By Abu Dania By Abu Dania

Objectives Objectives 1. Explain emergency care as a collaborative, holistic approach 1. Explain emergency care as a collaborative, holistic approach

that includes the pt, the family, and significant others.that includes the pt, the family, and significant others.

2. Discuss priority emergency measures instituted for any pt 2. Discuss priority emergency measures instituted for any pt with an emergency condition.with an emergency condition.

3. Describe the emergency management of pts with 3. Describe the emergency management of pts with intraabdominal injuries.intraabdominal injuries.

4. Identify the priorities of care for the pt with multiple 4. Identify the priorities of care for the pt with multiple injuries.injuries.

5. Compare and contrast the emergency management of pts 5. Compare and contrast the emergency management of pts with frostbite.with frostbite.

6. Specify the similarities and differences for the emergency 6. Specify the similarities and differences for the emergency management of patients with swallowed or inhaled poisons.management of patients with swallowed or inhaled poisons.

DefinitionDefinition; ;

Emergency management ; - Emergency management ; - carecare given to given to patients with urgent and critical needs. patients with urgent and critical needs.

Scope and Practice of Emergency Scope and Practice of Emergency NursingNursing

Characteristics of emergency nurse; Characteristics of emergency nurse;

Specialized education & TrainingSpecialized education & Training

Experience.Experience.

Terminology Terminology Triage/sortingTriage/sorting : : process of assessing patients to process of assessing patients to

determine management priorities. determine management priorities. EmergentEmergent: : triage category signifying life triage category signifying life

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

urgenturgent: : triage category signifying serious triage category signifying serious illness or injury that is not immediately life-illness or injury that is not immediately life-threatening. threatening.

non-urgent: non-urgent: triage category signifying episodic triage category signifying episodic or minor injury or illness in which treatment or minor injury or illness in which treatment may be delayed several hours or longer without may be delayed several hours or longer without increased morbidity. increased morbidity.

RoleRole emergency Nursing;emergency Nursing;

1.1. Organization Organization

2.2. Preparation Preparation

3.3. Care giver Care giver – assessing and identifying patients’ health care problems in assessing and identifying patients’ health care problems in

crisis situations.crisis situations.

– establishes prioritiesestablishes priorities

– Monitors and continuously assessesMonitors and continuously assesses

4.4. SupportsSupports

5.5. Supervises allied health personnel Supervises allied health personnel

6.6. Teaches patients and families within a time-limited . Teaches patients and families within a time-limited .

FactsFacts;;

Nursing interventions are accomplished Nursing interventions are accomplished interdependently, in consultation with the interdependently, in consultation with the direction of a licensed physician or nurse direction of a licensed physician or nurse practitioner.practitioner.

The strengths of nursing and medicine are The strengths of nursing and medicine are complementary in an emergency situation. complementary in an emergency situation.

Appropriate nursing and medical interventions Appropriate nursing and medical interventions are anticipated based on assessment data. are anticipated based on assessment data.

The emergency health care staff members The emergency health care staff members work as a team. work as a team.

The nursing process provides a logical The nursing process provides a logical framework for problem solving in this framework for problem solving in this environment. environment.

Pts in the ED have a wide variety of actual or Pts in the ED have a wide variety of actual or potential problems, and their condition may potential problems, and their condition may change constantly. change constantly.

Issues In Emergency Nursing Care Issues In Emergency Nursing Care

1.1. Documentation of Consent(legal issue);Documentation of Consent(legal issue);

Its part of ED record.Its part of ED record. The pt must consent to invasive procedures The pt must consent to invasive procedures

If the pt is unconscious and brought to the If the pt is unconscious and brought to the ED without family or friends, this fact ED without family or friends, this fact should be documented.should be documented.

Any care delivered to pt in ED. Any care delivered to pt in ED.

2. Safety ; 2. Safety ;

All emergency health care providers All emergency health care providers should adhere strictly to standard should adhere strictly to standard precautions for minimizing exposure.precautions for minimizing exposure.

3. Providing Holistic Care;3. Providing Holistic Care;Pt-focused intervention.Pt-focused intervention.Family –focused intervention. Family –focused intervention.

The continuum of care :The continuum of care :

one principle underlying emergency care is one principle underlying emergency care is that the patient will be that the patient will be rapidlyrapidly assessed, assessed, treatedtreated, and , and referredreferred to the appropriate to the appropriate setting for ongoing care.setting for ongoing care.

This makes the ED a very temporary point This makes the ED a very temporary point on the continuum of care.on the continuum of care.

Principles of Emergency CarePrinciples of Emergency Care

1.Triage/ sorting;1.Triage/ sorting;

French word French word meaning “ meaning “to to sortsort.” .”

In the daily routine of the ED, triage is used In the daily routine of the ED, triage is used to sort patients into to sort patients into groupsgroups basedbased on the on the severityseverity of their health problems. of their health problems.

Triage categories:Triage categories:

Emergent, Urgent, and Non-urgent; Emergent, Urgent, and Non-urgent;

1.Emergent1.Emergent patientspatients have the highest have the highest priority—their conditions are priority—their conditions are life threateninglife threatening, , and they must be seen immediately.and they must be seen immediately.

2.Urgent 2.Urgent patients have serious health patients have serious health problems, but not immediately problems, but not immediately lifethreatening ones; they must be seen lifethreatening ones; they must be seen within 1 hour. within 1 hour.

3.Non-urgent 3.Non-urgent patients have episodic illnesses patients have episodic illnesses that can be addressed within 24 hours that can be addressed within 24 hours without increased morbidity .without increased morbidity .

Note:Note: fast-track; fast-track; These patients require These patients require simple first aid or basic primary care.simple first aid or basic primary care.

TIPTIP; Triage is an advanced skill; emergency ; Triage is an advanced skill; emergency nurses spend many hours learning to classify nurses spend many hours learning to classify different illnesses and injuries to ensure that different illnesses and injuries to ensure that pts most in need of care do not wait to receive pts most in need of care do not wait to receive it.it.

Routine hospital triage directs all available Routine hospital triage directs all available resources to the pts who are most critically resources to the pts who are most critically ill, regardless of potential outcome.ill, regardless of potential outcome.

Nurses in the triage area collect crucial Nurses in the triage area collect crucial initial data: initial data: vitalvital signssigns and and historyhistory, , neurologicneurologic assessment findings, and assessment findings, and diagnostic data diagnostic data if necessary.if necessary.

QuestionsQuestions

1.1. What were the circumstances, precipitating What were the circumstances, precipitating events, location, and time of the injury or events, location, and time of the injury or illness?illness?

2.2. When did the symptoms appear?When did the symptoms appear?

3.3. Was the patient unconscious after the injury Was the patient unconscious after the injury or onset of illness?or onset of illness?

4.4. How did the patient get to the hospital?How did the patient get to the hospital?

5.5. What was the health status of the patient What was the health status of the patient before the injury or illness?before the injury or illness?

6. Is there a medical or surgical history? A history of 6. Is there a medical or surgical history? A history of admissions to the hospital?admissions to the hospital?

7. Is the patient currently taking any medications, 7. Is the patient currently taking any medications, especially hormones, insulin, digitalis, anticoagulants?especially hormones, insulin, digitalis, anticoagulants?

8. Does the patient have any allergies? If so, what are 8. Does the patient have any allergies? If so, what are they?they?

9. Does the patient have any bleeding tendencies?9. Does the patient have any bleeding tendencies?

10. When was the last meal eaten? (This is important if 10. When was the last meal eaten? (This is important if general anesthesia is to be given or if the patient is general anesthesia is to be given or if the patient is unconscious.)unconscious.)

Principles of Emergency Care Principles of Emergency Care cont…cont…

2. Assessment and intervention ; 2. Assessment and intervention ; primary assessment of survey; primary assessment of survey; ‾ focuses on stabilizing life-threatening focuses on stabilizing life-threatening

conditions.conditions.

The ED staff work collaboratively and follow The ED staff work collaboratively and follow the the ABCDABCD methodmethod;;

1.1. Establish a patent airway.Establish a patent airway.

2.2. Provide adequate ventilation (Provide adequate ventilation (Trauma pts Trauma pts must have the cervical collarmust have the cervical collar))

3.3. Evaluate and restore cardiac output by Evaluate and restore cardiac output by maintaining or restoring effective circulation.maintaining or restoring effective circulation.

4. Determine neurologic disability .4. Determine neurologic disability .

Secondary assessment of survey;Secondary assessment of survey;

1.1. A complete health history and head-to-A complete health history and head-to-toe assessmenttoe assessment

2.2. Diagnostic and laboratory testing.Diagnostic and laboratory testing.

3.3. Insertion or application of monitoring Insertion or application of monitoring devices such as (ECG) electrodes.devices such as (ECG) electrodes.

4.4. Splinting of suspected fracturesSplinting of suspected fractures

5.5. Cleaning and dressing of woundsCleaning and dressing of wounds

6.6. Performance of other necessary Performance of other necessary interventions based on the pt’s conditioninterventions based on the pt’s condition

Acute airway obstructionAcute airway obstructionlife-threatening medical emergency. life-threatening medical emergency. PartiallyPartially - lead to progressive hypoxia, - lead to progressive hypoxia,

hypercarbia, and respiratory and cardiac hypercarbia, and respiratory and cardiac arrest.arrest.

completelycompletely - death will occur within 3 to 5 - death will occur within 3 to 5 minutes secondary to hypoxia.minutes secondary to hypoxia.

Causes;Causes; Aspiration of foreign bodies Aspiration of foreign bodies AnaphylaxisAnaphylaxis Viral or bacterial infectionViral or bacterial infection TraumaTrauma Inhalation or chemical burns. Inhalation or chemical burns. NoteNote: : In In adultsadults, aspiration of a bolus of meat is the most , aspiration of a bolus of meat is the most

common cause. common cause. In In childrenchildren, small toys, buttons, and coins , , small toys, buttons, and coins ,

Peritonsillar abscesses, and epiglottitis are the most Peritonsillar abscesses, and epiglottitis are the most common causes. common causes.

Clinical Manifestations:Clinical Manifestations: Chocking, apprehensive appearance, Chocking, apprehensive appearance,

inspiratory and expiratory stridor.inspiratory and expiratory stridor. Labored breathing.Labored breathing. Use of accessory muscles.Use of accessory muscles. Flaring nostrils.Flaring nostrils. Increasing anxiety.Increasing anxiety. RestlessnessRestlessness Confusion Confusion Cyanosis and loss of consciousness develop as Cyanosis and loss of consciousness develop as

hypoxia worsenshypoxia worsens..

Assessment and Diagnostic FindingsAssessment and Diagnostic Findings

Simply asking the person whether he or she is Simply asking the person whether he or she is choking and requires help.choking and requires help.

Typically, the victim with a foreign body airway Typically, the victim with a foreign body airway obstruction cannot speak, breathe, or coughobstruction cannot speak, breathe, or cough

If the person is unconscious, inspection of the If the person is unconscious, inspection of the oropharynx may reveal the offending object. oropharynx may reveal the offending object.

Laryngoscopy, or bronchoscopy also may be Laryngoscopy, or bronchoscopy also may be performed.performed.

Initial AssessmentInitial Assessment

Is the airway patent? Is the airway patent?

Is breathing adequate? Is breathing adequate?

Look, listen, and feel. Look, listen, and feel.

If patient is not breathing, open the If patient is not breathing, open the airway and assist ventilations as airway and assist ventilations as necessarynecessary

ManagementManagementSimple by repositioning the patient’s head to Simple by repositioning the patient’s head to prevent the tongue from obstructing the prevent the tongue from obstructing the pharynx.pharynx.

Removal of secretion or a foreign body Removal of secretion or a foreign body ((Brunner pp: 2153 ; guidelines for managing a Brunner pp: 2153 ; guidelines for managing a foreign foreign body airway) )

By maneuversBy maneuvers– Head-tilt–chin-lift maneuverHead-tilt–chin-lift maneuver– The jaw-thrust maneuver, The jaw-thrust maneuver,

By insertion of oropharyngeal airway or By insertion of oropharyngeal airway or endotracheal intubation. endotracheal intubation.

Head-tilt–chin-lift maneuverHead-tilt–chin-lift maneuver

head-tilt–chin-lift maneuver;head-tilt–chin-lift maneuver;►The pt is placed supine on a firm, flat surface.The pt is placed supine on a firm, flat surface.►one hand is placed on the victim’s forehead, and firm one hand is placed on the victim’s forehead, and firm

backward pressure is applied with the palm to tilt the backward pressure is applied with the palm to tilt the head back.head back.

►The fingers of the other hand are placed under the The fingers of the other hand are placed under the bony part of the lower jaw near the chin and lifted up. bony part of the lower jaw near the chin and lifted up.

►The chin and the teeth are brought forward almost to The chin and the teeth are brought forward almost to occlusion to support the jaw.occlusion to support the jaw.

JAW-THRUST MANEUVER;JAW-THRUST MANEUVER;►After one hand is placed on each side of the After one hand is placed on each side of the

patient’s jaw, the angles of the victim’s lower patient’s jaw, the angles of the victim’s lower jaw are grasped and lifted, displacing the jaw are grasped and lifted, displacing the mandible forward. mandible forward.

►its a safe approach to opening the airway of a its a safe approach to opening the airway of a victim with suspected neck .victim with suspected neck .

jaw-thrust maneuverjaw-thrust maneuver

Oropharyngeal airway insertion;Oropharyngeal airway insertion;►Advice inserted over the back of the tongue Advice inserted over the back of the tongue

into the lower posterior pharynx in a patient into the lower posterior pharynx in a patient who is breathing spontaneously but who is breathing spontaneously but unconscious. unconscious.

Advanced Airway ManagementAdvanced Airway Management

Endotracheal intubation is clearly the Endotracheal intubation is clearly the preferred method of advanced airway preferred method of advanced airway management in prehospital emergency management in prehospital emergency care.care.

Endotracheal Intubation IndicatorsEndotracheal Intubation IndicatorsRespiratory or cardiac arrest Respiratory or cardiac arrest

Unconsciousness Unconsciousness

Risk of aspiration Risk of aspiration

Obstruction due to foreign bodies, trauma, Obstruction due to foreign bodies, trauma, burns, or anaphylaxis burns, or anaphylaxis

Respiratory extremis due to disease Respiratory extremis due to disease

Pneumothorax, hemothorax, Pneumothorax, hemothorax, hemopneumothorax with respiratory difficultyhemopneumothorax with respiratory difficulty

Complications ofComplications ofEndotracheal Intubation Endotracheal Intubation

Equipment malfunction Equipment malfunction

Teeth breakage and soft tissue lacerations Teeth breakage and soft tissue lacerations

Hypoxia Hypoxia

Esophageal intubation Esophageal intubation

Tension pneumothoraxTension pneumothorax

HemorrhageHemorrhageManagement in EDManagement in ED Assess airway &breathingAssess airway &breathing Fluid replacementFluid replacement Essential to maintain circulation. Essential to maintain circulation. Two large-bore intravenous cannula are Two large-bore intravenous cannula are

inserted . inserted . Blood samples are obtained for analysis, Blood samples are obtained for analysis,

typing, and cross-matching. typing, and cross-matching.

Replacement by lactated Ringer’s, normal Replacement by lactated Ringer’s, normal saline.saline.

Or by blood transfusion Or by blood transfusion

Control of external hemorrhage Control of external hemorrhage

1.1. Rapid assessment Rapid assessment

2.2. Cut the pt`s clothes away Cut the pt`s clothes away

3.3. Apply direct, firm pressure over the bleeding area or Apply direct, firm pressure over the bleeding area or the involved arterythe involved artery

4.4. Apply a firm pressure dressingApply a firm pressure dressing

5.5. elevated the injured part.elevated the injured part.

6.6. If the injured area is an extremity, Immobilized it to If the injured area is an extremity, Immobilized it to control blood loss. control blood loss.

7.7. A tourniquet is applied only as a A tourniquet is applied only as a last resort when the external last resort when the external hemorrhage cannot be controlled in hemorrhage cannot be controlled in any other way. any other way.

Control of internal bleeding Control of internal bleeding

►If the patient shows no external signs of If the patient shows no external signs of bleeding but exhibits bleeding but exhibits

►TachycardiaTachycardia►Falling blood pressureFalling blood pressure► ThirstThirst►ApprehensionApprehension►Cool and moist skin, or delayed capillary refillCool and moist skin, or delayed capillary refill

internal hemorrhage is suspected.internal hemorrhage is suspected.

ManagementManagement Administered packed RBC (O- ve) are at a Administered packed RBC (O- ve) are at a rapid rate. rapid rate.

The pt is prepared for more definitive The pt is prepared for more definitive treatment (eg, surgery, pharmacologic treatment (eg, surgery, pharmacologic therapy). therapy).

Arterial blood specimens are obtained to Arterial blood specimens are obtained to evaluate pulmonary function and tissue evaluate pulmonary function and tissue perfusion and to establish baseline perfusion and to establish baseline hemodynamic parameters hemodynamic parameters

The pt is maintained in the supine position The pt is maintained in the supine position and monitored closely until hemodynamic or and monitored closely until hemodynamic or circulatory parameters improve, or until circulatory parameters improve, or until transport to the operating room or intensive transport to the operating room or intensive care.care.

ANY QUESTIONSANY QUESTIONS