therapeutics:
1. Stabilize respiratory and cardiac functions. Avoid
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diluting gastric contents since this mayincrease gastric absorption.
2. Nasogastric tube
3. Activated Charcoal: 1 gm/kg body weight q 6
hours for 2 days
4. Sodium sulfate 15-30 grams in 100 ml H2O orally
or per NGT with every other doses of
activated charcoal to prevent charcoal