Download - NATIONAL EMERGENCY LIFE SUPPORT

Provider Course for Nurses

NATIONALEMERGENCYLIFESUPPORT

National Emergency Life Support – Provider Course for Nurses

LIST OF CONTRIBUTORS

CORE COMMITTEE MEMBERS 1. Dr. MRIDULA PAWAR

Consultant

Ministry of Health and Family Welfare

Government of India

New Delhi.

2. Dr. RATHI BALACHANDRAN

Additional Director General (Nursing)

Directorate General of Health Services

Government of India

New Delhi

3. Dr. HARINDARJEET GOYAL

Ex-Vice Principal

R.A.K. College of Nursing

Lajpat Nagar-IV

New Delhi

4. Dr. MANJU VATSA

Ex-Principal

College of Nursing, AIIMS

Ansari Nagar,

New Delhi

5. Dr. DAISY THOMAS

Acting Vice-Principal,

RAK College of Nursing

Lajpat Nagar-IV

New Delhi


EXPERT COMMITTEE MEMBERS 1. Dr. SAILAXMI GANDHI

Additional Professor and Head

Department of Nursing

Nursing Consultant,

Adult Psychiatry Unit V & PRS

NIMHANS (INI), Bengaluru

2. Prof. T. S. RAVI KUMAR

Ex-Professor & Head, Emergency Nursing

College of Nursing

Christian Medical College

Vellore

3. Dr. SUKHPAL KAUR

Associate Professor

NINE, PGIMER

Chandigarh

4. Mrs. THRESIA HALDANE

Tutor (Vice Principal I/C)

College of Nursing

Dr. Ram Manohar Lohia Hospital

New Delhi

5. Dr. L. GOPICHANDRAN

Associate Professor

College of Nursing

AIIMS

New Delhi

6. Mrs. MADHUMITA DEY

Assistant Professor

R.A.K. College of Nursing

Lajpat Nagar-IV

New Delhi

7. Mrs. SANDHYA SHARMA

Ex. Deputy Nursing Superintendent


New Delhi.

8. Mrs. SAUMINI PRASANNAN

Ex. Nursing Officer & CNF Facilitator

Kalawati Saran Children’s Hospital

New Delhi

9. Ms. CICILY NIANG HOU LUN

Nursing Officer & ATLS Coordinator

ATLS Simulation Centre


New Delhi

10. Mr. AJO JOSE P.

Nursing Officer and CNE Facilitator


New Delhi


National Emergency Life Support (NELS) Provider Course for Nurses

Contents

Sl.

No.

Topic Page No.

1. Introduction to NELS 1-5

2. The NELS Approach: Initial Assessment & Action 6-39

3. Oxygenation, Airway and Breathing 40-66

4. Skills for maintaining oxygenation, airway and breathing 67-109

5. Circulation: Shock, Chest pain and Peri ArrestArrhythmias

110-165

6. Skills for maintaining circulation 166-215

7. Disability: Neurological Emergencies (Stroke, Alteredsensorium, Seizure and Acute Headache)

216-243

8. Trauma : Head, Chest, Abdomen, Pelvis, Musculoskeletal,Spine & Burn

244-312

9. Trauma Skills (Cervical Collar application, Helmentremoval, Splints, Pelvis binder)

313-333

10. Hospital Preparation for Emergencies and Disasters 334-349

11. Medical, Emergencies (Nursing): Acute Fever,Environmental Emergencies, Poisioning

350-374


12. Surgical Emergencies (Nursing) : Acute Abdomen 375-384

13. Neonatal and Paediatric Emergencies 385-452

14. Gynecological and Obstetric Emergencies 453-532

15. Group Dynamics and team approach 533-537

16. Human aspects to consider while dealing withemergencies.

538-542

17. Ethical & legal issues 543-551

National Emergency Life Support – Provider Course for Nurses Page 1

Lesson 1

NELS COURSE: Introduction

Lesson 1 Introduction to NELS Objectives Upon completion of the lesson the trainee would be able to:

Understand the concept of NELS Course Visualize the aim and need of the course Understand the process and schedule of the course Learn the importance of cognition, psychomotor and

affective domains of learning Develop an attitude to save a life


Lesson 1 INTRODUCTION TO NELS COURSE 1.1 Introduction

NELS encompasses correcting the physiological effects of illness or injury prior to making a definitive diagnosis and management by an expert. In an emergency, the correct path requires competence and confidence at the front line which NELS course aims to impart.

It seeks to benefit all nurses along with emergency team, wishing to learn the practical and comprehensive approach for dealing with acute conditions causing risk to life and / or limb. It also aims to meet the expectations of those nurses who do not regularly treat serious emergencies and trauma. Thus, NELS is multi professional and multi-disciplinary, which is important for management in a critically ill patient encountered in emergency department (ED).

NELS approach aims that, by the end of the course all participants will be able to promptly assess and manage a critically ill or injured patient so as to prevent mortality and morbidity. Most important is to do best possible in the existing circumstances as per availability of resources and do no further harm, consult expert and finally transport safely to the appropriate place for further management.

Hence NELS is dedicated to our Nation in the hope that preventable morbidity and mortality may be avoided.

1.2 What was the need to develop NELS? Saving a life is a top most priority of any nurse to the best of his/her capability and available resources. All nursing professionals know medical treatment of typhoid but suppose typhoid fever patient comes in shock, which if not treated promptly, can be life threatening. Priority will be to stabilize oxygenation and circulation/ perfusion first, suspect enteric perforation and ask for help from surgeon to make final diagnosis of intestinal perforation due to enteric fever and do further definitive management / surgical intervention. Time is the essence in any seriously sick patient so a straight forward protocolised approach to deal with any patient can save time and resources leading to better outcome for such a patient.

There is no national life saving skill training course for emergency situations at the hospital level, at present. International training courses of American Heart Association like Basic life Support (BLS), Advance cardiac life support (ACLS) which are only relevant in cardiac problem or cardiac arrest situations and, Advance trauma life support (ATLS) and Advance Trauma Care for Nurses (ATCN) are for trauma victims. These courses do not train in comprehensive lifesaving skills


required to manage all emergencies. Moreover, cost of these training courses is not affordable by all, so it was important to develop economically viable, a comprehensive life saving skill training tool relevant to Indian scenario, where any critically ill patient irrespective of diagnosis can be saved by any front-line medical and nursing care provider and referred at the earliest possible for definitive treatment to be imparted by the specialist.

So, there was need for one training program for life threatening or potentially life and / or limb threatening problem for all medical and nursing personnel dealing with such patients.

NELS skill course is comprehensive meaning irrespective of diagnosis-respiratory, cardiac, trauma, medical, surgical, patient of obstetric or paediatric hence it integrates all situations, starting from hospital care in emergency and then safely transferring for definitive care. It teaches from basic to advance lifesaving skills and meant for front line health care providers including nurses who deal first with patient and who may have not been earlier trained in dealing with very sick patients.

1.3 How is it conducted? NELS is a skill and competency based practical course for all health care professionals including nurses, to build capacity and confidence at the front line to preserve life and limbs of patients arriving with serious illness or injury, so that they can be safely transferred to a specialist if required for complete recovery. Specialty of this course is that different common emergency situations are presented and discussed with respect to assessment and management. It is mainly interaction of participants with faculty based on a scenario. This is aimed to be achieved by intense hands-on training in practical procedures provided under supervision of experienced faculty in skill lab using mannequins, models, simulator and live demonstrations by faculty of different scenarios of undifferentiated emergencies, in addition to focused teaching in small groups.

All participants are required to attend complete course to understand all aspects of assessment and management of all types of emergency situations.


1.4 Schedule NELS course for nurses is conducted over five days by experienced and specially trained faculty, providing personal attention to all, with a systematic programme aiming to ensure that at all stages the nurse is focused on correct assessment and necessary action to improve the outcome for the patient, always with attention to three principles of preserving life and limb, initiating correct treatment and safe transfer for definitive treatment: Bring the patient alive, keep them alive and make them better.

All participants gain knowledge of affective, cognitive and psychomotor domains of basic and advance life saving aspects of oxygenation, airway, breathing, basic life support, assessment and management of a trauma victim, cardiac, neurological and other medical emergencies, specialty emergencies of obstetrics and paediatrics.

An evaluation of all domains of knowledge are assessed by expert faculty during the course by multi choice questions, by teaching a lifesaving skill to another participant, scenario practice on mannequins and moulage volunteers. Throughout the training programme participants are encouraged to participate in the management of scenarios of critically ill patients as if it is a real patient, with the help from passionate trainers to improve participants’ attitude towards saving a life.

1.5 Learning Learning has three components, cognitive, knowledge/ mental skills, Psychomotor/ manual or physical skills, and last but not the least, affective/ feeling/ emotional or attitude. To be a good human being especially a health care giver, we need to acquire all the three domains in equal proportion to give best care to our patients. Conduct of the course tries to teach participants, all the domains and skills but learning / performing in real situations will depends on their attitude.

There is a saying that ‘Practice makes a person perfect’ but motto of NELS is ‘Repeated perfect practice makes a person perfect’.

Skill once learnt with positive attitude comes back in real situation to save someone's life. Participants are encouraged to find opportunity to learn and continue to keep themselves practicing all the lifesaving skills learnt in the course in their hospitals.

Logo of NELS (Namaskar) depicts all these three domains of learning Three ‘H’: ‘Head’ for cognitive, ‘Hands’ for psychomotor and ‘Heart’ for attitude.


Clinical Pearls

Saving a life is the top priority.

Greeting by doing Namaskar in India, signifies all the three domains of learning.


Lesson 2 NELS APPROACH: INITIAL ASSESSMENT & ACTION

Lesson 2 NELS Approach: Initial assessment & Actions

Objectives Upon completion of the lesson the trainee would be able to: Apply NELS approach by listing the priorities in

assessment and management of all emergencies and trauma patients

Assess and manage life threatening problem. Apply the universal precautions Understand the concept of triage, team and Non

technical skills


Lesson 2 NELS APPROACH: INITIAL ASSESSMENT & ACTION 2.1 Core Concepts

Impaired oxygenation and perfusion to vital organs are the commonest cause of morbidity and mortality in a critically ill patient.

NELS approach includes continuous circle of assessment and action of A (Airway), B (Breathing), C (Circulation), D (Disability / Neurological) and E (Exposure & Environment) to find out and treat life threatening conditions.

The priority for initial assessment and management, in all patients must be ABCD

A rapid and accurate clinical assessment of patient’s condition by Look, Listen and Feel, for symptoms & signs and taking life, limb & organ saving actions in the critically ill or injured patients, must be undertaken without delay.

Early and correct application of the NELS approach and management is advocated without exception for correction and reversal of the first physiological and then pathological derangement.

Give oxygen to all breathing patients first with the maximum percentage of oxygen in an emergency.

2.2 NELS Approach: 2.2.1 Assessment: A critically ill or injured patient is one with an acute risk to systemic oxygenation and perfusion to vital organs, caused by clinically significant adverse effects on Airway (A), Breathing(B), Circulation(C) or Disability (D) from life threatening or potentially life-threatening illness or injury; risks to vital organs, limb or eyesight must also be considered as urgent priority. Typically, the routine sequence in nursing is, first asking history of present illness, past history then perform general physical and systemic examination, reach a nursing diagnosis, and perform necessary actions and evaluations. However, there is no time to go through this sequence in a critically ill patient. It is important to form a general impression in a critically ill / trauma victim by just looking at a patient, even before taking a history or conducting a formal assessment. We are able to form a general impression based on key observations as to whether patient is critically ill or injured and requiring what kind of urgent or immediate clinical attention. When we are


dealing with several patients together, it also helps us to identify those patients who may be sicker and need to be attended first. Initial approach is thus a crucial and essential step for the nurse who must promptly prioritize and provide appropriate management. A critically ill or injured patient can be identified and life-threatening issues can be managed without aiming at a definitive diagnosis.

Compromised airway and breathing will harm the patient regardless of underlying cause or pathology since heart and brain cannot survive without oxygen for long. Impaired circulation and perfusion to tissues, will lead to an adverse neurological outcome in patient having neurological problem. Hence, safeguarding patient’s oxygenation and circulation takes precedence over all else. The nurse must always assess the patient and take necessary action according to the ABCD priority.

Patient’s respiration, perfusion and mental status can be assessed in just a few seconds by asking questions to the patient and observing the response. In case response is appropriate, ABCD are alright at that moment. But it is essential to repeatedly observe and re-assess for any deterioration in the ABCD.

Use monitors at the earliest possible to assess and reassess the effect of life saving interventions: Pulse oximeter for airway and breathing, NIBP (non-invasive Blood Pressure monitor), ECG (Electrocardiography), Urinary output, temperature for circulation/ perfusion.


ABCDE Assessment by Look, Listen and Feel.

Airway: Face and Neck

• Colour of lips/skin• Swelling / hematoma/injury• Signs of airway difficultyLook• Talking in clear voice: Airway is clear• Gurgling, snoring• Stridor, Hoarse voiceListen• Air movement• Crepitation on neck,faceFeel

Breathing: Neck and Chest

• Chest wall movements, Respiratory Rate• Accessory muscles of respiration• Neck veins, injury, swellingLook• Talking full sentences• Noisy breathing• WheezeListen• Trachea• Crepitus, tenderness, ribs, clavicle• Cold, sweatyFeel


Circulation• Skin colour for pallor, cyanosis, injury, bleeding• Capillary refill time, distended neck veins• Abdominal distension, • Limb swelling, deformity• Restless, drowsy

Look• Breath and Heart sounds• bowel sounds• Blood pressureListen• Extremities warm or cold• Percussion Chest• All Pulse: rate, volume, regularity, equality• Abdominal tenderness, pelvic stability

Feel

Disability( Neurological)

• Level of consciousness, facial asymmetry• Pupil (Size and Reaction)• Limb movements • Seizures• GCS (Eye Opening)

Look• Orientation to person, time and place• Type of speech• GCS (Verbal Response)Listen• Muscle tone and power• Sensory Response to external stimuli and pain• GCS (Motor Response)Feel


Note: Though these are the major areas of concern, but, nurses must assess ABCD as per NELS approach.

Table 2.1: Area of concern with respect to ABCD as indicated by look, listen or feel of the patient.

2.2 Assessment and Action: 2.2.1 General Management:

High-flow oxygen must be started in all critically ill patients at the earliest possible. possible. Give oxygen to all breathing patients with maximum percentage of oxygen in the acute situation and later de-escalate oxygen percentage, to keep Saturation of Peripheral Oxygen (SpO2) of more than 94%.

The Airway, Breathing, Circulation, Disability (ABCD) approach is of utmost importance for first assessment and management of injured and critically ill patients.

Simultaneously, try to find out the cause and if required take expert opinion or send to proper facility with resources for definitive management.

Using this approach, the first assessment and actions are performed simultaneously and repeatedly.

Early use of vital signs monitoring is helpful to assess, reassess and check response to the management. Pulse-oximeter, Electrocardiogram (ECG) monitor and cyclical non-invasive blood pressure monitor must be applied to all critically ill patients, as soon as possible.

Exposure and Environment

• Expose to see front and logroll to see back for bleeding, injury, swelling, foreign body, bite marks

• BurnLook

• Listen to focussed historyListen• Swelling, step down deformity of spine• Per rectal examination for pelvic injuryFeel


Never leave a deteriorating patient without a priority management.

AIRWAY

Assessment Actions Remarks/Skills 1. Check for Airway patency. A person who is awake

and talking clearly can be assumed to have a patent airway.

With a completely

obstructed airway, there is no effective airflow despite respiratory effort.

Noisy breathing is

present in a partially obstructed airway.

2. Identify patients with facial trauma, inhalation burns, allergy: may have a muffled or hoarse voice, suggesting an impending airway obstruction.

Airway obstruction can be treated in majority of cases using simple methods such as airway opening maneuvers, suction, and insertion of airway adjuncts.

Check for obvious injury and/or obstruction and remove any foreign bodies present.

Insert oropharyngeal or, nasopharyngeal airway.

Perform endotracheal intubation and consider use of Laryngeal Mask Airway (LMA) or, Laryngeal Tube Airway (LTA) if endotracheal intubation cannot be achieved.

Look for sign of inhalational burns: change in voice, presence of carbon particles on the face and singeing of facial hair.

Airway must be protected in patients with absent airway reflexes or decreased level of consciousness Glasgow Coma Scale (GCS) score of 8 or less. Perform chin lift or jaw thrust maneuver. Definitive airway, with the help of cuffed Endotracheal tube or, cricothyroidotomy tube in trachea may be required for airway patency and airway protection. Endotracheal(E.T) intubation or front of neck access (Cricothyroidotomy) may be required in some patients with facial trauma, oedema of airway or laryngeal stridor.


3. Cervical spine must always be protection in patients with suspected or known cervical spine injury.

Maintain cervical spine in neutral position with manual in-line stabilization or, use blanket rolls or other devices for immobilization.

Use sand bags, cervical collar, and manual in-line stabilization.

BREATHING

Assessment Actions Remarks/skills 1) Assess for the presence and adequacy of breathing Look for signs of

respiratory difficulty such as tachypnoea, sweating, central cyanosis, accessory muscles of respiration are working , inadequate or laboured breathing.

2) Determine the respiratory rate and depth of breathing.

High and increasing rates are markers of illness and a warning that the patient is deteriorating

Low respiratory rate is usually in dangerous zone and need immediate action.

3) Assess abnormal breathing patterns like agonal or Kussmaul respirations.

Expose the chest. If breathing is

inadequate, assisted ventilation must be started using bag mask device.

Administer high flow oxygen using a non-rebreather face mask.

If required, airway

can be secured using supraglottic device, endotracheal intubation or surgical airway.

Observe for the movement of the thoracic wall for symmetry and the use of accessory muscles of respiration.

By looking and feeling by hand the chest wall, one can detect injuries that may compromise ventilation like fracture ribs. Use bag-valve mask device with reservoir to ventilate patients or, to assist ventilation, if breathing is inadequate. Bronchospasm should be treated with bronchodilators. Administer oxygen, if saturation is low.


4) Perform percussion of the chest and listen to unilateral dullness or resonance. On auscultation of chest look for air entry which may be reduced or abnormal sounds may be heard.

5) Adequately assess Jugular venous

engorgement: seen in acute severe asthma, heart failure, tension pneumothorax or cardiac tamponade. Signs and symptoms of cardiac temponade are Beck’s Triad which includes: venous pressure elevation (distended neck veins), decline in arterial pressure (hypotension) and muffled heart tones.

Position of the trachea : deviation to right or left indicates mediastinal shift e.g., tension pneumothorax, massive haemothorax.

Use pulse oximeter to

know oxygenation.

Acute cardiac

tamponade due to trauma is best managed by thoracotomy.

Pericardiocentesis may be used as a temporizing maneuver when thoracotomy is not an available option.

Perform intubation as needed for ventilator support.

Assist physician to

relive tension pneumothorax and it must be relieved immediately by inserting a wide bore cannula in the second intercostal space in midclavicular line/ 5th intercostal space anterior to midaxillary line (needle thoracocentesis) to be followed by chest

It is vital to immediately diagnose and treat the life-threatening conditions with breathing problems ,such as acute severe asthma, pulmonary oedema, tension pneumothorax and massive haemothorax. The signs and symptoms of tension pneumothorax are respiratory distress, neck vein distension, tachycardia, hypotension, tracheal deviation and absent breath sounds on the affected side. Signs and symptoms of an open pneumothorax is a large open defect in the chest wall causing a change in equlibrium between the intrathoracic and atmospheric pressure.


drain placement. Open pneumothorax

is sealed with occlusive dressing taped securely on three sides.

CIRCULATION

Assessment Actions Remarks 1) The circulatory status of a patient can be assessed by level of consciousness, pulse rate, quality, regularity and volume, capillary refill, skin colour, moisture and temperature, blood pressure and urine output. 2) Assess for early shock : Blood pressure may be

entirely normal, as compensatory mechanisms increase peripheral vascular resistance.

A low diastolic BP

suggests arterial vasodilatation (as in anaphylaxis or sepsis).

Apply requisite monitors like pulse oximeter, non invasive blood pressure (NIBP), ECG, End tidal carbon dioxide (EtCO2), if feasible and record its findings.

Assess mental status. Insert one or more large

(14 or 16 G) intravenous cannula and draw blood sample for blood grouping, cross- matching and other haematological, biochemical, coagulation and microbiological investigations.

A rapid fluid challenge (over 5-10 minutes) of 500ml of warmed isotonic crystalloid solution (preferably Ringer Lactate) should be given

Adequate perfusion of vital organs is essential for optimal recovery of patients. Decreased level of consciousness may indicate poor brain perfusion due to blood loss. The diagnosis of cardiovascular compromise will determine the specific treatment but should be targeted at fluid replacement, haemorrhage control and restoration of tissue perfusion. Fluid therapy should be guided by the response of the patient.


A narrowed pulse

pressure is suggestive of arterial vasoconstriction (cardiogenic shock or hypovolaemia).

3) Look for signs of injury and external haemorrhage from wounds or collection in drains or evidence of concealed haemorrhage in thoracic cavity, intraperitoneal or into gut. 4) Assess for features suggestive of severe cardiac failure such as raised JVP, ankle oedema and lung crepitation.

to a patient followed by another 500ml.

Reassess the pulse rate and BP regularly (every 5 minutes), target> 100 mmHg systolic except in patient with suspected ongoing blood loss, keep systolic BP around 90 mmHg to reduce further blood loss.

The effects of hypovolaemia can be alleviated by placing the patient in the supine position and by elevating the patient’s legs.

Bleeding control must be

kept on top priority. Apply direct pressure to control bleeding.

Early use of blood and blood products should be considered in hemorrhagic shock.

If required, prepare for surgical intervention in case of internal hemorrhage.

Smaller volumes (250 ml)

should be given in patients with known cardiac failure and closely monitor for crepitation after each bolus and alternative means of improving tissue perfusion (e.g., inotropes or vasopressors) can be used in patients.

Check for signs of immediately life-threatening conditions such as cardiac tamponade, massive or continuing haemorrhage etc and treat urgently. If patient shows no sign/ transient improvement, meaning non-responder or transient responder, try to find the cause and treat.


5) Assess for tension pneumothorax and pericardial tamponade as they can compromise the patient’s circulatory state and should be ruled out at the earliest possible stages.

Auscultate the heart sound for quality and rate.

Differentiate between sign and symptoms of pericardial tamponade (distended neck veins, hypotension, muffled heart tones, pulses paradoxus and narrowing pulse pressure) and tension pneumothorax (respiratory distress, neck vein distention, tachycardia, hypotension, tracheal deviation and absent breath sounds on the affected side.)

Incase of pericardial tamponade, consider resuscitative thoracotomy. Nurses should assist above procedure if required and maintain strict aseptic technique.

Tension pneumothorax must be relieved immediately by inserting a wide bore cannula in the second intercostal space in midclavicular line/ 5th intercostal space anterior to midaxillary line (needle thoracocentesis) to be followed by chest drain placement.

Pericardial tamponade and tension pneumothrax are having similar sign and symptoms, so careful assessment of the patient to be done in order to differentiate between them. If resuscitative thoracotomy cannot be performed immediately then, pericardiocentesis may be used as a temporizing measure.


DISABILITY (Neurological Evaluation)

Assessment Actions Remarks/skills 1) The level of consciousness can be assessed using Glasgow Coma Score. Examine the pupils for

size, equality and reaction to light.

2) Rapid assessment should be done simultaneously using CVPU score where the patient is graded as conscious (C), voice responsive (V), pain responsive (P), or unresponsive (U). Assess for hypoxaemia

and hypotension. 3) Look for drug-induced reversible causes of depressed consciousness. 4) Measure the blood glucose level.

If GCS is less than 8, consider intubation with ventilation.

Consult a neurosurgeon, if required.

Hypoxaemia and hypotension

should be managed by giving blood and fluids.

Administer appropriate antagonist at the earliest possible.

A decreased level of

consciousness due to low blood glucose can be corrected quickly with glucose infusion.

Common causes of unconsciousness other than head injury include profound hypoxaemia, hypercapnia, cerebral hypoperfusion, metabolic causes like hypoglycaemia, poisoning or overdose of sedatives or analgesic drugs. Review the ABC to exclude hypoxaemia and hypotension. Hypoglycemia is one of the commonest cause of unconsciousness and sweating especially in a diabetic patient.


EXPOSURE

Assessment Actions Remarks/skills 1) Assess the patient by undressing and fully examining the front and back to see for any signs of trauma, bleeding wounds, skin reactions (rashes), needle marks, bite marks etc. 2) Body temperature can be recorded by touching the skin or using a thermometer when available.

All findings must be taken into account for the diagnosis.

To prevent hypothermia, warming measures like warm blankets, convectional heating devices are to be used.

Clothing should be removed to allow a thorough physical examination to be performed while maintaining dignity of the patient.


2.3 Scenarios

Scenario 1

A 35 years man is brought to the emergency department on a stretcher, restless, cyanosed, cold and clammy skin, breathing very slowly, snoring and not moving one side of the body.

Based on the following observations patient in the scenario is critically ill requiring immediate lifesaving treatment

Airway

Assess: Does the patient have a patent airway? The answer is No, as he is snoring due to tongue fall obstructing the laryngeal inlet.

Action: Open the airway using jaw thrust.

Breathing

Assessment: Is the breathing inadequate? Does patient require oxygen? The answer is Yes, (The patient is breathing very slowly, restless and cyanosed which are signs of inadequate breathing hence hypoxia).

Action: Assist breathing with the help of bag mask or another ventilation device. Start oxygen supplementation with a maximum percentage of inspired oxygen.

Reassess for airway patency and breathing after implementation of above measures and above all improvement in oxygenation by checking oxygen saturation with help of a pulse oximeter.

Circulation

Assess: Does the patient have circulation(C) problem? The answer is Yes. He is having cold and clammy skin

Action: Raise the legs of the patient if clinically appropriate. Gain Intravenous (IV) access with two large bore cannula. Immediately administer intravenous fluid to fill the circulatory volume while you seek the cause and treat it. Check blood pressure and pulse.

Reassess for Circulation: Skin colour and temperature , capillary refill, consciousness for improvement, pulse and blood pressure, urinary output if a catheter is in situ.

Disability

Assess: Does the patient have a disability (D)/ neurological problem? Answer is yes. Patient is not moving one side of the body


Action: Ensure no further harm, maintain oxygenation and circulation and call for expert help at the earliest.

Exposure

Assess: Expose the patient to find any potential cause of illness, keep him warm and protect his spine,

Re-assess airway, breathing, circulation and maintain oxygenation and perfusion while appropriate steps are taken to find the cause of the physiological derangement of ABCD and definite care is provided. Scenario 2

A 37 year woman has met with a road traffic accident. He is unconscious and snoring, has bleeding and gurgling sound from mouth and injuries of extremities, bilateral deformed thighs.

Airway: Assessment, Action and Re-assessment

Assess Airway: Is airway patent? The answer is No , patient is unconscious, bleeding and gurgling from mouth. Action: Oral suctioning is done to remove blood from mouth till no more gurgling sound is heard Re-assess: Is airway patent? The answer is No, patient is snoring. Action: Jaw thrust is performed and snoring sound disappears. Oropharyngeal airway is (OPA) inserted as gag reflex is absent. Assess: Is the airway protected? The answer is No, as there is absence of gag reflex and patient is tolerating oropharyngeal airway. Action: Insert a definitive airway with a cuffed endotracheal tube. Administer oxygen at all times to maintain SpO2 more than 94%. Since she is a trauma victim, all airway manoeuvres should be performed with cervical spine stabilization using Manual Inline Stabilization (MILS) and cervical collar application. Re-assess: Oxygenation and Airway

Breathing: Assessment, Action and Re-assessment Assess: Respiratory rate and depth. Air entry is normal on chest auscultation. Percussion note is normal. Action: Provide breaths if required with help of Bag valve mask device (BVM) with a reservoir bag filled with high flow of oxygen till a ventilator is attached. Maintain SpO2> 94%. Re-assess: Oxygenation and Breathing.


Circulation: Assessment, Action and Re-assessment Assess: pulse rate (PR), blood pressure (BP) and capillary refill time. Is perfusion adequate? The answer is No, as PR is 140/ min, BP is 80/60 mmHg, capillary refill time is 4sec. Action:

Secure two wide bore (16G,18G) IV lines, withdraw blood samples for blood grouping and cross matching and other necessary investigations . Infuse warm IV fluid like Ringer Lactate (RL) / Normal Saline (NS): 1 litre boluses over 10-15 min. Control bleeding if present, from obvious external wounds by applying direct pressure and splint the injured extremities. After splinting, feel for the presence of distal pulse, which should be present. Do FAST (Focussed Assessment with Sonography In Trauma). FAST is negative.

Reassess: Is the perfusion adequate now? After 1.5 litre RL has been infused and external bleeding has been controlled. Perfusion is adequate as the PR is 95/min, BP is 104/60, and capillary refill time (CRT) is 2 sec.

Disability: Assessment, Action and Re-assessment Assess: Check neurological status using Glasgow Coma scale (GCS), pupil size and reaction, lateralizing signs, blood glucose and drug effect. On assessment GCS is 8, pupils are bilateral equal and reacting, no lateralizing signs, Blood sugar is 92 mg/dl and no drug effect Action: Take expert consultation while continuing to manage hypoxia, hypercarbia and hypotension to prevent secondary brain injury. Re-assess: Neurological Status.

Exposure Assess:

Expose the patient and look for signs of other injuries. The history should include

A - Allergies M- Medication (Anticoagulants, insulin and cardiovascular medications etc) P - Previous medical/surgical history/pregnancy in child bearing age group females L- Last meal (Time) E - Events / Environment surrounding the injury. Enquire about exactly what happened?


A detailed history is to be followed by a detailed head to toe, front and back examination.

Special investigations and repeat assessment of the patient is done to assess improvement or deterioration to take further clinical action as appropriate.

2.4 Universal Precautions

“Universal Precautions” as defined by Centre for Disease Control (CDC), are a set of precautions designed to prevent the transmission of Human Immunodeficiency Virus (HIV), Hepatitis B virus (HBV), and other blood borne pathogens when providing first aid or health care.

*Standard safety precautions, if carefully followed, will prevent spread of HIV, Hepatitis B, hepatitis C infections in health setting. Thus, all blood and body fluids, substances, secretions and excretions must be considered to be potentially infectious regardless of the perceived risk of exposure.

Standard work precautions to be followed to control infection are:

1) Hand hygiene (annexure) 2) Disinfection and sterilization of equipments (annexure) 3) Use of personal protective equipments based on the risk of the

procedure (annexure) 4) Standard precautions against air borne pathogens (annexure) 5) Standard precautions against blood borne pathogens (annexure)

* 1) HAND HYGIENE Hand washing is one of the simplest, but often overlooked procedure that can be followed to prevent infection from spreading.

Importance of hand hygiene:

1. Keeping hands clean through improved hand hygiene is one of the most important ways to prevent sickness and spreading germs to others.

2. Good hand washing can fight the spread of the common cold, meningitis, bronchitis, influenza, hepatitis A, and most types of infectious diarrhea.

Steps of hand washing:

1. Remove watches and all the jewellery.

2. Wet hands up to wrist.

3. Apply soap on the palms, back of the hand, between fingers and around the thumb.

4. Right palm over left dorsum and left palm over right dorsum.

5. Palm to palm fingers interlaced.


6. Backs of fingers to opposing palms with fingers interlocked.

7. Rotational rubbing of right thumb clasped in left palm and vice-versa.

8. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa.

9. Dry arms and hands.

10. Turn off the tap with elbow or paper towel. When to use Effect on

germs How to use

Soap and water Use this technique when hands have visible dirt and whenever you come in contact with a patient.

Removes germs

Apply soap on the palms, back of the hands, between fingers, around the thumb and rub for at least 15 seconds and rinse in running water.

Alcohol rub If no visible dirt on hands and before procedures needing the aseptic technique.

Kills germs Place 3-5 ml on dry hands and rub following all the steps of hand washing until dry.

Surgical scrub Done before surgery or procedure needing sterile technique

Kills germs 1.Clean under nails with stick.

2.Wet up to elbow

3.Use antiseptic as long for 2-6 minutes with all the steps of hand washing.

4.Rinse and dry

‘5 Moments’ of Hand Hygiene

The 5 Moments for Hand Hygiene approach defines the key moments when health-care workers should perform hand hygiene..

This approach recommends health-care workers to clean their hands

before touching a patient, before clean/aseptic procedures, after body fluid exposure/risk, after touching a patient, and after touching patient surroundings.


2) DISINFECTION AND STERILIZATION OF EQUIPMENTS Definitions

Cleaning Disinfection Sterilization Decontamination

Cleaning is the process that remove the foreign material (e.g. soil,organic material, micro-organisms) from an object.

Disinfection is the process that reduces the number of the pathogenic microorganisms, but not necessarily bacterial spores, from inanimate objects or skin, to a level which is not harmful to health.

Sterilization is a process that destroys all microorganisms including bacterial spores.

Use of physical or chemical means to remove, inactivate or destroy blood borne or other pathogens on a surface or item, to the point where they are no longer capable of transmitting infectious particles, and the surface or item is rendered safe for handling, use or disposal.

Guidelines for disinfection and sterilization

Device classification

Devices examples Types of process Process examples

High risk(Enters sterile tissue or vascular system, includes dental instruments)

Implants, scalpels, needles, other surgical instruments and endoscopic accessories.

Sterilization Steam under pressure, dry heat, ethylene oxide gas, chemical gas sterilizers.

Intermediate risk( Touches mucous membranes or broken skin)

Flexible endoscopes, laryngoscopes, endotraheal tubes, respiratory therapy and anaesthesia equipment, diaphragm fitting rings, and other similar devices.

High level disinfection (Exposure time 20 mins)

2% gluteraldehyde, hydrogen peroxide 6%, Sodium hypochlorite 5.25% in 1:50 dilution

Thermometers. Intermediate level disinfection(Exposure time 10 mins)

Ethyl or Isopropyl alcohol(70% to 90%).


Smooth, hard surfaces such as hydrotherapy tanks.

Intermediate level disinfection (Exposure time 10 mins)

Ethyl or Isopropyl alcohol (70% to 90%), sodium hypochorite 5.25% , phenolic detergent, Iodophor detergent.

Low risk

(Touches intact skin)

Stethoscopes, tabletops, floors, bed, furniture etc

Low level disinfection

Ethyl or Isopropyl alcohol(70% to 90%), sodium hypochorite 5.25% in 1:500 dilution , phenolic detergent, Iodophor detergent.

Disinfectants in use Name of the disinfectant

Method of dilution Contact time Shelf life

Gluteraldehyde 2% e.g. Cidex

Add activated powder/ liquid in the 5L jar and use undiluted.

Disinfection:20 to 30 minutes

Sterilization: 10 hours

14 to 28 days

Combination of Gluteraldehyde and chemically bound formaldehyde e.g. Korsolex, Bacilloid

Korsolex: Water

1 part: 9 parts

Bacillocid: Water

1 part: 49 parts

(20ml:980ml)

Disinfection 15 minutes

Sterilization 5 hrs 30 minutes

14 days

24 hrs

Ethanol Isopropyl alcohol 70% e.g. Bacillol-25

Do not dilute 2-10 minutes 24 hrs

Hydrogen peroxide 6% ( available as 30% stabilized solution)

20ml H202-with 80 ml Normal saline=6% H202

6-8 minutes Use immediately after preparation


Sodium hypochlorite solution 1% e.g. Polar beach available in 5% and 10% concentrations

5%: 80ml water+20 ml bleach solution

10%: 90ml water+ 10ml bleach solution

20-30 minutes 8 hrs

Calcium hypochlorite e.g. Bleaching powder(70% available Cl2)

14 gm/L dissolved property for visibly contaminated articles. 1.4 gm per L for clean objects

20-30 minutes 24 hrs

Note:

The equipments contaminated by HBV can be sterilized by heating for 600C for 4 hrs. The recommended pressure and holding time for autoclaving at 1210C is 15lbs

pressure at 20 minutes. Blood stained cotton cloth gowns should be disinfected with the help of sodium

hypochlorite.


BIOMEDICAL WASTE MANAGEMENT

Type of colour code for collection of bio-medical waste (as per 2016 rules):

Colour Waste type as per 2016 rules (Category as per 1998 rules)

Type of container Treatment/disposal options

Yellow

. Human anatomical waste (1)

. Animal waste (2)

. Microbiologyand Biotechnology waste (3)

. Soiled waste (6)

. Cytotoxic or Expired medicines (5)

. Chemical waste (10)

Non-chlorinated Plastic bags

Incineration or plasma pyrolysis or deep burial

Red . Contaminated wastes (recyclables)-tubing, bottles, IV tubes, sets, catheters, urine bags, syringes without needles and gloves (6,7)

Non-chlorinated plastic bag or containers

Autoclaving /Microwaving /Hydro chemical treatment and then sent for recycling. Not to be sent to landfill.

White . White sharps including metals (4)

(Translucent) Puncture, Leak and Tamper proof containers

Autoclaving or dry heat sterilization followed by shredding or mutilation or encapsulation

Blue . Glass wares (7) Cardboard boxes/ Puncture proof and leak proof boxes with blue colored markings

Disinfection or Autoclaving /Microwaving /Hydro chemical treatment and then sent for recycling (destructive Shredding)

3) USE OF PERSONAL PROTECTIVE EQUIPMENTS

PPE is designed to protect employees from workplace injuries or serious illnesses resulting from contact with chemical, radiological, physical or mechanical or other workplace hazards.

PPE When to wear Gloves Wear sterile gloves when handling sterile supplies, doing invasive

procedures. Wear clean gloves when cleaning or managing waste.

Eye wear (goggles, visor, face shield)

Protect eye when anticipating splash of infectious body fluids


Gowns and aprons Protect skin when risk of splashing or spraying of blood or body fluids contact is expected using impervious/plastic gowns. Prevent soiling of clothing during procedures that may involve contact with blood or body fluids.

Masks(Cloth or paper)

Protect mouth and nose from potential splashes from infectious fluid. Use when handling patient with respiratory diseases. Doing any invasive procedures. Conducting delivery.

Caps Used to keep the hair and scalp covered so that flakes o skin and hair are not shed into the wound during surgery.

Footwear Worn during procedures and patient-care activities when large-particle droplet spatter or sprays of blood or body fluids is anticipated.

Using appropriate PPE during common nursing procedures

Protection required

Common nursing procedures Types of exposure

Gloves helpful but not necessary

Bed making, back care, sponge bath, mouth care, minor wound dressing, perineal care, taking temperature, BP.

Low risk(Chances of direct contact with infectious body fluids is minimal)

Use gloves with waterproof aprons, for intubation, wear gloves, masks, goggles and apron.

Injections, lumbar puncture, insertion and removal of IV needles, PV examination, dressing large wounds, handling blood spills, intubations, suctioning and collecting blood.

Medium risk

All PPE Vaginal delivery, uncontrolled bleeding, surgery, endoscopes, dental procedures.

High risk

Sequence of donning of personal protective equipments

1. Footwear

2. Gown:

The correct gowning technique includes:

a. Unfold the sterile gown keeping inside of the gown towards the body without allowing outside of the gown to touch any area.

b. With hands at shoulder level, slip both the arms into the armholes simultaneously. c. Ask the other nurse to fasten the ties at the neck and back.


d. Remove gown avoiding touching of the soiled parts on the outside of the gown.e. Roll up the gown with the soiled part inside and discard.

3. Head cover

4. Mask:

The correct way of using mask includes:

a) Hold mask by top two strings and ties two top ties at the top of the back of head.b) Tie two lower ties snugly around the neck with the mask well under the chin.c) Ensures the mask covers mouth and nose adequately.d) When removing a mask, first unties the lower strings of the mask.e) Discard in appropriate container.

5. Goggles or face shield

6. Gloves:

The correct gloving technique:

i. Open the sterile glove packet of proper size on flat surface.ii. Identify the right and left hand and glove the dominant hand first.iii. With thumb and the first two fingers of the non dominant hand grasp on the edge of the

glove’s cuff touching only the inside surface.iv. Carefully pull the gloves over the dominant hand.v. With the gloved dominant hand, slip fingers underneath the second glove’s cuff.vi. Carefully put the second glove over the non dominant hand.vii. After the second glove is on, interlocks the finger together.

The technique of removal of gloves:

I. Remove the first glove by grasping it on its palmar surface. Pull the first glovecompletely rolling the glove inside out.

II. Place the first two fingers of the bare hand inside the glove and remove the secondcontaminated glove.

III. Dispose in appropriate container.Sequence of doffing of personal protective equipments

a. Glovesb. Gogglesc. Gownd. Mask or respiratore. Head gearf. Shoe cover


4) Standard precautions against airborne pathogens

Role of nurse while caring a patient with air borne diseases:

a. Separation of sputum smear for TB. b. Identify procedures that may put a health care provider at risk for airborne pathogens

like suctioning, nebulizer, bronchoscopy etc. c. Use mask appropriately. d. Ensure good ventilation. e. Educate patient and families to:

Report signs and symptoms of airborne pathogens. Observe cough hygiene. Complete course of treatment. Ensure good ventilation around.

5) Standard work precautions against blood borne pathogens

In health care settings, injuries from needles or other sharp instruments are the number-one cause of occupational exposure to blood borne infections. All staff who come in contact with sharps, from doctors and nurses to those who dispose of the trash are at risk of infections.

Sharps :

The term sharps refers to any sharp instrument or object used in the delivery of health care services, including hypodermic needles, suture needles, scalpel blades, sharp instruments, IV catheters, and razor blades.


Prevention of injuries from Sharps :

• Handle hypodermic needles and other sharps minimally after use and use extreme care whenever sharps are handled or passed.

• Use the "hands-free" technique when passing sharps during clinical procedures.

• Do not bend, break, or cut hypodermic needles before disposal.

• Do not recap needles.

• Dispose of hypodermic needles and other sharps properly.

Handling Sharps :

During a clinical procedure, healthcare workers can accidentally stick one another or their clients when passing sharps, especially when there is sudden motion by staff members carrying unprotected sharps, when clients move suddenly during injections, or when sharps are left lying in areas where they are unexpected (such as on surgical drapes).

Safe-passing of Sharp Instruments :

Uncapped or otherwise unprotected sharps should never be passed directly from one person to another. In the operating theatre or procedure room, pass sharp instruments in such a way that the surgeon and assistant are never touching the item at the same time. This way of passing sharps is known as the "hands-free technique:

1. The assistant places the instrument in a sterile kidney basin or in a designated "safe zone" in the sterile field.

2. The assistant tells the service provider that the instrument is in the kidney basin or safe zone.

3. The service provider picks up the instrument, uses it, and returns it to the basin or safe.

Managing Injuries and Exposure :

Studies have shown that cleaning a wound with an antiseptic or squeezing it does not reduce the risk of infection. If you are accidentally exposed to blood or other body fluids, either by a needle stick, an injury from another sharp object, or a splash of fluid:

• Wash the needle stick site or cut with soap and water.

• Flush splashes to the nose, mouth, or skin with water.

• Irrigate splashes to the eyes with water or saline.

Safe Disposal of Sharps:

Improper disposal of contaminated sharp objects can cause infections in your health care facility and community. Any delay in the disposal of sharps will increase the occurrence of accidents. To dispose of sharps correctly:

• Do not recap, bend, or break needles before disposal, and do not remove the needle from the syringe by hand.


• Dispose of needles and syringes immediately after use in a puncture-resistant sharps-disposal container.

• Incinerate sharps-disposal containers in an industrial incinerator whenever the containers become three-quarters full.

• To discourage scavenging of discarded sharps, decontaminate needles and syringes that cannot be incinerated and render them harmless before burying them.

Sharps-disposal Containers :

Puncture-resistant sharps-disposal containers should be conveniently located in any area where sharp objects are frequently used (such as injection rooms, treatment rooms, operating theaters, labour and delivery rooms, and laboratories). Decontaminating Needles and Syringes :

Whenever possible, make hypodermic needles and other sharps unusable by incinerating them. If sharps cannot be incinerated, reduce the risk of infections by decontaminating them before disposal, and bury them in a pit to make it difficult for others to scavenge them.

2.5 Concept of Triage Triage is an important concept in Emergency and Trauma care. Understanding it clearly and including it in the clinical policy will enable the patients to be treated in the correct area of the hospital.

There are three major reasons why triage is beneficial in the emergency and trauma care:

1. Triage separates out those who need rapid medical care to save life or limb. 2. By separating out the minor injuries, triage reduces the urgent burden on medical

facilities and organizations. On average, only 10-15% of disaster casualties are serious enough to require over-night hospitalization.

3. By providing for the equitable and rational distribution of casualties among the available hospitals, triage reduces the burden on each to a manageable level, often even to "non-disaster" levels.

When in a hospital setup

Triaging of patients in Emergency department In the emergency department “triage” refers to the methods used to assess patients' severity of injury or illness within a short time after their arrival, assign priorities, and transfer each patient to the appropriate place for treatment.

The Emergency Severity Index (ESI) is a five-level emergency department triage algorithm, initially developed in 1999. This differs from standardized triage algorithms used in several other countries, such as the Australasian Triage Scale, which attempt to divide patients based on the time they may safely wait.


The ESI levels are numbered one through five, with level one indicating the greatest urgency. The levels are as follows:

Level Name Description Examples

1 Resuscitation Immediate, life-saving intervention required without delay

Cardiac arrest Massive bleeding

2 Emergent High risk of deterioration, or signs of a time-critical problem

Cardiac-related chest pain Asthma attack

3 Urgent Stable, with multiple types of resources needed to investigate or treat (such as lab tests plus X-ray imaging)

Abdominal pain High fever with cough

4 Less Urgent Stable, with only one type of resource anticipated (such as only an X-ray, or only sutures)

Simple laceration Pain on urination

5 Non urgent Stable, with no resources anticipated except oral or topical medications, or prescriptions

Rash Prescription refill

Patient with ESI score 1 should get immediate attention and a patient with ESI score 5 can be treated in a non urgent basis.

When in outside hospital:

a. START Triage b. SALT Triage

START Triage

• Simple Triage And Rapid Transport. • Gold standard for field adult Mass Casualty Incident (MCI) triage in US and

numerous other countries. • Utilizes the four standard color triage categories. • Used for primary triage.

Triage level and colour coding

• Red Triage Tag (“Immediate” or T1 or Priority 1): Patients whose lives are in immediate danger and who require immediate treatment such as in the presence of severe and immediate risk to ABC requiring reversal, correction or safeguarding.


• Yellow Triage Tag (“Delayed” or T2 or Priority 2): Patients whose lives are not in immediate danger and who will require urgent, not immediate, medical care.

• Green Triage Tag (“Minimal” or T3 or Priority 3): Patients with minor injuries who will eventually require treatment;

• Black Triage Tag (“Expectant” or No Priority): Patients who are either dead or who have such extensive injuries that they can not be saved with the limited resources available.

Steps of START triaging 1. Fastest way to triage in the multiple causality event is to talk to the patient Hence, the

1st step in the Triage begins with checking of responsiveness.If response by replying to your question is clear and coherent, it means ABCD are alright at that moment.

2. If the patient does not respond, check for breathing and carotid pulse simultaneously, if both respiration and carotid pulse are absent, label the patient as BLACK, which means‘dead’.

3. Perform ABCD assessment in case of patient is responsive or unresponsive but presence of carotid pulse with or without breathing.

4. Label the patient as RED if respiration is absent or respiration present, but obstructed

breathing, Respiratory Rate > 30 or <8/ min or Absence of radial pulse or Capillary Refill > 2 sec or victim not following simple commands.

YELLOW category is assigned if the risks to ABCD are developing and should be taken care after red category patients have been taken care.

GREEN colour is assigned to walking and wounded patients who can be treated on outpatient basis.

BLUE colour is sometimes, assigned to patients who are called expectant, meaning, these patients need lots of resources in form of manpower, time and equipment compared to red and yellow category patients, hence are given priority after red and yellow category patients.


1. SALT TRIAGE : SALT MASS CASUALTY TRIAGE ALGORITHM (Sort, Assess, Life Saving Interventions, Treatment/Transport)

STEP 1: SORT SALT begins with a global sorting of patients, prioritizing them for individual assessment. Patients who can walk should be asked to walk to a designated area and should be assigned last priority for individual assessment. Those who remain should be asked to wave (ie, follow a command) or be observed for purposeful movement. Those who do not move (ie, are still) and those with obvious life-threatening conditions should be assessed first because they are the most likely to need lifesaving interventions STEP 2: ASSESS The individual assessment should begin with limited rapid lifesaving interventions. STEP 3: LIFESAVING INTERVENTIONS • Control major hemorrhage through the use of tourniquets or direct pressure provided by

other patients or other devices. • Open the airway through positioning or basic airway adjuncts (no advanced airway devices

should be used). If the patient is a child, consider giving 2 rescue breaths • Chest decompression • Auto injector antidotes Lifesaving interventions should be performed only within the responder’s scope of practice and only if the equipment is immediately available. STEP 4: TREATMENT/TRANSPORT Colour coding and categorization Patients should be prioritized for treatment and/or transport by assigning them to 1 of 5 categories: immediate, expectant, delayed, minimal, or dead. 1. GREEN Patients who have mild injuries that are self-limited if not treated and can tolerate a delay in care without increasing their risk of mortality should be triaged as minimal and should be designated with the color green. 2. BLACK Patients who are not breathing even after lifesaving interventions are attempted should be triaged as dead and should be designated with the color black.


3. RED. Patients who do not obey commands, or do not have a peripheral pulse, or are in respiratory distress, or have uncontrolled major hemorrhage should be triaged as immediate and should be designated with the color red. 4. GREY Providers should consider whether these patients have injuries that are likely to be incompatible with life given the currently available resources; if the injuries meet this qualification, then the provider should triage these patients as expectant and they should be designated with the color grey. 5. YELLOW The remaining patients should be triaged as delayed and should be designated with the color yellow. After immediate patients have been cared for, patients designated as expectant, delayed, or minimal should be reassessed as soon as possible, with the expectation that some patients will have improved and others will have decompensated. In general, treatment and/or transport should be provided for immediate patients first, then delayed, then minimal Expectant patients should be provided with treatment and/or transport when resources permit. Efficient use of transport assets may include mixing categories of patients and using alternate forms of transport. Some patients may only require treatment at the scene and not transport.


Adapted from: SALT mass casualty triage Algorithm: concept endorsed by the American College of Emergency Physicians, American College of Surgeons Committee on Trauma, American Trauma Society, National Association of EMS Physicians, National Disaster Life Support Education Consortium, and State and Territorial Injury Prevention Directors Association. Disaster Med Public Health Prep. 2008 Dec;2(4):245-6. [PubMed Citation] Conclusion This chapter focuses attention on the value of applying the simple but essential and important clinical approach of systematic assessment and action. Look, Listen and Feel (inspection, percussion, palpation and auscultation) to identify the risk to ABCD while ruling out important conditions as outlined in the NELS protocol and to treat these promptly and correctly.


In summary, NELS will give the skills to deal with serious illnesses and injuries. Throughout the course there are charts, exercises, discussions and practise sessions to impart the systematic approach to the practitioner and to provide the confidence in dealing with threats to life, limb and organs. The continuous application of Assessment followed by Action, first on the overall basis and then on organ specific basis will achieve best possible results for the patient and the clinical team.

Bibliography 1. Disaster Preparedness and Response. Tintinalli’s Emergency Medicine: A

Comprehensive Study Guide.2. KPP Abhilash. Trauma and Triage. Emergency Medicine Best Practices. 2019.3. Guidelines for common bio-medical waste treatment facility (august 2003). Central

pollution control board, New Delhi.4. The management of biomedical waste in Ontario. Legislative authority: Environmental

Protection Act, RSO 1990.5. Sax H, et al. ‘My five moments for hand hygiene’: a user-centred design approach to

understand, train, monitor and report hand hygiene. Journal of Hospital Infection. 2007.6. Pittet D, et al. Infection control as a major World Health Organisation priority for

developing countries. Journal of Hospital Infection. 2008.7. Allegranzi B, Pittet D. The role of hand hygiene in healthcare associated infection

prevention. Journal of Hospital Infection. 2009.8. Ellingson K, et al. Strategies to Prevent Healthcare Associated Infections through Hand

Hygiene. A Compendium of Strategies to Prevent Healthcare associated Infections inAcute care Hospitals. 2014.

9. Rutala W A, Weber D J. Centers for Disease Control and Prevention. Guideline forDisinfection and Sterilization in Healthcare Facilities. 2008.

10. Decontamination and Reprocessing of Medical Devices for Healthcare Facilites.WHOand Pan American Health Organization. 2016.


Lesson 3: Oxygenation: Airway and Breathing Lesson 3 Oxygenation: Maintaining Airway and Breathing

Objectives Upon completion of the lesson the trainee would be able to: Maintain oxygenation Identify airway patency and maintain it Predict a difficult airway Assess and manage airway problem Assess and manage breathing problem


Lesson 3: Oxygenation: Maintaining Airway and Breathing 3.1 Core Concepts

Maintenance of oxygenation and tissue perfusion is the primary goal of

resuscitation.

Assessment and management of the airway takes precedence over all other

management.

Oxygen must be administered to all critically ill or injured patients.

Assessment is not a one-time requirement; reassessment is required as pathology may worsen.

3.2 Clinical Anatomy and Physiology Airway is the passage through which the air passes during respiration.

It may be subdivided into :-

Upper Airway : from the nares and lips to larynx (mouth, nose, nasopharynx,

oropharynx, pharynx and larynx).

Lower Airway : comprising of the tracheobronchial tree (trachea, bronchi,

bronchioles and alveoli).

3.3 Oxygenation

3.3.1 Introduction Oxygen is a colorless, odorless, tasteless gas that is essential for the body to function

properly and to survive. The air that we breath in contains around 21% oxygen.

Oxygen is required to sustain life and it is carried from air through upper airway to

lungs in the alveoli, from where it diffuses into the blood.Normal functioning of heart

helps to circulate oxygen enriched blood to all organs of the body

Oxygen is carried in the blood combined with haemoglobin and dissolved in plasma

to reach all tissues and cells of the body for aerobic metabolism.


Oxygen is a gas, but when administered as a supplement to normal atmospheric air,

may also be considered as a medication (or drug).

Supplemental oxygen is used to treat medical conditions in which the tissues of body

do not get enough oxygenation.

3.3.2 Hypoxemia

Definition: Hypoxemia is low levels of oxygen in the blood and hypoxia is when oxygen supply is insufficient.

Management of hypoxia Assessment Actions Remarks

Look if patient is

breathing normally,

look for features

suggestive of

hypoxia such as

restlessness,

agitation, decreased

consciousness level,

cyanosis (late sign),

low SpO2.

Monitor oxygen saturation

using a pulseoximeter at the

earliest.

If breathing is abnormal,

assist ventilation with

oxygen .

Identify and treat the cause

of hypoxia.

Give oxygen therapy, if

features are suggestive of

hypoxia or oxygen

saturation is below normal

(SpO2< 94%).

Remember in a patient

with suspected chest

trauma always ventilate

with caution.

A tension

pneumothorax should

always be ruled out.

Do a needle/tube chest

decompression

immediately if a tension

pneumothorax is

suspected.

Administer oxygen to

all critically ill and

injured patients.

3.3.3 Oxygen therapy

Definition

A therapeutic intervention for administering more oxygen than that exists in the

atmosphere is called as oxygen therapy. The provision of therapeutic oxygen is required

whenever hypoxemia occurs.


Purposes

To relieve hypoxia

To relieve anoxia

To relieve respiratory distress

Signs and symptoms of respiratory

distress

Indications

Tachycardia.

Tachypnea.

Dyspnea.

Shortness of breath.

Restlessness.

Mental confusion and weakness.

Cyanosis.

Respiratory failure.

Cardiac conditions : myocardial

infarction and congestive heart

failure.

Pulmonary edema, shock,

hemorrhage.

Airway obstruction.

All trauma patients should receive

oxygen, if possible.

3.3.4 How and how much oxygen to be administered

Assessment of

the condition

Amount of oxygen to be

administered

Method of administration

Chronic

obstructive

pulmonary

disease (COPD).

Oxygen at an oxygen flow of

3L/min.

Target SpO2 is between 88 to 92%

in order to preserve hypoxic

respiratory drive.

Initiate oxygen therapy with a

venturi mask at 24% oxygen.

If the patient is

critically ill or in

peri-arrest

condition.

Oxygen flow 12 L/min should be

given.

Higher levels of supplemental

oxygen aiming for higher

saturations during their initial

resuscitation phase should be

Patients should be made to sit in

upright posture as far as possible

(or the most comfortable posture

for the patient) unless there is a

reason to immobilize the patient

(e.g., skeletal or spinal trauma).


given.

In these situations, invasive or

noninvasive ventilation may be

indicated.

A high flow of oxygen using a

non-rebreathing mask with

reservoir or Bag Valve Mask

(BVM) device should be used.

Apnoeic patient. Oxygen flow of 12 L/min. BVM device

Mild hypoxia

(SpO2 is 90-

94%).

Oxygen flow of 4-6 L/min.

Nasal cannula, simple face mask

or venturi mask.

Hypoxia is

moderate (SpO2

75–89%), and

severe (SpO2 <

75%)

Oxygen flow of 12 L/min. Non- rebreathing mask or BVM

device.

If the SPO2 does

not improve

In an alert patient.,

Consider non-invasive

positive pressure ventilation

(NPPV)

If the patient cannot tolerate

NPPV or the patient is not alert,

Consider performing tracheal

intubation and respiration

needs to be assisted with

oxygen enrichment.

3.3.5 Method of oxygen administration

Equipment for oxygen delivery

Oxygen source (cylinder or central pipeline), pressure gauge, flow meter, key to

open cylinder

Tubing connecting the oxygen source to patient’s oxygen administration device,

with or without humidifier bottle.


Oxygen administration devices like nasal cannula, face mask, non-rebreathing

mask which are variable performance devices while Venturi mask, BMV device

are fixed performance devices.

For advanced airways, Laryngeal mask airways, Combitube, endotracheal tube and tracheostomy tube etc. are used.

Oxygen administration devices

Nasal cannula/prongs.

Masks

– Simple mask

– Venturi mask

– Partial re-breather mask

– Non re-breather mask

– Bag and mask ventilation

Oxygen hood

Table 3.1 : Various oxygen devices, concentration and its rate

*Oxygen flow at 1L/min will yield an oxygen delivery of 24%. Increasing the oxygen flow by

every 1 litre/min will increase the inspired oxygen concentration by 4% approximately.

S. No Device Oxygen delivered (Litre / mt) FiO2 (%)

1 Nasal cannula /prongs 1-6 24-44

2 Simple mask 6-10 40-60

3 Venturi mask 4-12 24-60

4 Partial re-breather 6-15 70-90

5 Non re-breather 6-15 60-90

6 Bag and mask ventilation 8-12 90-100

7 Oxygen hood 12 -15 50-60


Nasal cannula/prongs

Simplest method and best for most patients with breathing difficulty who are unable

to tolerate mask. It delivers oxygen through two cylindrical hollow tubes with half inch prongs placed

into patient’s nostrils. Mainly used to provide low concentration of oxygen and long term oxygen therapy.

The oxygen flow rates for nasal prongs range from 1 to 4 litre/min. Oxygen flow at 1L/min will yield an oxygen delivery of 24%.Increasing the oxygen

flow by every 1 litre/min will increase the inspired oxygen concentration by 4% approximately.

Ideal for patients with chronic lung disease. Nasal prongs are ineffective for patients in respiratory distress or arrest.

Simple face masks

Simple face mask fit over the nose and mouth with open side ports to allow air to get

entrained and allow the escape of carbon dioxide.


The mask fitted carefully around the head with the help of an elastic strap and tubing attached to an oxygen source, in order to avoid any oxygen leakage.

Mask should be comfortable, snug but not too tight against the patient’s face so that patient can breath through nose or, mouth.

A simple face mask can deliver a concentration of oxygen between 35%-50%. The oxygen flow rate is 5-10 L/min.

Venturi mask

Venturi masks provide a more predictable oxygen concentration to the patient by

mixing precise amount of oxygen and atmospheric air.

Adapters within the tube which are color coded or regulated by a dial system permitting only specific amounts of room air mix with oxygen.

The oxygen flow required to achieve the appropriate concentration is defined on the mask attachment.

Humidification can be added.

Table 3.2 : Colour coding and oxygen concentration of Venturi mask

S.NO. COLOUR FiO2 (%) RATE OF OXYGEN (LITRE/MINUTE)

1 BLUE 24 2 L/min

2 WHITE 28 4L/min

3 ORANGE 31 6 L/min

4 YELLOW 34 8 L/min

5 RED 40 12 L/min

6 GREEN 60 15 L/min


Partial re-breather mask

Inhales a mixture of atmospheric air, oxygen from its source, and oxygen contained

with in reservoir bag.

It provides a means for recycling oxygen and venting all the carbon dioxide during expiration from the mask.

During expiration first third of exhaled air enters the reservoir bag.

This contains high proportion of oxygen as it comes from upper airways.

Once the reservoir bag is filled the remainder for exhaled air is forced from the mask through small ports.

Non - rebreather mask

All exhaled air leaves the mask rather than partially entering the reservoir bag.

Designed to deliver FiO2 of 90-100% when the flow is set to greater than 11 L/min.

Contain one way valve that oxygen from its source and as well as the oxygen in the reservoir bag to be inhaled.


Has a series of one-way valves preventing exhaled air from returning to the bag.

No air from the atmosphere is inhaled.

All the air that is exhaled is vented from the mask.

Humidification is not used.

The oxygen reservoir should be full prior to placing the mask on a patient and the flow rate is set so that the when the patient inhales, the bag does not collapse.

Bag and mask ventilation

Bag Value Mask (BVM) is a hand-held device used to provide positive pressure

ventilation to a patient who is not breathing or who is breathing inadequately. It consists of a self-inflating bag, one-way valves and face mask. Squeezing the bag as the victim inhales helps to deliver oxygen in respiratory

depression. It can deliver up to 100 percent oxygen to a breathing or non-breathing victim when

attached to emergency oxygen. Oxygen should be attached and the flow rate of oxygen should be set at 12 L/min.

Oxygen hood


An oxygen hood is used for babies who can breathe on their own but still need extra oxygen.

A light portable structure made of clear plastics & attached to a motor driven unit.

Useful for high concentrations of oxygen (50-60%) & for circulation of moist air around the patient.It will provide low moderate concentration of oxygen in a temperature controlled environment.

Secure tent & place machine at head of bed with control knobs on opposite side where working area is required.

Signs and symptoms of oxygen toxicity

Non –productive cough and sore throat

Substernal chest pain

Nasal stuffiness and headache

Nausea, vomiting and fatigue

Hypoventilation

Safety precautions associated with oxygen therapy

Ensure that the patient is having patent airway and check for any conditions that may prevent it like nasal congestion, secretions etc.

Post "Oxygen" and "No Smoking" signs.

Check for continuous humidified oxygen supply with no interruptions and kink in the oxygen tubes.

Inform the patient and visitors of the requirement for no smoking and no open flames in the room.

Ensure that oil or grease is not used around the oxygen fittings.

If an oxygen tank is used, secure it away from the door and high traffic areas.

Use only non sparking wrenches on tanks/cylinders.

Ensure that all electrical equipment is properly grounded.

When transporting a large oxygen cylinder, strap it to the carrier.

Always secure the oxygen cylinder. Upon falling, the weight of the cylinder may injure personnel or patients and damage equipment, walls, and flooring and the valve of the cylinder could possibly break off.

Documentation

Indications for oxygenation.

Percentage of litre flow of oxygen administration.

Type of delivery device.


Duration of oxygenation.

Patient’s response to oxygen therapy.

Signature, date and time.

3.4 Is the airway patent (not obstructed)? 3.4.1 Airway obstruction

Introduction

A blockage or obstruction in the airway may partially or totally prevent air from

getting into the lungs. It may occur at any point from the mouth down to the trachea

and bronchial tree. Airway obstruction may be partial or complete. Patients with

complete airway obstruction rapidly get hypoxic, while in partial obstruction, the onset

of hypoxia may be insidious.

Upper airway obstruction occurs in the area from nose and lips to larynx.

Lower airway obstruction occurs in the area between larynx and lungs, generally

caused by increased resistance in the bronchioles leading to reduction in the amount of

air inhaled with each breath. Causes of upper airway obstruction

Intraluminal mechanical obstruction due to the presence of blood, vomitus, foreign

body, secretions or tumor.

Tongue falling back against the posterior pharyngeal wall. This is seen in patients with

reduced conscious level as in head injury, effect of drugs and toxins e.g.

benzodiazepines, opiates and alcohol.

External compression of the airway caused by hematoma, tumor or a large goiter.

Swelling and edema of the soft tissues of pharynx and larynx following trauma (e.g.

blunt trauma to maxilla, mandible, larynx, burns, smoke inhalation) and infections

(e.g. croup, epiglottitis, tracheitis, peritonsillar abscess or retropharyngeal abscess).

Allergy/ angioedema.

Artificial airways if present may get displaced or blocked due to secretions or kinking.

Tracheal stenosis following prolonged mechanical ventilation.

Neuromuscular disorders such as myasthenia gravis, Guillain Barre syndrome.

Paralysis of the vocal cord.


Causes of lower airway obstruction

Asthma.

Chronic obstructive pulmonary disease (COPD) that include chronic bronchitis and

emphysema.

Bronchiolitis.

The signs and symptoms suggestive of an obstructed airway

Inability to speak clearly and in complete sentence.

Noisy breathing.

Laboured breathing- suprasternal, intercostal, and subcostal retraction, increased use

of accessory muscles of respiration, paradoxical chest and abdominal movements

(‘see-saw’ respirations)

Breathing may be rapid, shallow, or slow

The ominous and paradoxical absence of airway sounds, no air movement can be felt,

breath sounds are absent on auscultation.

Hand-to-the-throat choking sign.

Agitation/ restless/ fidgeting, confusion due to hypoxia.

Bluish discoloration of skin and mucous membrane(cyanosis) may occur due tohypoxia (a late sign of hypoxia).

3.5 Predicting a difficult airway

Several factors such as facial hair, shape of jaw, abnormal or absent teeth, limited mouth opening, large tongue, short neck, high larynx, pregnancy, soft tissue swelling as a result of burns, allergy/angioedema, infection and haematoma, maxillofacial or mandibular trauma, cervical spine injury or arthritis and obesity may cause difficulty in managing the airway.

To predict difficulty in bag-mask ventilation, one may use the mnemonic MOANS or BONES.

MOANS

M Mask seal difficult or impossible (e.g. facial abnormality)

O Obesity (BMI>26) or upper airway Obstruction

A Advanced age

N No teeth

S Snorer


BONES B Bearded individual

O Obesity (BMI>26)

N No teeth

E Elderly (age>55 years)

S Snorer

Patients having ≥ 2 predictors are likely to have difficult mask ventilation.

The mnemonic "LEMON" represents five simple and rapid assessment methods, which are helpful in assessing for potentially difficult laryngoscopy and intubation.

L Look externally Look for anatomic features suggestive of potential difficulties such as a short neck, obesity, facial hair, edentulous patient, buck teeth, high arched palate, big tongue, facial or neck trauma or swelling, etc.

E Evaluate the 3:3:2 rule

Examination of the airway anatomy the 3-3-2 rule.

Full mouth opening can accommodate 3 (patient's) fingerbreadths.

Distance between the mentum and the hyoid bone is 3fingerbreadths. It measures the ability of the mandible toaccommodate the tongue.

Distance between the top of the thyroid cartilage and themandible (floor of mouth) is 2 finger breadths. Thismeasurement externally assesses for a high larynx.

M Mallampati classification

Intraoral structures visible

Class I : Soft palate, fauces, uvula, pillars (easy laryngoscopicview of glottis)

Class II : Soft palate, fauces, portion of uvula(easylaryngoscopic view of glottis)

Class III : Soft palate, base of uvula (difficult laryngoscopicview of glottis)

Class IV : Hard palate only (impossible view of glottis usingconventional laryngoscopy).


O Obstruction of the airway

If evidence of obstruction is present, one has to find that, Is the obstruction above, at or below the level of glottis? Is the obstruction fixed or mobile? How rapidly is the obstruction progressing?

N Neck mobility Can the patient flex neck (rest chin on chest) and extend the head at atlantoaxial joint (look at the ceiling)? Normal movements are flexion >25-30º Extension >80-85º Rotation >70-75º.

Mallampati classification of the oropharyngeal view. It indicates the amount of space within the oral cavity to accommodate the

laryngoscope and tracheal tube. To perform a Mallampati evaluation, have the patient seated, head protruding

forward mimicking the sniffing position, mouth wide open, sticking the tongue outwithout phonation.

The observer's eye should be at the level of patient's mouth. Observe the degree to which faucial pillars, soft palate, uvula and hard palate are

visible. In supine patients, the Mallampati score can be estimated by asking the patient to

open the mouth fully and protrude the tongue; in comatose patients use a tongueblade.

CLASS I Soft palate, uvula, fauces, pillars visible (easy laryngoscopic view of glottis)

CLASS II Soft palate, uvula, fauces visible (easy laryngoscopic view of glottis)

CLASS III Soft palate, the base of uvula visible (difficult laryngoscopic view of glottis)

CLASS IV Hard palate only visible (impossible view of glottis using conventional laryngoscopy)


Algorithm 1: Airway Assessment and Management

*MILS (Manual Inline Stabilization) Algorithm 2: Airway patent or protected


Is the airway patent or obstructed?Refer to algorithm 1 The quickest method to assess airway and breathing is by talking to a patient and getting an

appropriate verbal response.

ASSESSMENTS ACTIONS REMARKS

Look for signs

suggestive of airway

obstruction

- Suprasternal,intercostal, andsubcostalretraction,

- Increased use ofaccessory musclesof respiration,

- Paradoxical chestand abdomenmovement,

- Signs of airwayinjury(haematoma),

- Swelling inneck/mouth.

Listen for noisy

breathing, snoring,

stridor.

Feel for air movement

(in complete airway

obstruction there may

be a total absence of

airway sounds, no air

movement can be felt

and breath sounds are

absent on auscultation.

However, a transient

tracheal tug,

supraclavicular and

If there are signs of partial or complete

airway obstruction, take measures,

depending on the cause, to relieve this

obstruction.

If there are secretions, blood,

vomitus, etc. in the mouth, it

should be cleared using a suction

device. Remove a foreign body, if

visible, in the mouth.

In an unresponsive patient, airway

obstruction may occur, due to

tongue falling back against the

posterior pharyngeal wall. Simple

maneuvers such as head tilt-chin

lift and jaw thrust may help in

relieving airway obstrction.

Use of airway devices such as

oropharyngeal or nasopharyngeal

airway may be considered.

Advanced airway device such as

laryngeal mask airways or tracheal

tube may be required in some

cases to maintain airway patency.

A simple Heimlich maneuver may

be useful in relieving airway

obstruction due to choking.

A patient with airway obstruction

It should be remembered

that in patients in whom

trauma is suspected, no

airway maneuver or

procedure should be

done prior to taking

measures for cervical

spine protection such as

manual in-line

stabilization. In these

patients jaw thrust

maneuver is done, if

required, and head tilt-

chin lift maneuver is

avoided.

Continuous monitoring

should be done. ( Cardiac

monitor, noninvasive

blood prerssure, pulse

oximeter)

Intravenous line should

be secured

All airway equipment

should be kept at hand.

(working laryngoscope,

ETTs)

All appropriate drugs


intercostal indrawing,

paradoxical chest and

abdomen movement

may be seen until

frank respiratory arrest

supervenes.)

may have positioned himself in the

best breathing position for optimal

airflow thus making this patient

supine may precipitate the loss of

airway.

Patients with lower airway

obstruction require treatment with

bronchodilator albuterol by multi

dose inhaler or nebulizer; and oral

or intravenous corticosteroids

depending on the severity.

If the patient is to be ventilated, set

up the ventilator and prepare drugs

for long-term sedation

should be ready.

Personal protective

equipment should be

present (gloves, mask,

eye shield)

3.6 Is the airway protected? If there is no airway obstruction or it has already been taken care of then, look for airway protection.


Assess or Gag

reflex, is it

intact?

Gurgling sound,

Drooling,

absence of

swallowing

reflex,

unconscious

patient, tolerating

oropharyngeal

airway suggest

that airway is not

protected.

Aim is to protect the airway of the patient and prevent aspiration Recovery position (lateral)

may be given to patients who

have a reduced conscious level

(e.g. alcohol excess). This

position lowers the risk of

aspiration and protects the

airway. The tongue and jaw is

pushed forward, maintaining

airway patency and allows

passage for secretions or vomit

out of the mouth, with the help

of gravity.

The head end of the bed or

Recovery position should not

be given to patients in whom

trauma is suspected.

An airway that appears

uncomplicated may deteriorate

rapidly as pathology worsens.

One must anticipate and

recognize such situations (e.g.

upper airway burns,

anaphylaxis, penetrating

injuries to the neck) and act

promptly and correctly.

A simple airway may be

rendered difficult due to

improper positioning, non-


Assess to diagnose

the potential for a

difficulty airway and

be prepared, (lack of

indicators of a difficult

airway is not an

assurance).

trolley may be lowered to

allow gravity to drain

secretions away from the

glottic opening to prevent

aspiration.

Patients who are unconscious,

in whom airway reflexes are

not intact, require tracheal

intubation (definitive airway)

so that there is no soiling of the

airway with gastric contents.

Definitive airway is defined as

a tube placed in the trachea

with the cuff inflated below the

vocal cords, the tube connected

to some form of oxygen-

enriched assisted ventilation

and the airway secured in place

with a tape, e.g. endotracheal

tube and tracheostomy tube.

Watch for signs of airway

deterioration; these require

urgent intervention. An

increasing work of breathing,

fatigue, decreasing conscious

state, restlessness and cyanosis

(late sign) are suggestive of a

deteriorating airway.

Recognize an immediate need

for a surgical airway in cannot

ventilate/cannot intubate

scenario.

availability of proper

equipment and lack of trained

personnel.

Maintaining oxygenation is

most important. It is not wise

to pursue attempts to place a

tracheal tube rather than

maintaining oxygenation.


3.6.1 Indications for placing a definitive airway include: Patients with Glasgow Coma Scale (GCS) score < 9.

Apnoea.

Unstable midface trauma, Airway injuries.

Flail chest or lung contusion causing respiratory failure.

High aspiration risk with no gag reflex.

Inability to otherwise maintain an airway or oxygenation.

Tracheal intubation in a trauma patient with suspected cervical spine injury should

be done after applying manual in-line stabilization (MILS). If a tracheal tube cannot

be inserted, ventilation via advanced airway adjuncts such as a laryngeal mask

airway may be attempted as a bridge to a definitive airway.

If attempts to intubate have failed and ventilation is not possible using other

advanced airway adjuncts or by bag valve mask device, in such a case surgical

cricothyroidotomy, must be performed immediately.


3.7 Breathing Assessment and Management (refer to Algorithm 2 and 3)

Once airway patency and airway protection have been taken care, next step is to assess and manage the breathing.

Algorithm 2: Breathing Assessment and Management

Algorithm 3: Breathing Assessment and Management

Go to algorithm 2



Look:

Is patient's colour

normal or appears

cyanosed?

Does he look

distressed? Chest

wall movement, is it

normal and

symmetrical?

Is the patient using

accessory muscles

of respiration?

Is the respiratory

rate

normal/slow/fast?

Is breathing pattern

regular/irregular?

Listen: Can patient speak in

full sentence?

Is breathing noisy?

On auscultation,

check that the

breath sounds are

bilateral, equal on

both sides or not.

Feel: Is the trachea

central?

Is there distension

of neck veins?

Check for soft

Make the patient in a

comfortable position

If a stethoscope is available,

lung auscultation should be

performed and, if possible, a

pulse oximeter should be

applied.

Check if patient is breathing.

This can be simply done by

observing the chest rise for

five to ten seconds

If the patient is breathing,

you need to assess whether

his breathing is normal or

abnormal. In an adult, the

normal respiratory rate is

between 12 to 20 breaths /

minute.

In a patient who is not

breathing (gasping is also

considered as not breathing),

check for the presence of

carotid pulse.

If carotid pulse is present,

give breaths (10 to 12

breaths/min) using a bag-

valve-mask device,

preferably with a reservoir

bag. Attach oxygen at 12

l/min flow rate

However, if a carotid pulse is

absent, immediately start

Identify the pattern of

breathing:

Tachypnoea

Hyperpnoea

Hyperventilation

Hypoventilation

Cheyne-Stokes

respiration

Biot’s respiration

Kussmaul's

respiration

Apneustic

Ataxia

Treat the suspected

cause

For eg.

- Tension

pneumothorax

- Open

pneumothorax

- Massive

haemothorax

- Flail chest

- Rib fractures

- Lung contusions.

Ensure proper

monitoring -

saturation, respiratory

rate, pulse, ECG,


tissues (surgical

emphysema/crepitu

s) and bony

structure of chest

wall for integrity.

cardiopulmonary

resuscitation (CPR): 30:2

If patients already have an

advanced airway in place,

they should be given

continuous chest

compressions and breaths at

the rate of 10/minute.

However, if no advanced

airway is in place follow 30

compressions and 2 breaths

sequence.

Inhaled medications can be

given to treat bronchospasm.

blood pressure.

3.8 Scenarios

Scenario 1

A 30 years man, has met with a road traffic accident, he is unconscious, has blood stained secretions in the mouth, gurgling and snoring sound is heard.

Assess: Is the airway patent? The answer is no because he has bloody secretions in the mouth, gurgling and snoring sound are heard.

Action: Since, he is a trauma victim, ask an assistant to apply MILS. An oropharyngeal suction is done, jaw thrust is given to open the airway. The airway is now patent. To maintain airway patency, insert an oropharyngeal airway (has an absent gag reflex).

Assess: Is the airway protected? The answer no, because he is unconscious and his gag reflex is absent.

Action: Prepare for tracheal intubation with MILS as airway protection is needed.

Assess: Is he breathing normally? After tracheal intubation, respiratory effort appears to be adequate.


Scenario 2

An 18 years boy is assaulted with a bamboo stick. He is conscious, has extensive facial injuries and is bleeding from mouth and nose. He is spitting blood out of his mouth.

Assess: Is the airway patent? May be not, as there is blood in oral and nasal cavity which can

be potential threat to patency of the airway. Attach the monitors.

Action: Since he is a trauma victim ask an assistant to apply a cervical collar and MILS

whenever required. Perform oropharyngeal suction and administer oxygen (according to

SpO2 measurement).

After oral suction patient is now talking, means that airway is patent.

Assess: Is the airway protected?

The answer is yes, as he is able to spit blood and able to talk.

Assess: Is he breathing normally? Yes, suggested by regular chest movement and able to talk

clearly.

Assess and Reassess frequently neck and chest or life threatening injuries and GCS for

neurological trauma.

Caution / Risk: If he loses consciousness, the clinician should be prepared to support his

airway and breathing. Scenario 3 A 57 years man has difficulty in breathing, He is conscious, has laboured breathing, has supraclavicular and intercostal indrawing and is unable to speak in full sentence. He has a past history of coronary artery disease and CABG was done four years back. There is no history of trauma.

Assess: Is the airway patent? The answer is yes.

Assess: Is the airway protected? The answer is yes.

Assess: Is he breathing normally? The answer is no, he has laboured breathing,

supraclavicular and intercostal indrawing and is unable to speak in full sentence.

Action: Administered high flow O2 @12 L/min through the non-rebreathing mask. Applied

vital sign monitors.


Assess: Respiratory rate is 38/min, pulse rate is 142/min, BP is 170/104 mmHg, SpO2is 90%,

chest bilateral basal fine crepts are present.

Action: Keep in propped up position, give high flow oxygen through non rebreathing mask.

If required support ventilation by using noninvasive positive pressure ventilation (NPPV) or

invasive positive pressure ventilation (IPPV).

Re-assess: Identify and treat the cause.

Scenario 4

A 20 year man starts coughing while eating. He is not able to speak and has stridor. He is seen to be clutching his neck.

Assess: Is the airway patent? The answer is no, probably a food bolus is obstructing the

airway.

Action: Ask "Are you choking?" He nods to say "yes." Inform him and give Heimlich

Maneuver to relieve the obstruction. After four abdominal thrusts, food bolus comes out, the

airway is now patent.

Assess: After the maneuver is the airway protected? The answer is yes.

Assess: After the maneuver, check: Is he breathing normally? The answer is yes.

Scenario 5 45 years morbidly obese lady, was operated for cholecystectomy, a day before. In the post-operative ward, after some sedative medication, her breathing becomes laboured, the monitor shows fall in oxygen saturation (88%), she is conscious and oriented but restless.

Assess: Is the airway patent? The answer is no, as there is obstructed breathing.

Action: Insert a nasopharyngeal airway (to relieve obstruction, as the gag reflex is present),

Administer oxygen using a venturi mask (50% oxygen).

Assess: Obstructed sound disappears, can breathe comfortably. The oxygen saturation

improves to 95%.

Assess: Is the airway protected? The answer is yes.


Assess: Is she breathing normally? The answer is yes.

Scenario 6 A 29 years young man comes to the emergency room with difficulty in breathing for 1 day. He has history of fever, sore throat and cough for the last 2 days. He appears distressed and is using accessory muscles of respiration. He is a known asthmatic for four years taking salbutamol inhaler, off and on.

General appearance: Looks distressed

Assess Airway: Talk to the patient. He is able to speak coherently but speaks with difficulty

in interrupted sentences with frequent pauses. Upper airway is patent and protected.

Assess Breathing: He appears distressed and is using accessory muscles of respiration,

respiratory rate is 30/min, the trachea is central. On auscultation, air entry is diminished

bilaterally with a widespread expiratory wheeze. SpO2 is 91% on room air.

Actions: Give fowler’s position.

Give oxygen by the nasal prongs at 4L/min.

Give Salbutamol and Ipratropium nebulization to the patient.

Salbutamol 2.5 mg/dose by nebulization (2mg/5ml of solution), or, by multidose inhaler, 4

puffs (100ug/puff) at 2-3 min intervals.

Secure a vascular access and administer drugs (Hydrocortisone IV 5 mg/kg body weight)

Antimicrobials: Intramuscular Injections of Ampicillin (25-50 mg/kg/day) 400 mg 6 hourly,

Gentamicin 60 mg once a day and Cloxacillin 400 mg 6 hourly.

After acute phase recovery, follow oral antimicrobial: Ampicillin (125mg/5ml suspension)

50-100 mg/kg/day, per oral in divided doses every 6 hourly, maximum 12 gm per day

Assess Circulation: Patient is warm and sweaty, capillary refill is <2 seconds, pulse rate is

110 per minute, blood pressure is 110/75 mmHg, heart sounds are normal on auscultation.

Action: There appears to be no circulatory problem. Tachycardia is probably due to hypoxia.

Assess Disability: Neurological status of the patient is intact.

Action: No further action is currently required for neurological status.

Reassess: Patient has symptomatically improved.

Airway: Patent.

Breathing: Respiratory rate is 18/min; SpO2is 94% on nasal prongs with oxygen 3 L/min.


Circulation: Pulse rate is 90/min; BP is 124/80 mmHg

Action: Continue the nebulization, steroids and antimicrobial drugs.

Bibliography 1. Managing airway obstruction. British Journal of Hospital Medicine 2012; 73 (10): 156-60.

Available from:http://www.ucl.ac.uk/anaesthesia/StudentsandTrainees/ManagingAirwayObstruction.

2. Khan RM. Airway Assessment. In: Khan RM, Maroof M, editors. Airway management.4th ed. Paras medical; 2011.P. 14-37.

3. Airway and ventilatory management, ATLS manual 9th edition, P. 30-49.

4. Airway Management of the Trauma Victim

Available from: http://www.trauma.org/archive/anaesthesia/airway.html

5. O’Driscoll BR, Howard LS, Earis J, et al. BTS guideline for oxygen use in adults inhealthcare and emergency settings. Thorax 2017; 72:i1-i90.

6. Taylor CR, Lillis C, LeMone P, Lynn P. Fundamentals of Nursing: The Art and Science ofNursing Care 7th edition; 2012.P.1377.


Lesson 4

Skills: Airway and Breathing

Lesson 4 Skills for maintaining airway and breathing for nurses

Objectives Upon completion of the lesson the trainee would be able to perform / assist the following procedures for maintaining Airway and Breathing. A. Performed Procedures

1. Oro-pharyngeal / Nasopharyngeal suctioning. 2. Head tilt chin lift. 3. Jaw thrust to open the airway. 4. Oro-pharyngeal airways insertion. 5. Nasopharyngeal airways insertion. 6. Bag valve mask (BVM) / bag mask ventilation. 7. Manual in line stabilization. 8. Endotracheal intubation. 9. Backward, upward, rightward pressure

(BURP). 10. Supraglottic devices (SGD) Placement and

Application. 1) Classic Laryngeal mask airway (C-LMA). 2) Intubating Laryngeal mask airway (ILMA). 3) Pro Seal Laryngeal mask airway (PLMA).

11. Perform Heimlich manoeuver in adult and babies.

12. Placement in Recovery Position. 13. Mechanical Ventilation in Adults in ED.

B. Assisted Procedures

1. Needle cricothyroidotomy 2. Surgical cricothyroidotomy


Lesson 4 Skills: Airway and Breathing A) Performed Procedures

SKILL 1: ORO-PHARYNGEAL/NASO- PHARYNGEAL SUCTIONING

DEFINITION

Aspirating secretion of upper respiratory tract through a catheter connected to a suction machine or wall suction outlet can be defined as oro-pharyngeal/Naso pharyngeal suctioning.

Routes for Suctioning

Oral To remove secretions from the mouth and performed using a yankeur suction catheter.

Oropharyngeal Extends from the lips to the pharynx. Oropharyngeal suctioning requires the insertion of a suction catheter through the mouth to the pharynx.

Nasopharyngeal Extends from the tip of the nose to the pharynx. The suction catheter is inserted through the nostrils in to the pharynx.

PURPOSES

To open the airway

INDICATIONS

Secretions seen in oral cavity. Gurgling sounds in semi conscious or, unconscious patients. Patient feels/ indicates the presence of secretions in his / her airway. Airway obstruction. Altered chest movements. Restlessness. Cyanosis and Decreased oxygen saturation levels. Diminished air entry. Tachypnoea. For assessment of airway patency, sputum sample collection and cough reflex

stimulation.


EQUIPMENTS

Vacuum source with adjustable pressure. Regulator suction jar. Stethoscope. Sterile gloves. Sterile suction catheter (rigid or, soft plastic). Mask. Sterile disposable container for fluids. Sterile water/Normal saline (to liquidifying the thick secretions). Bag Valve Mask device with oxygen attached at 12L/min to pre-oxygenate the

patient.


PROCEDURE No STEPS 1 Perform a comprehensive respiratory assessment including following parameters and

document on the Respiratory assessment chart Breath sounds Oxygen saturation Respiration rate and pattern Haemodynamic parameters (pulse rate, Blood pressure) Cough effort. Sputum characteristics (colour, volume, consistency and odor) Ventilator parameters (PIP, TV and FiO2)

2 Explain procedure to patient /care taker to reduce stress 3 Assemble equipment within easy reach: ensuring suction apparatus is in correct working

order and set to appropriate pressure Neonate 60-80 mm Hg Child 80-100 mm Hg Older Child/ Adult 100-120 mm Hg

4 Turn on the wall suction or portable suction machine and adjusts the pressure regulator according to policy. Test the suction equipment by occluding the connection tubing.

5 Place the linen-saver pad or towel on the patient’s chest.

6 Place in a comfortable secure position. Ask for assistance if needed. Encourage care taker’s involvement if appropriate. a. For Oropharyngeal suctioning: Semi-Fowler’s position with patient’s head turned toward the nurse. b. For Nasopharyngeal suctioning: Semi-Fowler’s position with patient’s head

hyperextended (unless contraindicated). 7 Wash hands and apply alcohol gel.

Put on disposable apron and facial equipment as appropriate.

8 Don sterile gloves; keep the dominant hand sterile; consider non dominant hand non sterile.

9 Pour sterile saline into the sterile container, using the non dominant hand. 10 Pick up the suction catheter with the dominant hand and attach it to the connection

tubing (to suction). 11 Put the tip of the suction catheter into the sterile container of normal saline solution and

suction a small amount of normal saline solution through the suction catheter. Apply suction by placing a finger over the suction control port

12 Analyse the depth to which to insert the suction catheter: a. Oropharyngeal suctioning: Measure the distance between the edge of the patient’s

mouth and the tip of the patient’s ear lobe. b. Nasopharyngeal suctioning: Measure the distance between the tip of the patient’s

nose and the tip of the patient’s ear lobe. 13 The patient should receive hyper oxygenation by the delivery of 100% oxygen for >30

seconds prior to the suctioning (by increasing the FiO2 of mechanical ventilator).


14 Using the non dominant hand, remove the oxygen delivery device, if present. If the patient’s oxygen saturation is < 94%, or if he/she is in any distress, administer supplemental oxygen before, during, and after suctioning

15 Lubricate and insert the suction catheter: a. Oropharyngeal suctioning 1) Lubricate the catheter tip with normal saline. 2) Using the dominant hand, gently but quickly insert the suction catheter along the side

of the patient’s mouth into the oropharynx. 3) Advance the suction catheter quickly to the pre measured distance (usually 7 to 10 cm

in the adult), being careful not to force the catheter. 4) Apply continuous suction while rotating the suction catheter during removal. b. Nasopharyngeal suctioning 1) Lubricate the catheter tip with water soluble lubricant. 2) Using the dominant hand, gently but quickly insert the suction catheter into the naris. 3) Advance the suction catheter quickly to the premeasured distance (13 to 15 cm in the

adult), being careful not to force the catheter. 4) If resistance is met, try using the other naris. 5) Apply continuous suction while rotating the suction catheter during removal.

16 Place a finger (thumb) over the suction control port of the suction catheter and start suctioning the patient. Apply suction while withdrawing the catheter in a continuous rotating motion.

17 Limit suctioning to 5 to 10 seconds. 18 After the catheter is withdrawn, clear it by placing the tip of the catheter into the

container of sterile saline and apply suction. 19 Lubricate the catheter and repeat suctioning as needed, allowing at least 20-second

interval between suctioning. For nasopharyngeal suctioning, alternate nares is chosen each time when suctioning is repeated.

20 Coil the suction catheter in the dominant hand. Pull the sterile glove off over the coiled catheter. (Alternatively, wrap the catheter around the dominant gloved hand and hold the catheter while removing the glove over it.)

21 Make the patient comfortable. 22 Replace Articles. 23 Wash hand. 24 Record the procedure :

The amount, consistency, color and odor of the secretions. Client breathing status (including Respiratory rate and Spo2) before and after

suctioning Record complications including trauma and bleeding during procedure

COMPLICATIONS

Hypoxia / hypoxemia. Tracheal and / or bronchial mucosal trauma. Cardiac or respiratory arrest. Pulmonary hemorrage / bleeding Cardiac dysrhythmias Pulmonary atelectasis


Bronchoconstriction / bronchospasm Trauma, coughing, gagging/vomiting and bradycardia due to vagal stimulation. Hypotension / hypertension Elevated ICP Interruption of mechanical ventilation Pneumothorax Bacterial infection Discomfort/pain Overstimulation of secretions Laryngospasm Sepsis Nosocomial infection

SKILL 2: HEAD TILT-CHIN LIFT MANEUVER

Fig: Head tilt and chin lift maneuver

DEFINITION The head-tilt/chin-lift is a procedure used to prevent the tongue obstructing the upper airways. In patients who have a decreased level of consciousness, the tongue can fall backward and obstruct the hypopharynx. This form of obstruction can be corrected readily by the chin-lift or jaw-thrust maneuvers. The airway can then be maintained with an oropharyngeal or nasopharyngeal airway. Maneuvers used to establish an airway can produce or aggravate c-spine injury, so inline immobilization of the c-spine is essential during these procedures.

PURPOSE

To open the airway.

To inspect for actual or potential obstruction.

STEPS

One hand is placed on the patient’s forehead and gentle, firm, backward pressure is applied using the palm of the hand.


The fingers of other hand are placed under the bony part of the chin.

Lift the chin forward and support the jaw, helping to tilt the head back.

This manoeuvre lifts the patient’s tongue away from the back of the throat and provide an adequate airway.

POINT TO REMEMBER

If a cervical spine injury is suspected, then the modified jaw thrust would be used in place of "head-tilt, chin-lift" - the jaw thrust is a technique used on patients with a suspected spinal injury and is used on a supine patient

. SKILL 3: JAW THRUST

Fig: Jaw thrust

DEFINITION

The jaw thrust maneuver is a procedure used to prevent the tongue from obstructing the upper airways. This is used in cervical injurypatients and is also an alternative if a head tilt/ chin lift is unsuccessful.

PURPOSE

To open the airway

STEPS

Stand behind the patient.

Grasp the angles of the patient’s lower jaw, and lift upwards with both hands towards ceiling, one on each side displacing the mandible forward.

Suction the airway for secretions and debris using a tonsil tip suction device or large suction tubing, if required.


Documentation Record the procedure. Mention the reason of unsuccessful procedure.

SKILL 4: ORO-PHARYNGEAL AIRWAY


DEFINITION

An oropharyngeal airway (also known as an oral airway, OPA or Guedel airway) is a medical device that is used to maintain or open a patient's airway by preventing the tongue from covering the epiglottis. An oropharyngeal airway is made of plastic and is available in various sizes. (0 to 6 Fr). OPAs come in four adult sizes (6, 5, 4, 3, 2) and three (1, 0, 00) for children.

PURPOSE

To open the airway and prevent falling back of tongue.

It displaces the tongue anteriorly and relieves soft tissue obstruction of the airway.

USES

1) To maintain open airway.

2) Prevent endotracheal tube occlusion.

3) Prevent tongue bite.

4) Facilitate suction.

5) Conduit for passing devices into oropharynx.

6) Obtain a better mask fit.

CONTRAINDICATIONS

1) Intact gag reflex.

2) Oropharyngeal growth.

EQUIPMENTS

Oropharyngeal airway

Tongue depressor

Xylocaine jelly

Suction catheter

Suction apparatus


STEPS

Choose an oropharyngeal airway of appropriate size by measuring the distance from the corner of patient’s mouth to the angle of the jaw and apply xylocaine jelly. If the airway is improperly sized, it will occlude the airway and may harm the patient.

Open mouth using cross finger or scissor finger technique.

Insert the airway upside down with its tip pointing towards the roof of mouth; upon touching the soft palate (posterior aspect of pharynx) rotate it through 180° into anatomical position, with flange resting against lips or teeth.

Alternatively, a tongue depressor may be used to depress the tongue, the airway is then inserted in anatomical position following the normal curvature of oropharynx with flange resting on lips or teeth.

Suction should always be available to clear the airway of any visible secretions or foreign body.

Assess for the airway patency and auscultate the breath sounds.

POINTS TO REMEMBER

If gag reflex or, oro-pharyngeal trauma is present, do not use Oro-Pharyngeal Airway.

Never use an oro-pharyngeal airway which is small in size, as it may depress the tongue back into pharynx obstructing the airway.

Never use an oro-pharyngeal airway which is long in size, as it may press the epiglottis against the entrance of the trachea obstructing the airway.

COMPLICATION

Airway trauma

Intolerance requiring removal

Vomiting/aspiration in patient with intact gag reflex

Incorrect size or placement can potentially exacerbate airway obstruction.

DOCUMENTATION

Date and Time of insertion. Name of the Nurse on duty.


Document the size of airway. Condition and reaction of the patient.

SKILL 5: NASOPHARYNGEAL AIRWAY

Fig: Nasopharyngeal airway

DEFINITION

A nasopharyngeal airway is a type of airway adjunct that is designed to be inserted into the nasal passageway to secure an open airway in conscious or, semi conscious patients. A nasopharyngeal airway is usually made of plastic or rubber and is available in various sizes i.e- (6.0–9.0).

PURPOSE

To maintain airway patent in patients with an intact gag reflex. It reduces risk of unintentional extubation. It enables swallowing and oral hygiene.

EQUIPMENTS

Nasopharyngeal airway

Xylocaine jelly

STEPS

Choose a nasopharyngeal airway of appropriate size by measuring the tip of thepatient’s nose to their ear lobe. One thing to keep in mind is the diameter of theairway in relation to the patient’s nostril.

Lubricate the end of the tube well with lubricating jelly.

When inserting the airway, lift slightly on the tip of the nose with the free hand andgently insert it into the patient’s nostril with the bevel facing the nasal septum.

Advance the device carefully along the floor of the nasopharynx, following its naturalcurvature until the flange rests against the nostril in the posterior pharynx behind thetongue.


Never force the tube, if resistance is felt.

Inorder to aid nasopharyngeal tube insertion, rotate the tube gently.

Try inserting nasopharyngeal tube through other nostril, if resistance persists.

Check for airway patency and auscultate breath sounds.

POINTS TO REMEMBER

Never consider nasal airways in patients, who have face or, nasal trauma, basilar skull fractures, nose deformities and coagulation disorders.

COMPLICATION

Epistaxis

Incorrect size or placement will compromise effectiveness.

Exacerbate injury in base of skull fracture.

Known history of nasal polyp.

DOCUMENTATION

Date and Time of insertion. Name of the Nurse on duty. Document the size of airway. Reaction and condition of the patient. Bleeding, if occurred.

SKILL 6: BAG AND MASK VENTILATION

Fig: A Fig: B


DEFINITION

A bag valve mask is a manual resuscitator or "self-inflating bag" commonly used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately.

PURPOSE

To assist or provide ventilation.

EQUIPMENTS

Bag mask valve device,

Appropriate size face mask

O2 connecting tubing

Gloves

Disposable Face mask

Oxygen @ 15 l/min attached to bag-mask valve device.

STEPS

Put on face mask and gloves Apply the mask on patient’s face. Create an airtight seal between the mask and his face using one hand (E-C clamp

technique) and squeeze the bag with the other hand to provide ventilation. If unable to create a leak proof seal with one hand, then two persons work together.

The first person applies the mask to the patient’s face, performing a jaw-thrust maneuver and ascertaining a tight seal with both hands. The second person provides ventilation by squeezing the bag with both hands and maintain a patent airway.

Check for chest rise and maintain adequate respiratory rate and tidal volume by ventilating the patient by delivering breath over one second.

Ventilation has to be done till definitive airway and ventilation methods are achieved. POINT TO REMEMBER

Avoid being too aggressive while ventilating with bag mask as it may cause gastric distention which may lead to aspiration and vomiting.


COMPLICATION

Distention of stomach due to wrong holding of the mask. This may lead to regurgitation of gastric contents.

DOCUMENTATION

Client status: Vital signs, SpO2

Mask size used.

SKILL 7: MANUAL IN-LINE STABILIZATION (MILS)

DEFINITION

Manual In-Line Stabilisation (MILS) is a procedure that provides a degree of stability to the cervical spine prior to the application of a cervical collar.

PURPOSES

To prevent cervical spine movement during performance of a procedure such as tracheal intubation, during transport, applying cervical collar or during cricothyroidotomy.

STEPS

Aim is to splint cervical vertebrae/ neck which is the most mobile part of the body to avoid further damage to cervical spine.

MILS can be achieved from varying positions dependant on the scene environment, access to the patients and the patient’s presenting position.Splinting is done by fixing patient’s head and chest using different hands and arm positions

The head should always be supported by two hands or both knees on either side of the head (top right) to maintain adequate stabilisation.The nurse providing MILS should attempt to stabilise their elbows/arms on the ground, against another stable object or on their knees/torso to prevent their arms from swaying as they become fatigued.

In one of the methods, the mastoid processes of the patient are firmly grasped, to prevent movement of the cervical spine during tracheal intubation.Force is applied to counteract the lifting force of the laryngoscope during tracheal intubation to minimize displacement of the cervical spine.

Some of the ways to protect cervical spine are shown in figures below.


Fig: A Fig: B

Fig: C Fig: D

COMPLICATIONS

Worsens laryngeal visualization during direct laryngoscopy. DOCUMENTATION

Date and time of the procedure performed. Purpose for carrying out the procedure. Name of the Nurse on duty.

SKILL 8: ENDOTRACHEAL INTUBATION


DEFINITION

Endotracheal intubation is a procedure by which a flexible tube is inserted through the mouth or nose and into the trachea beyond the vocal cords that acts as an artificial airway.

PURPOSES

To have a definitive airway.

Removal of secretions and allows for deep tracheal suction.

Allows mechanical ventilation.

Inflated balloon seals off trachea so aspiration from the GI tract cannot occur.

Generally easy to insert in an emergency, but maintaining placement is more difficult so this is not for long-term use.

EQUIPMENTS

1) Laryngoscope (with alternative blade size available) and working light source (check batteries and bulb regularly)

2) Appropriately sized endotracheal tube (disposable, single use) with low pressure cuff with connector to connect tube to ventilator or resuscitation bag.

3) Stylet to guide the ET tube 4) Gum-elastic bougie 5) Oral airway (assorted sizes) or bite block to keep patient from biting into and

occluding the ET tube 6) Laryngeal mask airway 7) A tie to secure it Sterile anesthetic lubricant jelly (water-soluble) 8) 10-mL syringe 9) Suction source 10) Suction catheter and tonsil tip suction device 11) Resuscitation bag and mask connected to oxygen source 12) Sterile towel 13) Gloves


14) Face shield 15) End tidal CO2 detector

STEPS

Prepare the patient for intubation. Remove dentures, if any(if the patient has full dentures is better to retain it in place. Place the patient in supine position. Rise the head 2 inches . Remove the headboard of bed.

Prepare the drugs beforehand and confirm patient trolley can be tilted. Select a endotracheal tube of appropriate size. Usually for adults the size will be 8-9mm. Check its cuff for leaks. By inflating and deflating the cuff. Make sure that the laryngoscope is in functioning condition. Ventilate and pre-oxygenate the patient for atleast 3 minutes before intubation, using

Ambu bag with tight fitted mask. This decreases the chances for development of myocardial ischemia and arrhythmia.

In case of no cervical spine injury, elevate the patient’s head about 10 cm with a folded sheet or pillow, while resting the shoulders on the bed (sniffing position), or in neutral position with application of MILS if cervical spine injury is suspected.

Open the mouth, inspect oral cavity and then, insert the laryngoscope from the right corner of the patient’s mouth and push the tongue left. Hold the laryngoscope in the left hand.

Lower the laryngoscope till it reaches to the root of tongue. Lift the laryngoscope forward(towards ceiling)without levering on the teeth to expose the

epiglottis. Lift the epiglottis with the blade of the laryngoscope for visualization of glottis and vocal cords.

If glottis is not visible, ask the assistance to press the larynx backward and upward. Once the vocal cord are visualized , hold the laryngoscope steady and insert a well

lubricated tube into the right corner of patient’s mouth . Guided by the blade and keeping the vocal cords in view, gently pass the tube through the space formed by the vocal cords Never exert any force . It can damage the vocal cords and injury the laryngeal nerves.

Suction the airway if and when required Stop the tube at the point when the cuff of the tube has passed beyond the vocal cords. Withdraw the laryngoscope, holding the endotracheal tube in place. Observe the expansion of the lungs in both sides by the movement of the chest. Also

assistance to auscultate the chest on the both sides for the air entry. Inflate the cuff with minimal amount of air. The pilot balloon of the cuff should be

distended. Connect the BVM device or ventilator to the endotracheal tube by means of an ET tube

connector. Confirm tube placement by capnography, auscultation Secure the ET tube adequately with a cloth tie or tape.


Post Intubation care of patient.

Connect the patient to monitor for hemodynamics monitoring. Give adequate Analgesia and Sedation to the patient. Secure the ET tube. Raise the head of the bed to at least 30°which may or may not help prevent Ventilator

Assisted Pneumonia (VAP), but it definitely helps lung mechanics. Confirm lung protective ventilation settings Humidify the air either with a humidification circuit on the ventilator or a Heat-Moisture-

Exchanger (HME) Place In-Line Suction catheter. In-line suctioning is better than intermittent with sterile

technique. Suction the mouth each time you suction the tube and also, whenever necessary.

Check the cuff pressure every day.

Initiate Gastric Tube feeding.

Provide oral care and skin care to the patients.

COMPLICATIONS

1. Laryngeal or tracheal injury

Sore throat, hoarseness of voice.

Glottic edema.

Trauma (damage to teeth or mucous membranes, perforation or laceration of pharynx, larynx, or trachea).

Aspiration.

Bronchospasm.

Laryngospasm.

Ulceration or necrosis of tracheal mucosa.

Vocal cord ulceration, granuloma, or polyps.

Vocal cord paralysis.

Formation of tracheal–esophageal fistula

Formation of tracheal–arterial fistula.


2. Lung infection & bradycardia (due to vagal stimulation).

3. Dependence on artificial airway (oesophageal or right main bronchus intubation, excessive leak, aspiration,cuff leak, tube occlusion.)

DOCUMENTATION

Date and Time of insertion Name of the Nurse on duty. Drugs given during intubation Document the size of ET Length of ET inserted Cuff pressure Mode of ventilation

SKILL 9: BACKWARD, UPWARD, RIGHTWARD PRESSURE (BURP)

DEFINITION

A technique commonly used during laryngoscopy, is the posterior displacement of the larynx by putting pressure on the thyroid or cricoid cartilage. The maneuver was termed BURP as an acronym for “backward-upward-rightward pressure” of the larynx.

PURPOSES

In case of a difficult intubation, it significantly improves the visualization of the vocal cords.

To prevent filling of the esophagus and stomach with air during use of a bag-valve-mask.

STEPS

This is performed by the clinician performing laryngoscopy.


The thyroid cartilage is grasped between the thumb and index or middle finger.

Pressure is applied in backwards direction (larynx abuts the cervical vertebrae), in upward direction (larynx is pushed superiorly) and rightward direction (lateral movement of the larynx).

COMPLICATIONS

Incorrect application may worsen glottic view in laryngoscopy.

Potential for airway trauma.

DOCUMENTATION

Date and time of procedure performed. Any complications.

Skill 10: Supraglottic devices (SGD) DEFINITION

Supraglottic devices are a group of airway devices that can be inserted into the pharynx to allow ventilation, oxygenation, and administration of anesthetic gases, without the need for endotracheal intubation. The most commonly used SGD in the operating room are the laryngeal mask airways (LMAs). These are not definite airways and is contraindicated where there is a risk of aspiration..

PURPOSE

Impending or actual loss of airway patency or protection, where advanced airway management is necessary, but the clinician is unable to secure airway through tracheal intubation. These are rescue airways in the failed intubation algorithm.

i) Classic Laryngeal Mask Airway (C-LMA)


DEFINITION

Laryngeal mask airway is composed of a tube with a cuffed masklike projection at the distal end, which is inserted through the mouth into the pharynx inorder to seal the larynx and leave distal opening of tube just above glottis, so it is called as supraglottic device. PURPOSE

a. Easy to place than ET tube because visualization of vocal cords is not necessary.

b. Provides ventilation and oxygenation comparable to that achieved with an ET tube.

STEPS

The optimal head position for insertion of the classic laryngeal mask airway (C-LMA) is sniffing position.

Choose the correct size of LMA usually size 3 for females and size 4 for males. Check the LMA cuff for leaks. Deflate and lubricate the posterior surface of LMA cuff with water soluble jelly. Hold the LMA with the dominant hand in a pen holding manner, with the index finger

placed at the junction of the cuff and the shaft and the LMA opening oriented over the tongue.

Pass the LMA behind the upper incisors, with the shaft parallel to the patient’s chest and the index finger pointing toward the intubator.

Push the LMA into position along the palatopharyngeal curve, with the index finger maintaining pressure on the tube and guiding the LMA into the final position.

Inflate the cuff with the correct volume of air (indicated on the shaft of the LMA). Check the placement of the LMA by applying bag-mask-to-tube ventilation. Visually observe chest excursions with ventilation.

ii) Intubating Laryngeal Mask Airway (ILMA)

DEFINITION

ILMA is designed to serve as a conduit for intubation. It consists of anatomically curved short stainless steel tube, sheathed in silicone, bonded to a laryngeal mask and a guiding stainless steel handle.


ILMA size 3, 4 and 5 can accommodate size 7, 7.5 and 8 mm tracheal tube respectively. STEPS

Choose correct size of ILMA usually size 3 for females and size 4 for males. Check the ILMA cuff for leaks. Deflate the cuff and lubricate the posterior surface of cuff with water-soluble jelly. Hold the ILMA by the metal handle. Open the patient’s mouth and insert the mask into the mouth with its posterior surface

on the hard palate, and push it back against the hard palate. Slide the mask backward, following the curve of the palate and posterior pharyngeal

wall. Swing the ILMA into place. Inflate the cuff to a pressure of 60 cm of water. Ventilate the patient with the ILMA. Slight adjustment in position may be necessary. Lubricate the tracheal tube and insert it through the ILMA to appropriate depth and

inflate its cuff. Resume ventilations. Check for correct placement. To remove ILMA, deflate the ILMA cuff and remove 15 mm adaptor from the ET

tube. Use the obturator to keep the ET tube at its correct depth while the ILMA is removed. As soon as possible, grasp the ET tube at the mouth. The ILMA is removed entirely. Reattach the 15-mm adaptor and resume ventilations. Check correct placement and secure the ET tube with adhesive tape.

iii) ProSeal Laryngeal Mask Airway (PLMA)


DEFINITION The LMA ProSeal has the addition of a channel for the suctioning of gastric contents. STEPS

Choose the correct size of PLMA usually size 3 for females and size 4 for males. Check the LMA cuff for leaks. Deflate and lubricate the posterior surface of PLMA cuff with water soluble jelly. Insert it like the classic LMA or after attaching it to a rigid insertion handle, it can be

inserted like ILMA. COMPLICATION

Failure to provide adequate airway or ventilation, It can precipitate vomiting and aspiration in a patient with intact airway reflexes,

airway trauma, patient intolerance. Laryngospasm and bronchospasm

DOCUMENTATION

Date and Time of insertion. Name of the Nurse on duty. Drugs given during insertion of LMA. Document the size of LMA. Cuff pressure.


SKILL 11: HEIMLICH MANEUVER OR ABDOMINAL THRUSTS

DEFINITION

The Heimlich maneuver is an emergency technique for removing a foreign object lodged in the airway that is preventing a child or an adult from breathing.This maneuver lifts diaphragm and creates positive pressure in the thorax which causes the foreign object to be expelled from airway.

PURPOSES

The Heimlich Maneuver is the most effective way to remove something stuck in an

adult’s or older child’s throat. It is indicated in victim of choking on objects that obstruct airway (pharynx) and it

helps to push out the foreign body. STEPS

For Adults

● Conscious and coughing: May be able to dislodge the object on his own. Encourage to

cough and you may give back blows.

● Conscious, not coughing, unable to speak or breathe, signaling for help, typically by

holding his hands around the throat


a) Get the person to stand up and take position behind the choking person and wrap your arm around his or her waist.

b) Make a fist and place thumb side of the fist against middle of person’s abdomen just above the navel and well below the ribs.

c) Grabthe fist with the other hand into the person’s abdomen and push it with quick, inwards and upward thrusts at the same time.

d) Perform five abdominal thrusts until the object is coughed up, or, the patient breathes on his own.

For Special cases

If the patient is pregnant or obese, then place your hand a little higheron the chest to compress, rather than on the abdomen.

Alternatively, if the person can’t stand up, straddle their waist, facing their head. Push your fist inward and upward in the same manner as you would if they were standing.

If unconscious, place the victim on the back and try to clear the airway with your finger in a sweeping motion, preferably under vision If you can’t remove the lodged object, start chest compressions.


For Infants

Determine if the infant can cry or cough. If infant is choking and cannot cough, cry or breathe, then follow the Heimlich Maneuver as follows : Step 1 - Sit down and hold the infant face down on your forearm, which should

be resting on your thigh Step 2 - Give 5 back blowsgently with the heel of your hand. If that doesn’t work, Step 3 - Position the infant face up and resting on your forearm and thigh so their

head is lower than their trunk. Step 4- Give 5 quick chest compressions by placing two fingers at the center of

their breastbone. Step 5 -Look in the mouth to check if you can see the object. Step 6 - Repeat steps 2and4 above until the object is expelled and the infant can

breathe or cough on their own. Following the expulsion of the object, keep the victim still. If the infant becomes unresponsive, perform CPR and call for medical assistance.

Fig: Heimlich Maneuver for infants

For children

Stand or kneel behind the child, who may be seated or standing. Make a fist with one hand, and place it with thumb toward the child, below the rib

cage and above the waist. Encircle the child's waist, placing the other hand on top of the fist then gives a series

of five quick and distinct inward and upward thrusts. If the foreign object is not dislodged, the cycle of five thrusts is repeated until the

object is expelled or the child becomes unresponsive. As the child is deprived of oxygen, the muscles of the trachea relax slightly, and it is possible that the foreign object may be expelled on a second or third attempt.

If the victim is unconscious or becomes unconscious, lay him or her on the floor, bend the chin forward, make sure the tongue is not blocking the airway, and feel in the mouth for the foreign object.


Astride the child's thighs and place the fists between the bottom of the victim's breast-bone and the navel then executes a series of five quick compressions by pushing inward and upward.

After the abdominal thrusts, repeat the process of lifting the chin, moving the tongue, feeling for and possibly removing the foreign material.

If the airway is not clear, repeat the abdominal thrusts as often as necessary. If the foreign object has been removed, but the victim is not breathing, start CPR.

The technique in children over one year of age is the same as in adults, except that the amount of force used is less than that used with adults in order to avoid damaging the child's ribs, breastbone, and internal organs.

COMPLICATIONS

Esophageal laceration Gastric rupture Rib fracture Retinal detachment Pneumomediastinum Diaphragmatic rupture Liver and spleen rupture Aortic dissection and aortic valve rupture

DOCUMENTATION

Date and time of procedure Reason for carrying out the procedure and the outcome. Reaction and level of consciousness of the victim. Notification to the physician..

SKILL 12: RECOVERY POSITION

DEFINITION

The recovery position is a position maintained on a lateral recumbent or three-quarters prone position of the victim which is unconscious but breathing and can be placed as part of first aid treatment.

PURPOSES

To keep their airway clear and open by pushing the tongue and jaw forward. It also ensures that any vomit or secretions won't cause victim to choke and drain out

with the help of gravity.


STEPS

Place the person lying on their back, then kneel on the floor at the side victim is to beturned.

Place the arm nearest to you at a right angle to their body with their hand upwards, towardsthe head. (Fig A)

Tuck their other hand under the side of their head across his chest, so that the back of theirhand is touching their cheek.(Fig B)

Bend the knee farthest from you to a right angle using one hand. With the other hand hold the victims far side shoulder. Carefully roll the victim on to your side by pulling with both your hands simultaneously. The

top arm should be supporting the head and the bottom arm will stop you rolling them toofar. (Fig C)

Keep the lower leg straight while keeping the upper leg bent. (Fig D) Open their airway by gently tilting their head back and lifting their chin, and check that

nothing is blocking their airway Stay with the person and monitor their condition.

Fig: A Fig: B

Fig: C Fig: D


COMPLICATIONS

In case of cervical injury, putting the victim in recovery position may lead to paralysis.

DOCUMENTATION

The nurse must record: Level of consciousness of the victim Duration of the position maintained Any complications like cervical injury.

SKILL 13: MECHANICAL VENTILATION IN ADULTS IN ED

DEFINITION

It is a useful modality for patientswho are unable to sustain the level of ventilation necessary to maintain the gas exchange functions -oxygenation and carbon dioxide elimination.

INDICATIONS

Clinical criteria

• Apnoea or hypopnea with respiratory arrest (RR<8/min)• Acute respiratory distress with altered mentation.• Clinically increasing work of breathing. (RR<35/min)• Obtundation and need for airway protection..• Acute lung injury (including ARDS, trauma).• Obstructive diseases like COPD.• Controlled hyperventilation ( in head injury)• Severe circulatory shock like hypotension including sepsis, shock, CHF• Neurological diseases such as Muscular Dystrophy and Amyotrophic Lateral

Sclerosis

Laboratory criteria (if equipments are available)

ABG values of PaO2<50 mm Hg with FiO2>60%, ABG values of PaCO2>50 mmHg and pH <7.32. Vital capacity <10ml/Kg, Negative Inspiratory force < 25 cm H2O and FEV1 <10

ml/Kg.

SETTING UP OF A VENTILATOR

Tidal volume

Tidal Volume (TV) of 5-8 mL/kg of ideal body weight is started and adjusted to keep plateau pressure less than 35 cm H2O.


Respiratory rate

Set a respiratory rate (RR) of 8-12 breaths per minute. Based on assessment of the patient and response to initial setting, respiratory rate may be decreased to as low as 5-6 breaths per minute in asthmatic patients, COPD ( Chronic Obstructive Airway Disease), ARDS( Acute respiratory Distress Syndrome) when using a permissive hypercapnic technique.

Supplemental oxygen therapy

Initial setting is kept at 100% oxygen. Once monitoring is initiated and patient is stabilized the lowest FiO2 that produces arterial oxygen saturation (SaO2) greater than 94% and a PaO2 greater than 60 mm Hg is adjusted.

Inspiration/expiration ratio

The normal inspiration/expiration (I/E) ratio to start with is 1:2. This is reduced to 1:4 or 1:5 in the presence of obstructive airway disease in order to avoid air-trapping (breath stacking) and auto-PEEP or intrinsic PEEP (iPEEP).

Inspiratory flow rates

Inspiratory flow rates are set at 60 L/min. Inspiratory flow rates are a function of the TV, I/E ratio, and RR and may be controlled internally by the ventilator.

Positive end-expiratory pressure (PEEP)

Use of PEEP of 3-5 cm H2O is common to prevent a decrease in functional residual capacity in normal lungs. The reasoning for increasing levels of PEEP in critically ill patients is to provide acceptable oxygenation and to reduce the FiO2 to nontoxic levels (FiO2 < 0.5). The level of PEEP must be balanced such that excessive intrathoracic pressure (with a resultant decrease in venous return, hemodynamic instability and risk of barotrauma) does not occur. PEEP reduces the incidence of ventilator-induced lung injury and decreases venous return to the right side of the heart by increasing intrathoracic pressure.

Mode of Ventilation in ED:

The choice of mode of ventilation in emergency setting would depend on the patient assessment with regards to the need of ventilation and respiratory status

Synchronous Intermittent Mandatory Ventilation (SIMV)

Synchronized intermittent mandatory ventilation (SIMV) is a versatile mode that can be used for initial settings. The ventilator delivers pre-set breaths in coordination with the


respiratory effort of the patient. Spontaneous breathing is allowed between breaths. Synchronization between pre-set mandatory breaths and the patient's spontaneous breaths attempts to limit barotrauma. One disadvantage of SIMV is increased work of breathing, though this may be mitigated by adding pressure support on top of spontaneous breaths.

Assist Control (A/C)

Assist Control (A/C) mode is a good choice in apnoeic, paralyzed intubated patient with normal lungs and is a full support mode in that the ventilator performs most, if not all, of the work of breathing. Full support reduces oxygen consumption and CO2 production of the respiratory muscles.

Pressure Support Ventilation (PSV)

Pressure Support Ventilation (PSV) is a good initial choice in a patient with therespiratory effort with moderate respiratory failure. For the spontaneously breathingpatient, pressure support ventilation (PSV) has been advocated to limit barotraumaand to decrease the work of breathing. Pressure support differs from A/C and SIMVin that a level of support pressure is set to assist every spontaneous effort. Airwaypressure support is maintained until the patient's inspiratory flow falls below acertain cut off (e.g., 25% of peak flow). The patient determines the tidal volume,respiratory rate, and flow rate. Withsome ventilators, there is the ability to set a back-up SIMV rate should spontaneous respirations cease.

PSV is frequently the mode of choice in patients whose respiratory failure is notsevere and who have an adequate respiratory drive. It can result in improved patientcomfort, reduced cardiovascular effects, reduced risk of barotrauma, and improveddistribution of gas.

Monitoring During Ventilatory Support

Cardiac monitoring, blood pressure, and pulse oximetry (SaO2) must be monitored. Arterial blood gas (ABG) measurement is frequently obtained 10-15 minutes after the institution of mechanical ventilation. End-tidal CO2 is breath to breath measurement and is indicator of ventilation and acid base status. It is also helpful in detection of tube blockade or ventilator disconnection. Peak inspiratory and plateau pressures should be assessed frequently. In general, however, parameters may be altered to limit pressures to less than 35 cm H2O. Expiratory volume is checked initially and periodically to ensure that the set tidal volume is delivered. Any indication of an air leak must prompt a search for underinflated tube cuffs, open tubing ports, or worsening pneumothorax. In patients with airway obstruction, monitor auto-PEEP.


NURSING CARE OF A PATIENT ON VENTILATOR

• Caring for a patient on mechanical ventilation requires teamwork, knowledge of caregoals, and interventions based on best practices, patient needs, and response to therapy. Mechanical ventilation has become a common treatment, and nurses must be knowledgeable and confident when caring for ventilator patients.

• Assess the patient first and then ventilator.• Assess patient’s vital signs, lung sounds, respiratory status, breathing pattern and note

any changes from previous findings. • Perform continuous cardiac monitoring, blood pressure and SpO2 level with

pulseoximeter and note any changes from previous findings• Monitor the patient’s blood pressure every 2 to 4 hours, especially after ventilator

settings are changed or adjusted.• Mechanical ventilation causes thoracic-cavity pressure to rise on inspiration, which

puts pressure on blood vessels and may reduce blood flow to the heart; as a result,blood pressure may drop.

• To maintain hemodynamic stability, you may need to increase Intravenous fluids oradminister inotropic drugs such as dopamine or norepinephrine, if ordered.

• Monitor skin colour for O2 saturation.• Monitor lungs for bilateral expansion, auscultate for breath sounds and note any

changes from previous findings. • Keep suction equipment near to the patient for usage.• Assess need for suctioning and Monitor color, amount and consistency of sputum• Maintain asepsis meticulously Maintain sterile technique when suctioning• Hyperoxygenate the patient before and after suctioning to help prevent oxygen

desaturation. • Don’t instill normal saline solution into the endotracheal tube in an attempt to

promote secretion removal. • Limit suctioning pressure to the lowest level needed to remove secretions.• Suction for the shortest duration possible.• Assess ventilatory settings• Compare current ventilator settings with the settings prescribed in the order.• Assess level of water in humidifier and temperature of humidification system• Ensure alarms are set• Familiarize yourself with ventilator alarms and the actions to take when an alarm

sounds • When cause of alarm cannot be determine, ventilate manually with resuscitation bag• Look for a bag-valve mask, which should be available for every patient with an

artificial airway; be sure you know how to hyperventilate and hyperoxygenate thepatient

• Turn the patient every 2 hourly.• Performing range-of-motion exercises and patient turning and positioning to prevent

the effects of muscle disuse• Having the patient sit up when possible to improve gas exchange, and providing

appropriate nutrition to prevent a catabolic state.• Assess the patient’s tolerance when nurse performs an activity by checking vital

signs, oxygenation status, and pain and agitation levels.• Have resuscitation equipment available at bedside.


• Secure ETT properly. • Monitor ABG value • Assess for possible early complications such as rapid electrolyte changes, severe

alkalosis and Hypotension secondary to change in Cardiac output.

• High levels of inspiratory pressure with PSV and PEEP increase the risk of barotrauma and pneumothorax. To detect these complications, assess breath sounds and oxygenation status often. To help prevent these conditions, use the lowest pressure level for ventilator-delivered breaths and adjust the level as tolerated.

• Monitor for signs of respiratory distress (Restlessness, Apprehension. Irritability and increase HR.)

• Begin tube feeding as soon as it is evident the patient will remain on the ventilator for a long time.

• Weigh daily.

• Monitor Intake and out put.

• Monitor bowel sounds.

• Monitor for GI Bleed.

• Communicating with the patient is essential, Provide writing tools or a communication board so patients can express their needs.

• Ask simple yes/no questions to which patient can nod or shake his head. • Assess the patient’s pain and anxiety levels. • Assess pain level using a reliable scale. • Keep in mind that a patient’s acknowledgment of pain means pain is present and must

be treated. • Self-extubation can occur despite physical restraints. It’s best to treat agitation and

anxiety with medication and non pharmacologic methods, such as communication, touch, presence of family members, music, guided imagery, and distraction.

• Keep the head of the bed elevated 30 to 45 degrees at all times, if patient condition allows.

• Every day, provide sedation “vacations” and assess readiness to extubate, indicated by vital signs and arterial blood gas values within normal ranges as well as the patient taking breaths on her own.

• Provide peptic ulcer disease prophylaxis, as with a histamine-2 blocker such as famotidine.

• Provide deep vein thrombosis prophylaxis, as with an intermittent compression device.

• Perform oral care with chlorhexidine daily. • Brush the patient’s teeth at least twice a day and provide oral moisturizers every 2 to 4

hours. • The cuff on the endotracheal or tracheostomy tube provides airway occlusion. Proper

cuff inflation ensures the patient receives the proper ventilator parameters, such as TV and oxygenation.

• With assistance from an experienced colleague, change the tracheostomy tube or tracheostomy ties and endotracheal tube-securing devices if they become soiled or loose. Incorrect technique could cause accidental extubation

• Wean the patient from the ventilator appropriately


• To ease distress in the patient and family, teach them why mechanical ventilation isneeded and emphasize the positive outcomes it can provide.

• Each time you enter the patient’s room, explain what you’re doing.

• Reinforce the need and reason for multiple assessments and procedures, such aslaboratory tests and X-rays.

• Communicate desired outcomes and progression toward outcomes so the patient andfamily can actively participate in the plan of care.

COMPLICATIONS

Pulmonary effects ● Barotrauma and volutrauma may result in pulmonary interstitial

emphysema, pneumomediastinum, pneumoperitoneum, pneumothorax, and/ortension pneumothorax. High peak inflation pressures (>40 cm H2O) are associatedwith an increased incidence of barotrauma.

● High-inspired concentrations of oxygen (fraction of inspired oxygen [FiO2] >0.5)result in free-radical formation and secondary cellular damage. These same highconcentrations of oxygen can lead to alveolar nitrogen washout and secondaryabsorption atelectasis.

● VAP (Ventilator Associated Pneumonia): ED physician has a responsibility toimplement measures to reduce the risk of VAP in the ED. These interventions areaimed at reducing the risk of aspiration and decreasing bacterial colonization byplacing the patient in a semi upright position, with the head of the bed elevated30-45o, in order to reduce the risk of aspiration, early placement of a nasogastrictube and oral care. Lastly, endotracheal cuff pressures should be monitoredinitially after intubation and every 4 hours thereafter, with goal pressures of 20-30cm H2O.

Cardiovascular effects Increased intrathoracic pressures associated with mechanical ventilation result in a decrease in cardiac output due to decreased venous return to the right heart, right ventricular dysfunction, and altered left ventricular dispensability. The decrease in cardiac output from reduction of right ventricular preload is more pronounced in the hypovolemic patient and in those with a low ejection fraction.

Renal, hepatic, and gastrointestinal effects Positive-pressure ventilation is responsible for an overall decline in renal function with decreased urine volume and sodium excretion. Hepatic function is adversely affected by decreased cardiac output, increased hepatic vascular resistance, and elevated bile duct pressure.

Venous thromboembolism (VTE) Mechanically ventilated patients are at high risk for development of VTE. In patients without contraindications, unfractionated or low-molecular-weight


heparin should be considered for VTE prophylaxis otherwise pneumatic compression devices should be used.

Stress-related injury of the gastrointestinal mucosa, gastrointestinal prophylaxis with a proton pump inhibitor, sucralfate, or histamine receptor antagonist should be considered in patients who are at high risk of gastrointestinal hemorrhage. These high-risk patients have been identified as those with coagulopathy, history of gastrointestinal bleeding, history of gastritis or peptic ulcer, or mechanical ventilation for more than 48 hours.

Ventilator Troubleshooting

● The commonly encountered complication in the ED include hypoxia, hypotension, high-pressure alarms, and low exhaled–volume alarms.

● Intubated patients who develop hemodynamic instability with respiratory compromise should immediately be disconnected from the ventilator and manually ventilated with 100% oxygen.

● One of the first diagnoses that should be considered in any hemodynamically unstable patient undergoing positive-pressure ventilation is tension pneumothorax. This is a clinical diagnosis and should be detected and treated with needle decompression prior to obtaining a chest radiograph.

● In the case of endotracheal tube obstruction, attempts to manually ventilate the patient are met with a significant amount of resistance and high-pressure alarms may sound. Endotracheal tube obstruction may be caused by extrinsic compression; tube plugs with mucus, blood, or foreign bodies; tube kinks; or tube biting. Tube suctioning and adequate patient sedation are recommended after other causes of obstruction are ruled out.

● High peak pressure with normal plateau pressures indicates increased resistance to flow, such as endotracheal tube obstruction or bronchospasm.

● An increase in both peak and plateau pressures suggest decreased lung compliance, which may be seen in disease states such as pneumonia, ARDS, pulmonary edema, and abdominal distension.

● Low exhaled volume alarms are triggered by air leaks. These are most frequently secondary to ventilatory tubing disconnection from the patient's tracheal tube but will also occur in the event of balloon deflation or tracheal tube dislodgement.

● The causes of high airway pressures and low exhaled volumes described above can result in hypoxia if they cause hypoventilation.

PREVENTION

VAP BUNDLE

• These interventions are aimed at reducing the risk of aspiration and decreasing bacterial colonization by placing the patient in a semi upright positionwith the head of the bed elevated 30º-45o, in order to reduce the risk of aspiration, early placement of a nasogastric tube and oral care.


• Daily "Sedation Vacations" and Assessment of Readiness to Extubate. • In order to reduce the risk of aspiration, early placement of a nasogastric tube and oral

care. • Peptic Ulcer Disease Prophylaxis. • Deep Venous Thrombosis Prophylaxis. • Daily Oral Care with Chlorhexidine. • Lastly, endotracheal cuff pressures should be monitored initially after intubation and

every 4 hours thereafter, with goal pressures of 20-30 cm H2O. DOCUMENTATION

The nurse should document:

Date and time of connecting mechanical ventilation. Number of days of patient being in ventilation Current mode of ventilation Type of ventilation provided to the patient Record the different parameter of ventilator like tidal volume, I/E ratio, PEEP etc Date and time of oral care provided.


B) Assisted Procedures SKILL 1: PERFORM NEEDLE CRICOTHROIDOTOMY

DEFINITION

Needle cricothyroidotomy involves passing an over-the-needle catheter through the cricothyroid membrane to provide a temporary secure airway to oxygenate and ventilate a patient in severe respiratory distress when other, less invasive methods have failed or are not likely to be successful. It is also referred as trans-tracheal catheter ventilation. This method can be used for children under the age of 12.

PURPOSES

Establishing a patent airway in case of trauma causing oral, pharyngeal, or nasal injury/hemorrhage.

Rescue airway when Laryngeal Mask Airway (LMA) and endotracheal intubation are ineffective or contraindicated..

Maintaining a patent airwayfor the patient who cannot be intubated and oxygenated.. To allow short term provision of oxygen until a definitive airway is established..

EQUIPMENTS

Sterile gloves Povidone iodine solution Sterile gauze pads, 4×4 Dilator Tape 10 - 14 gauge or larger through-the-needle or over-the-needle catheter Saline filled 5ml syringe IV extension tubing Oxygen source with appropriate connector/ jet ventilator set. Hand-operated release valve or pressure-regulating adjustment valve


STEPS

Ensure that the team has performed hand hygiene and put on sterile gloves and personal protective equipment.

Place the patient in the supine position. The doctor cleans the patient’s neck with a gauze pad soaked in antiseptic cleaning

solution. Hyperextend the patient’s neck to optimise identification of anatomy and to ease the

procedure in non trauma patient. Identify cricothyroid membrane and stabilize it with the non-dominant hand. Palpate the membrane with the index finger of the non-dominant hand and stabilise

the trachea with the thumb and middle fingers. The doctor assesses for hematomas, which may displace the trachea to the unaffected

side. The doctor then moves his fingers across the center of the gland, over the anterior

edge of the cricoid ring. Assist in draping the patient’s neck with sterile towels. Attach a 5 ml syringe (containing 1-2ml of saline) to a 14G or larger through-the-

needle or over-the-needle catheter with the dominant hands with fingers between the flange and the plunger. Insert the catheter into the cricothyroid membrane just above the cricoid ring. Filling the 5ml syringe with 1-2 ml of saline allows demonstration of the endpoint of bubbles when the airway is entered

The doctor then, insert the catheter downwards to the trachea at a 45-degree angle. This technique keeps the vocal cords from injury.In order for the cannula to reach the airway, a more perpendicular approach may be needed.

Doctor aspirates continuously as the needle-cannula unit advances into the airway and stops advancing once air is aspirated, ensuring the cannula tip is in the trachea.

When the catheter is at the trachea doctor removes the needle and syringe while stabilising the cannula hub with the non-dominant hand and then release the plunger of the syringe held by the dominant hand. If the tip of the cannula is incorrectly placed the plunger will be sucked back into the syringe barrel by the vacuum created by aspirating outside of the airway.

Assist the doctor to keep the catheter in place by fixing with tape.The plunger will stay in position if the cannula is correctly placed in the airway.

Doctor places the dominant hand underneath the syringe, holding the needle in a pencil grip with the hand resting against the chin or neck to immobilise the cannula.

Doctor advances the cannula over the needle into the trachea using your non-dominant hand and remove trochar. It should advance as easily as an IV.Do not remove the needle before the cannula is advanced, otherwise the cannula will kink.

Doctor ensures the cannula is held securely in position at all times. Using a syringe with 1-2 mL saline, connect to the cannula and repeat the full free aspiration of air from the cannula. Again, a lack of plunger recoil confirms airway placement. If the initial aspiration fails then slightly withdraw the cannula while aspirating — free aspiration of air suggests that the cannula tip was impacted against posterior tracheal wall.

Attach the catheter hub to one end of IV extension tubing. The other end is attached to the hand-operated release valve or a pressure-regulating adjustment valve and connects the entire assemble to the high flow oxygen source.


The doctor adjust the pressure-regulating valve to the minimum pressure needed for adequate lung inflation and auscultates breath sounds bilaterally .

Check the vital signs. Dispose gloves and wash hands.

POINTS TO REMEMBER

It is a simple, life saving technique but does not provide a definitive airway. It does not allow for effective ventilation, leads to hypercapnia and must be

followed by definitive airway. There may be a time lag before SpO2 improves following commencement of

effective transtracheal oxygenation Needle cricothyroidotomy may only be used for approximately 30 - 45 mins due to

carbon dioxide retention.

COMPLICATIONS

External scar from needle puncture Bleeding Hypercarbia (overly high levels of carbon dioxide in the blood) Surgical emphysema from jet insufflation or false placement of cannula. Danger of puncturing posterior wall of trachea and into the esophagus Obstruction of upper airways can cause chest barotraumas.

DOCUMENTATION

Date and time of procedure Location of the incision site Materials used during the procedure Vital signs before and after the procedure

SKILL 2: SURGICAL CRICOTHYROIDOTOMY


DEFINITION

A surgical cricothyrotomy is a potentially life saving procedure in which a incision is made through the skin and cricothyroid membrane to establish a patent airway during certain life-threatening situations, such as airway obstruction by a foreign body, angioedema, or massive facial trauma where orotracheal and nasotracheal intubation are impossible or contraindicated.. This method cannot be used for children under the age of 12.

The physician performs this procedure and the role of the nurse is to assist. However, in emergent cases and if the physician is not available, a trained nurse can perform cricothyrotomy procedure if the patient is likely to die before intubation. In ideal situations, cricothyrotomy is performed using a sterile technique but during emergent situations this may not be strictly possible.

PURPOSES

Establishing a patent definitive airway in “can’t intubate, can’t ventilate” situation to

eliminate hypoxaemia. To provide an emergency breathing passage for a patient whose airway is closed by

traumatic injury to the neck.

EQUIPMENTS FOR SCALPEL OR NEEDLE CRICOTHYROTOMY

Common items

Sterile gloves Povidone iodine solution Sterile gauze pads, 4×4 Blunt dissector Tracheal hook Tape Oxygen source

Scalpel cricothyrotomy

Scalpel (short and round). Small cuffed Endotracheal (size 6 or 7 mm ID)/Tracheostomy tube. Handheld resuscitation bag or T tube and wide-bore oxygen tubing.

Needle cricothyrotomy

14G or larger through-the-needle or over-the-needle catheter. 10 ml syringe. IV extension tubing. Hand-operated release valve or pressure-regulating adjustment valve.


STEPS OF CRICOTHYROTOMY PROCEDURE

Pre-procedure

Place the patient on supine position and hyper extend the patient’s neck to expose the area of the incision site.

Identify cricothyroid membrane and stabilize it with the non-dominant hand. Palpate the membrane with the index finger of the non-dominant hand and

stabilise the trachea with the thumb and middle fingers. The doctor assesses for hematomas, which may displace the trachea to the

unaffected side. The doctor then moves his fingers across the center of the gland, over the anterior

edge of the cricoid ring. Ask someone to hold the patient’s head in the correct position while performing

the procedure. Wash hands, don sterile gloves to prevent transmission of harmful

microorganisms. Clean patient’s neck with a sterile gauze soaked in povidone iodine solution. Use

circular strokes starting at the middle of the incision site outwards, to reduce the risk of contamination.

Locate the accurate incision site. This is done by sliding the thumb and fingers down the thyroid gland. One may locate the outer borders of the thyroid glands when the space between the fingers and thumb widens.

Move your fingers to the center of the gland, over the anterior edge of the cricoid ring.

If using a scalpel:

Make an incision horizontally about 1.3 cm or less than 0.5 inches long in the cricothyroid membrane just about the cricoid ring.

To keep the tissue from closing around the site of incision, use a dilator. In case a dilator is not available, use the handle of scalpel – insert it to the incision and rotate to about 90 degrees.

Insert a tracheostomy tube (#6 or smaller) to the opening. Make sure to secure it to maintain a patent airway. In cases where a tracheostomy tube is not available, you can tape the dilator or scalpel handle in place until a tracheostomy tube is available.

Attach a humidified oxygen source to the tracheostomy tube if the patient can breathe spontaneously. If the patient cannot breath, attach a handheld resuscitation bag. Inflate the cuff of the tracheostomy tube using a syringe to provide a positive-pressure ventilation.

Auscultate for breath sounds bilaterally and check the patient’s vital signs. Dispose gloves and wash hands.

If using a needle:

Attach a 10 ml syringe to a 14G or larger through-the-needle or over-the-needle catheter. Insert the catheter into the cricothyroid membrane just above the cricoid ring.


At a 45-degree angle, insert the catheter downwards to the trachea. This techniquekeeps the vocal cords from injury. Maintain a negative pressure by pulling the plunger of the syringe back as the catheter advances. When the air enters the syringe, that means the needle has entered the trachea.

When the catheter is at the trachea, advance it and remove the needle and syringe.Then tape the catheter in place.

The catheter hub is then attached to one end of IV extension tubing. The other endis attached to the hand-operated release valve or a pressure-regulating adjustment valve and connect the entire assemble to the oxygen source.

To introduce oxygen to the trachea and inflate the lungs, press the release valve.When inflated, release the valve to allow passive exhalation. Adjust the pressure-regulating valve to the minimum pressure needed for adequate lung inflation.

Auscultate breath sounds bilaterally and check the vital signs. Dispose gloves and wash hands.

Post Procedure care

After the procedure, it is important to check the incision site for bleeding, subcutaneous emphysema or inadequate ventilation and damage of the tracheal or vocal cord. For patients under 12 years old, scalpel cricothyrotomy is not advisable as it could damage the cricoid cartilage which is the only circumferential support to the upper trachea. Again, this procedure should only be performed by a physician or in emergent situations a trained nurse.

COMPLICATIONS

Aspiration (blood) Large visible external scar at the incision site Creation of a false passage into the tissues Subglottic stenosis/edema Haemorrhage or hematoma formation Oesophageal and tracheal laceration Mediastinal emphysema Laryngeal stenosis Pneumothorax Damage to the vocal cords/vocal cords paralysis resulting in hoarseness or a changed

voice

DOCUMENTATION

Date and time of procedure. Indications for the procedure. Vital signs after the procedure. Any complications.

Bibliography

1. American Heart Association – Advanced cardiovascular life support. Provider manual2016.

2. American Heart Association – Basic life support. Provider manual 2016.


3. Advanced Trauma Life Support. Student course manual. American college of surgeonscommittee on trauma

9th edition.

4. Dorsch JA, Dorsch SE. Understanding anesthesia equipment 5th edition.


Lesson :5 Circulation: Shock, Chest pain and Peri Arrest Arrhythmias and cardiac arrest

Lesson 5 Circulation: Shock, Chest pain and Peri Arrest Arrhythmias and cardiac arrest

Objectives Upon completion of the lesson the nurse would be able to: ● Define shock● Assess and manage different types of shock● Assess & manage patients with acute chest pain● Assess and manage STEMI and NSTEMI● Identify and Manage patient withperi-arrest rhythms● Identify heart block● Identify fatal arrhythmias and resuscitate immediately


Lesson :5 Circulation: Shock, Chest pain and Peri Arrest Arrhythmias and cardiac arrest

5.0 Shock 5.0.1 Core Concepts

Inadequate tissue perfusion leads to cellular dysfunction and breakdown in organfunction.

Early recognition of shock and timely management is necessary to preventirreversible organ damage.

5.0.1. Introduction Shock is a life-threatening condition with a variety of underlying causes. It is characterized by inadequate tissue perfusion that, if untreated, results in cell death. The nurse caring for the patient with shock or at risk for shock must understand the underlying mechanisms of shock and recognize its subtle as well as more obvious signs. Rapid assessment and response are essential to the patient’s recovery.

5.0.2. Definition Shock is best defined as a condition in which systemic blood pressure is inadequate to deliver oxygen and nutrients to support vital organs and cellular function. Shock can be defined as a condition in which tissue perfusion is inadequate to deliver oxygen and nutrients to support vital organs and cellular function. Adequate blood flow to the tissues and cells requires the following components: adequate cardiac pump, effective vasculature or circulatory system, and sufficient blood volume. When one component is impaired, blood flow to the tissues is threatened or compromised. Without treatment, inadequate blood flow to the tissues results in poor delivery of oxygen and nutrients to the cells, cellular starvation, cell death, organ dysfunction progressing to organ failure, and eventual death.

5.0.3 Pathophysiology In shock, the cells lack an adequate blood supply and are deprived of oxygen and

nutrients; therefore, they must produce energy through anaerobic metabolism. This results in low energy yields from nutrients and an acidotic intracellular

environment. Because of these changes, normal cell function ceases. The cell swells up and the cell membrane becomes more permeable, allowing

electrolytes and fluids to seep out of and into the cell. The sodium-potassium pump becomes impaired; cell structures, primarily the

mitochondria, are damaged; and death of the cell results.


5.0.4. Stages of Shock A convenient way to understand the physiologic responses and subsequent clinical signs and symptoms is to divide three into separate stages:

1. Compensatory, 2. Progressive, and 3. Irreversible.

Stage 1: Compensatory Stage

In the compensatory stage of shock

The patient’s blood pressure remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output.

The sympathetic nervous system and subsequent release of catecholamines (epinephrine and norepinephrine).

The body shunts blood from organs such as the skin, kidneys, and gastrointestinal tract to the brain and heart to ensure adequate blood supply to these vital organs.

Stage 2: Decompensated Stage In this stage of shock

The patient’s condition deteriorates as the body is unable to compensate for ongoing loss. The signs and symptoms are more pronounced.

Fall in blood pressure is a characteristic sign of this stage. Other signs are altered mental status, tachycardia, low volume and rapid pulse, tachypnea, reduced body temperature, skin is pale, cold and clammy, delayed capillary refill.

If untreated or inadequately treated, patient may progress into stage of irreversible shock.

Stage 3: Irreversible Stage In the irreversible stage of shock

Cell and organ damage has already occurred and recovery unlikely, despite aggressive resuscitation.

Patient may become unresponsive, cold, has decreased heart rate, decreased respiratory rate and profound hypotension.


5.0.5. CLASSIFICATION OF SHOCK Hypovolemic shock Cardiogenic shock Obstructive shock Distributive shock

1. Septic shock2. Anaphylactic shock3. Neurogenic shock

5.0.6.CRITERIA FOR DIAGNOSIS OF SHOCK Atleast four of the following criteria should be met irrespective of etiology for diagnosis of shock

1. Acute altered mental status or ill appearance2. Heart rate >100 bpm3. Respiratory rate >20 breaths/min or PaCO2 < 32 mmHg4. Arterial hypotension persisting for >30 continuous minutes5. Urine output < 0.5 ml/kg/hour6. Arterial base deficit < -4mEq/L or lactate > 4 mmol/L

5.0.7.NELS assessment of shock Assess perfusion status of the patient by simple and easy NELS approach.

Look for colour of the hands, fingers and toes (blue, pink, pale or mottled), sweating, respiratory rate, neckveins (flat or distended), level of consciousness, visible blood loss and urine output.

Listen for chest and heart by auscultation with a stethoscope (gallop/third heart sound of failure/significantmurmur).

Feel for the temperature of limbs (cool or warm), pulse rate and volume, capillary refill time (normal < 2 sec)and measure blood pressure.


Algorithm 1: NELS approach to a patient in shock

Algorithm 2: Approach to a patient with undifferentiated shock


5.1.0. ASSESSMENT AND MANAGEMENT OF DIFFERENT TYPES OF SHOCK

5.1.1. Hypovolemic shock

Hypovolemic shock, the most common type of shock, is characterized by a decreased intravascular volume. Body fluid is contained in the intracellular and extracellular compartments. Intracellular fluid accounts for about two thirds of the total body water. The extracellular body fluid is found in one of two compartments: intravascular (inside

blood vessels) or interstitial (surrounding tissues).

The volume of interstitial fluid is about three to four times that of intravascular fluid. Hypovolemic shock occurs when there is a reduction in intravascular volume of 15% to 25%. This would represent a loss of 750 to 1,300 mL of blood in a 70-kg (154-lb) person.

5.1.2.Pathophysiology

Major goals in treating hypovolemic shock are to (1) Restore intravascular volume to reverse the sequence of events leading to

inadequate tissue perfusion,(2) Redistribute fluid volume(modified Trendelenburg position) and(3) Correct the underlying cause of the fluid loss.(4) Medication can be given to treat the underlying cause.


Algorithm 3: Approach to patient with hypovolemic shock

5.1.3.NURSING CONSIDERATIONS IN HYPOVOLEMIC SHOCK

Assessment (NELS Appraoch)

Action as per ABCD priority

Remarks .

Assess Airway Breathing Circulation Disability for consciousness and vital statistics

Maintain airway and breathing, Administer oxygen, Check vitals, Assess consciousness, Make patient lie flat with legs elevated if no contraindication, Secure 2 wide bore iv cannulas and collect blood samples, Give warm fluid bolus (NS or RL 1 liter) Keep the patient warm, Catheterize the urinary bladder and assess for adequate urine output

Patient may develop tachycardia and tachypnea in the early stages, then hypotension in later stages. It’s important to note these changes in the patient. Monitoring vital signs could help to prevent hypovolemic shock, if caught early, and will also help to determine the patient’s response to treatment.

Level of consciousness should be assessed because it may decrease as the patient loses oxygenation of their brain. Decreasing LOC is a sign of advancing shock.

IV fluid should be administered with a pressure bag or rapid infuser


Shorter and thicker catheters will provide for faster fluid administration

Assess for risk and causes Blood loss from: Traumatic injuries Internal bleeding, such as a GI bleed or surgical complication Postpartum hemorrhage

Fluid loss from: Burns Diarrhea Vomiting

Nurses should assess their patient for the risk of developing hypovolemic shock. The patient may have lost some fluid already, or maybe they’re at risk for bleeding.

Monitor Hemodynamics Continuous monitoring PR (pulse rate) MAP (Mean Arterial Pressure) Oxygen saturation CVP (Central Venous Pressure) CO (Cardiac Output)

Hemodynamic measurements will tell us the severity of the shock and how well the patient is responding to treatment.

Prepare for procedures Arterial lines Central lines Airway management Preparing the operation theatre Taking written informed consent

Arterial lines are placed for invasive hemodynamic monitoring. Central lines are placed for administration of fluids and medications as well as hemodynamic monitoring Patients whose airway has been compromised due to ↓ LOC may need to be intubated to protect their airway, and placed on a ventilator

Administer Blood Products For patients who have lost significant amounts of blood due to trauma or hemorrhage, they should receive transfusions of blood products

Be sure that consent is obtained and that the patient is aware of possible reactions. Send a type and crossmatch to determine the patient’s blood type. Verify the blood product with another nurse prior to administering and monitor per facility protocol for transfusion reactions.


5.2.0. Haemorrhagic shock

5.2.1. Definition:

It is a condition of reduced tissue perfusion, resulting in the inadequate delivery of oxygen and nutrients that are necessary for cellular function.

5.2.2. Hypovolemic shock Vshemorrhagic shock

Hypovolemic shock refers to a medical or surgical condition in which rapid fluid loss result in multiple organ failure due to inadequate circulating volume and subsequent inadequate perfusion. Most often hypovolemic shock is secondary to rapid blood loss.(Hemorrhagic shock)

5.2.3. Causes:

1. Penetrating and blunt trauma2. Gastro intestinal bleeding3. Obstetric bleeding

5.2.4. Classes of Hemorrhage:

Hemorrhage may be external or internal:

External: Immediately recognizable as there is visible blood loss.

Internal: It is not easily identifiable

5.2.5. Symptoms:

1. Marked Tachycardia2. Decreased systolic BP3. Narrowed pulse pressure/immeasurable diastolic pressure4. Markedly decreased or no urine output5. Depressed mental status (Loss of consciousness)6. Cold and pale skin


Figure: Approximate blood loss and clinical presentation (in a 70kg adult)

Nursing considerations are similar as in hypovolemic shock

5.3.0. Circulatory shock Circulatory or distributive shock occurs when blood volume is abnormally displaced in the vasculature—for example, when blood volume pools in peripheral blood vessels. The displacement of blood volume causes a relative hypovolemia because not enough blood returns to the heart, which leads to subsequent inadequate tissue perfusion. The varied mechanisms leading to the initial vasodilation in circulatory shock further subdivide this classification of shock into three types:

1. Anaphylactic shock2. Septic shock3. Neurogenic shock


5.3.1.Pathophysiology

5.4.0. Anaphylactic shock

Anaphylactic shock is caused by a severe allergic reaction when a patient whohas already produced antibodies to a foreign substance (antigen) develops asystemic antigen–antibody reaction.

This process requires that the patient has previously been exposed to thesubstance. An antigen–antibody reaction provokes mast cells to release potentvasoactive substances, such as histamine or bradykinin, that cause widespreadvasodilation and capillary permeability.

Medical Management :

Treatment of anaphylactic shock requires removing the causative antigen (eg,discontinuing an antibiotic agent)

Administering medications that restore vascular tone, and Providing emergency support of basic life functions.Epinephrine is given for its vasoconstrictive action. Diphenhydramine (Benadryl) is administered to reverse the effects of histamine, thereby reducing capillary permeability.


Algorithm 4: Approach to patient with anaphylactic shock


5.4.1. NURSING CONSIDERATION IN ANAPHYLACTIC SHOCK Assessment (NELS Approach)

ACTION as per ABCD priority

REMARKS (Special consideration)

Assess Airway, Breathing, circulation and Disabilty for consciousness • Nasal congestion • Pruritus • Sneezing and coughing • Possible respiratory

distress (bronchospasm or edema of the larynx)

• Chest tightness • wheezing and dyspnea Skin manifestations • Flushing with warmth

and diffuse erythema • Generalized pruritus • Massive facial

angioedema Cardiovascular manifestations • Dysrhythmia • Pallor • Weak peripheral pulse • Hypotension • Circulatory failure, leading to coma and death Gastrointestinal problems • Nausea • Vomiting • Colicky abdominal pains • Diarrhea

Prepare airway cart, suction and oxygen source. Assessment of signs and symptoms of anaphylaxis

Establishing a patent airway and ventilation is essential. Early endotracheal intubation is essential to preserve airway patency, and oropharyngeal suction may be necessary. Be aware of the danger of anaphylactic reactions and the early signs of anaphylaxis for fast diagnosis and management.

History taking Ask the patient about previous allergies to medications, foods, etc. and treatment and response to the treatment.


• Before giving a foreign serum or other type of antigenic agent, ask the patient or caregiver whether he’s had it before. • Avoid giving medications to patients with hay fever, asthma, or other allergic disorders unless necessary.

• Avoid giving parenteral medications unless absolutely necessary, because anaphylactic reactions are more likely to occur when the agent is given parentally.

Administer Adrenaline Adrenaline via one of various routes is the specific treatment for particular episode

Subcutaneous injection for mild, generalized symptoms. Intramuscular injection when the reaction is more severe and progressive, and with the knowledge that vascular collapse will delay absorption of the medication Intravenous (I.V.) route (aqueous epinephrine diluted in saline solution and administered slowly), used in rare instances when there’s a complete loss of consciousness and severe cardiovascular collapse.

Additional treatment Other drugs for symptomatic treatment or tiding over the current episode.

• antihistamines(diphenhydramine) to block further histamine binding at target cells

• aminophylline titrated by I.V. drip for severe bronchospasm and wheezing refractory to other treatment

• albuterol inhalers or humidified


treatments to decrease bronchoconstriction

• crystalloids, colloids, or vasopressors to treat prolonged hypotension

• positive inotropes for reducedcardiac output; oxygen toenhance tissue perfusion

• I.V. benzodiazepines for controlof seizures, and corticosteroids(hydrocortisone) for prolongedreaction with persistenthypotension or bronchospasm

Post-resuscitative care and education

Observation, monitoring of vitals and preventing further similar episodes

After the acute symptoms have been treated, the patient is usually admitted to the hospital for observation and should be taught how to prevent future anaphylactic reactions.

5.5.0. Septic shock Septic shock is the most common type of circulatory shock and is caused by widespread infection

5.5.1.Etiology i. Nosocomial infections (infections occurring in the hospital) in critically ill

patients most frequently originate in the bloodstream, lungs, and urinarytract

ii. Other infections that may progress to septic shock include intra-abdominalinfections, wound infections, bacteremia associated with intravascularcatheters, and indwelling urinary catheters.

5.5.2.Pathophysiology When a microorganism invades body tissues, the patient exhibits an immune response. This immune response provokes the activation of biochemical mediators associated with an inflammatory response and produces a variety of effects leading to shock. Increased capillary permeability, which leads to fluid seeping from the capillaries, and vasodilation are two such effects that interrupt the ability of the body to provide adequate perfusion, oxygen, and nutrients to the tissues and cells.

5.5.3. Stages of septic shock Septic shock typically occurs in two phases. The first phase, referred to as the hyperdynamic, progressive phase, is characterized


i. By a high cardiac output with systemic vasodilation.ii. The blood pressure may remain within normal limits. The heart rate

increases, progressing to tachycardia.iii. The patient becomes hyperthermic and febrile, with warm, flushed skin

and bounding pulses.iv. The respiratory rate is elevated.v. Urinary output may remain at normal levels or decrease

vi. Gastrointestinal status may be compromised as evidenced by nausea,vomiting, diarrhea, or decreased bowel sounds.

vii. The patient may exhibit subtle changes in mental status, such as confusionor agitation.

The later phase, referred to as the hypodynamic, irreversible phase, is characterized by

i. Low cardiac output with vasoconstriction, reflecting the body’s effort tocompensate for the hypovolemia caused by the loss of intravascularvolume through the capillaries.

ii. The blood pressure drops, and the skin is cool and pale.iii. Temperature may be normal or below normal. Heart and respiratory rates

remain rapid.iv. The patient no longer produces urine, and multiple organ dysfunction

progressing to failure develops.

5.5.4.Medical Management

1. Current treatment of septic shock involves identifying and eliminating thecause of infection.

2. Fluid replacement must be instituted to correct the hypovolemia thatresults from the incompetent vasculature and inflammatory response.

3. If the infecting organism is unknown, broad-spectrum antibiotic agents arestarted until culture and sensitivity reports are received.

4. Aggressive nutritional supplementation is critical in the management ofseptic shock because malnutrition further impairs the patient’s resistanceto infection.

Algorithm 5: Approach to patient with septic shock


5.5.5.NURSING CONSIDERATION IN SEPTIC SHOCK Assessment (NELS Appraoch)

ACTION per ABCD priority

REMARKS (Spl considerations)

Assess Airway ,Breathing ,circulation and Disabilty for consciousness

Maintain Airway patent. Supplement Oxygen Start IV infusion

Assessment and identification of patients at risk for sepsis

Quicker identification and diagnosis helps in better prognosis of the patients.

People who are staying and getting treated in the ICU People with really weak immune systems Young children Seniors People exposed to invasive devices People with chronic illness

Identification of patients with sepsis

Fever Fast heart rate or pulse Rapid breathing Unusual sweating Abrupt changes in mental status Difficulty breathing Abdominal pain Significantly reduced urine output A decrease in platelet count

Early identification can help in starting therapeutic measures quickly.

Management of hyperthermia

Maintenance of normal body temperature is important.

Monitor the client’s temperature. Adjust environmental factors as indicated. Remove excess clothing as necessary. Provide tepid sponge bath and administer antipyretics as necessary.

Replacement of fluid volume in the body

Maintenance of circulatory volume.

Assess vital signs. Observe for excessively dry skin and mucous membranes. Monitor for peripheral edema in the legs, back, and scrotum.


Administer IV fluids as ordered. Reducing risk of infections Prevention of further

worsening Inspect wound and dressings and note any changes in the characteristics of drainage. Maintain aseptic technique in any procedure. Encourage intake of a balanced diet and frequent position changes. Promote meticulous perineal care and provide routine catheter care. Use proper hand washing technique and encourage the same in a patient.

Surviving Sepsis campaign Sepsis Care Bundle

Evidence-based interventions proven to improve survival

Measure lactate level. Remeasure if initial lactate level > 2 mmol/L.Obtain blood cultures beforeadministering antibiotics.Administer broad-spectrumantibiotics.Begin rapid administration of30mL/kg crystalloid forhypotension or lactate level ≥ 4mmol/L.Apply vasopressors if patient ishypotensive during or after fluidresuscitation to maintain MAP ≥65 mm Hg

5.6.1: Neurogenic shock In neurogenic shock, vasodilation occurs as a result of a loss of sympathetic tone. This can be caused by spinal cord injury, spinal anesthesia, or nervous system damage. It can also result from the depressant action of medications or lack of glucose (e.g. insulin reaction or shock).

5.6.2: Clinical Manifestation

It is characterized by dry, warm skin rather than the cool, moist skin seen in hypovolemic shock. Another characteristic is bradycardia, rather than the tachycardia that characterizes other forms of shock.


5.6.3. Medical Management

a) Treatment of neurogenic shock involves restoring sympathetic tone eitherthrough the stabilization of a spinal cord injury or, in the instance of spinalanesthesia, by positioning the patient properly.

b) If hypoglycemia (insulin shock) is the cause, glucose is rapidly administered.

5.6.4.NURSING CONSIDERATIONS IN NEUROGENIC SHOCK

Assessment (NELS Approach)

Action (As per ABCD Priority)

Remarks (Spl consideration)

Assess Airway ,Breathing ,circulation and Disabilty for consciousness

Maintain Airway patent. Supplement Oxygen Start IV infusion

Assessment of causes and risk factors

Taking a proper history and performing a thorough examination helps to make a quick diagnosis

Physical injury to the central nervous system, especially high thoracic spinal or damage to the brainstem’s vasomotor center Emotional trauma, with sudden loss of autonomic nervous system (ANS) control. Vagus nerve stimulation.

Assessment of signs and symptoms

cardioinhibitory effects, such as bradyarrhythmias

vasodepression, which causes peripheral vascular dilatation

bradycardia; hypotension; poikilothermy, hypothermia, warm, dry skin; and flaccid paralysis below the spinal injury level.

altered mental status.

Management Early diagnosis and treatment of acute signs and

Close observation, as in an intermediate or intensive care


symptoms.

Limit the effects of hypotension and bradycardia on the rate of secondary neurologic injury.

Restore adequate oxygenation to vital tissues and limit cellular damage.

unit.

Vital signs and fluid intake and output must be monitored at least hourly.

Orotracheal intubation and mechanical ventilatory support, if needed.

aggressive blood pressure support with cautious I.V. fluids and vasoactive drugs.

Slow rewarming and cardiac pacing if indicated.

Specific Interventions • managing the patient’sairway

• monitoring urine output• assessing for bladder

distention • implementing coughing

and deep-breathing exercises

• providing skin care• performing passive range-

of-motion exercises • implementing deep-vein

thrombosis prophylaxis • monitoring the patient’s

GI status. As appropriate, start nutrition early and consider a daily bowel regimen as soon as this can be done safely.

Based on general and critical nursing protocols

5.7.0: Cardiogenic shock

Cardiogenic shock occurs when the heart’s ability to contract and to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues. The causes of cardiogenic shock are known as either coronary or non-coronary.

Coronary cardiogenic shock is seen most often in patients with myocardialinfarction Coronary cardiogenic shock occurs when a significant amount of theleft ventricular myocardium has been destroyed.

Non-coronary causes can be related to severe metabolic problems (severehypoxemia, acidosis, hypoglycemia, and hypocalcemia) and tensionpneumothorax.


5.7.1: Pathophysiology

5.7.2:Medical management of cardiogenic shock

1. The vasopressors and inotropes used in Cardiogenic Shock are: Dobutamine (2-5 μg/ kg/min, titratedup to 20 μg/kg/min); Dopamine (3–5 μg/kg/min, titrated up to 20–50 μg/kg/min); Norepinephrine(2 μg/min, titrated as per response); Epinephrine (0.1–0.5 μg/kg/min).

2. Mechanical inotropic support with an intra-aortic balloon pump may be required in some cases whoare unresponsive to pharmacological management.

Early revascularization by percutaneous coronary intervention or coronary artery bypass grafting isthe treatment of choice in ischemic cardiogenic shock. If facility not available, or if there is prolongedtransport time to a centre for coronary intervention, thrombolytic therapy should be given in additionto supportive care


5.7.3: NURSING CONSIDERATIONS IN CARDIOGENIC SHOCK

Assessment (NELS Appraoch)

Action (As per ABCD priority)

Remark (Spl consideration)

Airway:Assess patent airway

Breathing : Look for:

Chest pain,

Respiratory distress

Rapid, shallow respiration,

Altered mental status

Administer high flow oxygen,

Tracheal intubation and mechanical ventilation may be required in patients with acute respiratory failure

Circulation :Assess hemodynamic status, look for signs of hypovolemia

Continuous monitoring- SpO2, PR, BP, ECG, ABG, Send serum electrolytes

Obtain IV access

Give restricted IV fluid at 75-100 ml/hour

Auscultate heart and lungs for crepts in lungs, cardiac murmurs and gallops

Cold ,clammy skin and excessive sweating may present

Assess urine output Catheterize the bladder Hypoperfusion of kidneys occurs in cardiogenic shock and can cause AKI.

Assess for change in skin colour(Pale/blue)

Correct hypoxia and maintain SpO2 >95%.

Skin may appear ashen or cyanotic

Disability: Level of consciousness

GCS score and Pupil response

Patient may require definite airwayif GCS score is less than 8


5.7.4.:Scenarios Scenario 1

A 19-year old boy was brought to the Emergency Room with history of vomiting and diarrhoea forfour days. How was he treated?

Assessed (A + B) On talking, the boy could speak in full sentences but appeared breathless.

Airway: There was no sign of obstruction or presence of any secretions. The airway appeared to be patentand protected.

Breathing: RR was 20/minute, no breathing difficulty was apparent, but the patient was restless.

Action taken: Gave high flow oxygen through a face mask (oxygen flow rate 12 L/min); applied monitors,SpO2 was 94% (room air) that improved with oxygen to 98%.

Assessed C: Looked pale with cold extremities, capillary refill time was > 2 seconds, pulse was low volumeand rate was 118/min and blood pressure was 80/65 mmHg.

Action taken: Secured two wide bore IV lines using 16/18G IV cannula.

Administered warm crystalloid fluid bolus of 1000 ml.

Reassessed and auscultated the lungs.

Sent blood samples for blood gas analysis, serum electrolytes, etc.

Corrected fluid and electrolyte imbalance, treated the cause, monitored and re-assessed treatment plan.

Scenario 2

29 year young man came to the Emergency Room with history of fever for 9 days, pain and

distension of abdomen, feculent vomiting and inability to pass faeces and flatus for 3 days. How was he managed?

Assessment

On general appearance of the patient, he looked sick.

(A + B): On talking to the patient, he was speaking with difficulty and appeared to be breathless.

Airway: There was no sign of obstruction or secretions, airway appeared to be patent and protected.

B: Breathing was rapid and shallow with RR of 36/min.


Action taken: Gave high flow oxygen through a face mask, applied monitors, SpO2 was 84% (room air) thatimproved with oxygen to 92%. Prepared to secure definitive airway and provided assisted ventilation.

C: Patient was febrile to touch (temp 38.4 oC), pulse rate was 140/min, bounding, blood pressure was 70/36mmHg.

Action taken

Secured two wide bore (16G/18G) intravenous lines. Administered IV fluids 30 ml/kg of Ringer Lactate (RL). Started vasopressor (target MAP ≥ 65 mmHg), gave Norepinephrine (NE) infusion. Inserted a CVP line. Catheterized bladder, inserted a nasogastric tube. Took samples for blood culture (aerobic & anaerobic bottles) before giving antibiotic

therapy. Administered broad spectrum IV antibiotics within the first hour of recognition of

septic shock. (Considered De-escalate to most appropriate therapy after susceptibility profile was known).

Identified and controlled source of infection. Took expert help to identify and control the source of infection.

On abdominal examination there was distension, guarding and rigidity, absent bowel sounds which suggested a provisional diagnosis of intestinal perforation with septic shock.

Sent blood investigations like complete haemogram, Serum electrolytes, blood gas analysis, blood culture, coagulation profile. Once clinical condition was stabilized, surgical intervention was performed. The patient was reassessed.

Scenario 3

A 23 year lady comes to the emergency room with excessive per vaginal bleeding following

childbirth at home two hours back. How was she treated?

Assessment and Actions:

On general appearance she looked very pale and disoriented.

(A + B): She was speaking irrelevant, appeared disoriented. Her RR was 36/minute, with rapid and

shallow breathing.

Action taken was: gave oxygen @ 12 L/min and applied monitors. Prepared for tracheal intubation

and assisted ventilation.

C : Cold and clammy extremities, Capillary refill time is > 2 seconds, the pulse is feeble, has tachycardia, blood pressure is not recordable.


Action:

Secured two large bore 16G/18G intravenous cannula. Gave warm Ringer Lactate (RL) 1 liter Kept the patient warm. Sent blood sample for grouping and cross-matching. Transfused blood and blood products. Replaced intravascular volume. Catheterized urinary bladder. Called for expert help.

Gynaecological examination showed that there was uterine atony, bleeding per vagina was present.

Actions taken: Gave uterine massage, inj oxytocin infusion, did an ultrasound for confirmation of retained products, followed by curettage.

On reassessment of the patient, now she was oriented, she had stable vitals and no bleeding pervagina.

5.8.0 Chest Pain 5.8.1 Core Concepts

A variety of conditions can lead to chest pain. The main aim of the initial assessment

is a rapid identification of life-threatening causes and their immediate management.

Obtain an ECG in all patients with chest pain and triage the patients accordingly.

However, a completely normal ECG does not exclude angina or acute myocardial

infarction.

5.8.2. Introduction

● A variety of conditions can lead to chest pain. The main aim of initial assessment israpid identification of life-threatening causes and their immediate management.

● Obtain an ECG in all patients with chest pain and triage the patients accordingly.However, a completely normal ECG does notexclude angina or acute myocardialinfarction.


5.8.3. Causes of acute chest pain Acute chest pain in a patient can not only be because of cardiac origin, but there are other causes as well.

Cardiac 1. Acute myocardial infarction 2. Unstable angina/stable angina 3. Pericarditis

Pulmonary 1. Pneumothorax 2. Pneumonia 3. Pleurodynia

Vascular 1. Pulmonary embolism 2. Aortic dissection

Abdominal and Gastrointestinal 1. Acute cholecystitis 2. Acute pancreatitis 3. Esophageal reflux/spasm 4. Esophageal rupture

Musculoskeletal a. Trauma b. Inflammation

5.8.4. Nursing Assessment and management of Chest pain

S. NO ASSESSMENT (NELS Approach)

ACTION as per ABCD REMARKS (SPL CONSIDERATION)

1 Assess Airway, Breathing, Ciculation and Disability for

consciousness

Maintain Airway patent

Supplement oxygen therapy

Start IV infusion

2. Type of pain

Assessing the type of pain in the form of PQRST

P implies to position or provoking factors

Where is the pain? Can be pointed at?

What makes the pain better?

What makes the pain worse?

a. Repositioning tends not to change chest pain caused by an AMI.

b. If repositioning improves the pain, perhaps it may be of musculoskeletal origin, pleuritic, or pericarditis (where the pain is sometimes relieved by sitting up and leaning forward).


What activity being done when the pain started?

Does the pain change with repositioning?

Q implies to the quality of pain Can describe the pain or

discomfort? Is it a dull ache, sharp,

stabbing or crushing pain?

R implies to whether the pain is radiating or just confined to a place

S implies to the severity of pain or other symptoms which can be related to it

Can you rate the pain out of ten?

Any other symptoms?

T implies to specific time when the pain is felt

How long have you had the pain for?

Is the pain intermittent

70-80% of pain associated with an AMI is reported in the middle/upper sub-sternal region and the pain is often described as “constricting” or a “crushing” sensation.

Roughly 66% of patients with an AMI will experience radiating pain.

Accompanying symptoms of an AMI may include nausea, vomiting and diaphoresis. The patient may also experience dizziness and bradycardia or a feeling of impending doom and feeling scared.

Angina typically lasts for 2-5 minutes (but can last up to 30 minutes) if the precipitating factor is relieved.

Sometimes the pain is atypical or even absent (a silent myocardial infarction (MI)). Patients with diabetes can present with a silent MI

Common sites include the anterior chest, shoulders and arms. Less common is pain that extends to the neck and jaw.


(starts and stops) or is it continuous (ongoing)?

3 Obtain focused history

a. Uncomfortable pressure, fullness, squeezing or pain in the centre of the chest

b. Pain lasting for several minutes 2-5 min, less than 20 min duration.

c. Chest discomfort spreading to shoulders, neck, one or both arms or jaw

d. Chest discomfort spreading into back or between shoulders

e. Relation to stress/ physical work

Associating pain with cardiac, vascular, pulmonary or musculoskeletal relatedness

4. Diagnostic findings ECG: Often normal when patient at rest or when pain-free; depression of the ST segment or T wave inversion signifies ischemia.

Cardiac enzymes (AST, CPK, CK and CK-MB; LDH and isoenzymes LD1, LD2): Usually within normal limits (WNL); elevation indicates myocardial damage.

Chest x-ray: Usually normal; however, infiltrates may be present, reflecting


cardiac decompensation or pulmonary complications.

Serum lipids (total lipids, lipoprotein electrophoresis, and isoenzymes cholesterols [HDL, LDL, VLDL]; triglycerides; phospholipids): May be elevated (CAD risk factor).

5. Assess the pain through pain scale None: No pain. Pain score is 0 on a scale of 0 to 10.

Mild: The pain does not keep you from work, school, or other normal activities. Pain score is 1-3 on a scale of 0 to 10.

Moderate: The pain keeps you from working or going to school. It wakes you up from sleep. Pain score is 4-7 on a scale of 0 to 10.

Severe: The pain is very bad. It may be worse than any pain you have had before. It keeps you from doing any normal activities. Pain score is 8-10 on a scale of 0 to 10.

6. Observe the positioning of the Treating angina. The nurse should instruct


patient to relieve angina the patient to stop all activities and sit or rest in bed in a semi-Fowler’s position when they experience angina, and administer nitroglycerin sublingually.

Reducing anxiety. Exploring implications that the diagnosis has for the patient and providing information about the illness, its treatment, and methods of preventing its progression are important nursing interventions.

7. Observe for compliance to treatment

Aspirin reduces the ability of your blood to clot, making it easier for blood to flow through narrowed heart arteries. Preventing blood clotting may reduce your risk of a heart attack.

Nitrates are often used to treat angina. Nitrates relax and widen your blood vessels, allowing more blood to flow to your heart muscle.

Beta blockers


Statins

Calcium channel blockers

Angiotensin-converting enzyme (ACE) inhibitors.

5.8.5.Types and Management of chest pain 5.8.5.0. STEMI (ST Elevation MI) or new LBBB: Defined as sustained chest pain suggestive of MI with Acute ST elevation

Assess on the basis of ECG:

1 mm of ST elevation in 2 contiguous leads is required to diagnose STEMI, however there are two major exceptions.

1. Anterior STEMI requires 2 mm of ST elevation in V2 and V3 in men > 40 years old according to the ACC/AHA definition. A total of 2.5 mm is required in men < 40 years old and only 1.5 mm required in women.

2. Posterior STEMI frequently has ST depression in V1-V3 instead of elevation since the vectors are completely reversed. If a posterior ECG were obtained, ST elevation will be seen in V7-V9, although sometimes subtle. Since these posterior changes occur from coronary thrombosis and urgent treatment is needed, it is classified as a STEMI.

● New LBBB

Localization of the involved myocardium based on ECG

Inferior wall - II, III, aVF Lateral wall - I, aVL, V 4 through V 6 Anteroseptal - V 1 through V 3 Anterolateral - V 1 through V 6 Right ventricular - RV 4, RV 5 Posterior wall - R/S ratio greater than 1 in V 1 and V 2, and T-wave changes in

V1, V 8, and V 9 Note: Left ventricular hypertrophy,early repolarization in young healthy individuals, pericarditis andleft ventricular aneurysm may have ST segment elevation seen on an ECG when there is no STEMI present.


Action: Patient to be planned for reperfusion therapy based on the facilities available. The choice of reperfusion therapy (Fibrinolysis vs percutaneous coronary intervention) will depend on time of presentation to the hospital from the onset of symptoms, availability of PCI facilities and the contraindications for fibrinolytic therapy, Absolute Contraindications of Fibrinolytic therapy

● History of any previous intracranial hemorrhage ● Known structural cerebral vascular lesion (eg, AVM) ● Known malignant intracranial neoplasm (primary or metastatic) ● Ischemic stroke within 3 months EXCEPT acute ischemic stroke within 3 hours ● Suspected aortic dissection ● Active bleeding or bleeding diathesis (excluding menses) ● Significant closed head trauma or facial trauma within 3 months

Relative Contraindications of Fibrinolytic therapy

● History of chronic, severe, poorly controlled hypertension ● Severe uncontrolled hypertension on presentation (SBP > 180 mm Hg or DBP > 110

mm Hg) ● History of prior ischemic stroke < 3 months, dementia, or known intracranial

pathology not covered in contraindications ● Traumatic or prolonged (>10 minutes) CPR or major surgery (<3 weeks) ● Recent (within 2 to 4 weeks) internal bleeding ● Noncompressible vascular punctures ● For streptokinase/anistreplase: prior exposure (< 5 days ago) or prior allergic reaction

to these agents ● Pregnancy ● Active peptic ulcer ● Current use of anticoagulants


Goal of Reperfusion Ensure to start percutaneous coronary Intervention within 90 minutes and Fibrinolytic therapy within 30 minutes of arrival to hospital.

• Door to Needle- 30 min • Door to Balloon- 90 min

Expected time from 1st contact in hospital to Percutaneous Coronary Intervention: 60-120 min: Decision about the choice of reperfusion therapy is based on the time interval from the symptom onset to the 1st contact in hospital

● Interval from onset of symptoms to 1st presentation < 2 hrs: Fibrinolysis followed by PCI

● Interval from onset of symptoms to 1st presentation is 2-3 hrs: Either fibrinolysis or PCI

● Interval from onset of symptoms to 1st presentation is 3-12 hrs: PCI

Expected time from 1st contact in hospital to Percutaneous coronary Intervention: > 120 min:

● Immediate fibrinolysis followed by early angiography and PCI if indicated. Percutaneous coronary intervention are not available: Immediate transfer to the facility with PCI facility.If patient cannot be transferred in a timely manner, then fibrinolytic therapy to be given followed by angiography / PCI within 4 hrs. Start Adjuvant Therapy

● 300-600 mg Clopidogrel ● IV Nitroglycerin

Indications: Recurrent or Continuing Chest Pain unresponsive to Sublingual NTG Hypertension Complicating STEMI Pulmonary Edema (Pink Frothy Secretions from mouth, Crepitationss in

Chest) End Point:

SBP < 90 mm Hg Limit Drop in SBP to 10% of baseline in normotensive Limit Drop in SBP to 30% of baseline in hypertensive

5.8.4.1. Non- ST elevation MI Chest pain suggestive of MI with Non-specific ECG changes (ST depression/T inversion/normal)& laboratory tests showing release of troponins


Assess on the basis of ECG and biomarkers:

• The ECG tracing can have multiple abnormalities, but, by definition, there is no ST segment elevation. The most common finding is ST segment depression. This ST segment depression is horizontal or down-sloping in shape. The T waves may be inverted, usually symmetrically.Common observations on ECG may be seen as ST Depression of >0.5 mm or Transient ST elevation of > 0.5 mm for < 20 min

ECG changes can be dynamic and the findings normal initially, so estimation of cardiac enzymes and ECGs 6-8 hourly is required to completely exclude unstable angina and non-STEMI. Also, cardiac enzymes (troponin and creatine kinase) require 3 to 4 hours after the injury before showing significant elevation.

Note: Unstable angina and non-STEMI can both occur, even with a normal ECG. The main distinguishing feature between the two: During non-STEMI, there will be elevation of the cardiac enzymes, indicative of myocardial necrosis. During unstable angina, there is no or only very minimal elevation of cardiac enzymes.

Action:

Start Adjuvant Therapy Non–enteric-coated, chewable aspirin (162 mg to 325 mg) as soon as possible ● Sublingual nitroglycerin (0.3 mg to 0.4 mg) every 5 minutes for up to 3 doses, after

which an assessment should be made about the need for intravenous nitroglycerin if not contraindicated

● IV Nitroglycerin @ 5-20 µg/min ● Clopidogrel 600 mg PO ● Atorvastatin 80 mg PO ● Enoxaparin: 1 mg/kg subcutaneous (SC) every 12 hours ● UFH IV: initial loading dose of 60 IU/kg (maximum 5000 IU) with initial infusion of

12 IU/kg per hour (maximum 1000 IU/h) titrated to PTT of 50-70 sec ● B Blockers : Oral beta-blocker therapy within the first 24 hours

Contra- Indications:Signs of HF, Evidence of low-output state, Increased risk for cardiogenic shock, Active asthma, or reactive airway disease.

● Calcium– Channel Blockers: In patients with NSTE-ACS, continuing or frequently recurring ischemia, and a contraindication to beta blockers, a nondihydropyridine


calcium channel blocker (CCB) like verapamil or diltiazem should be started as initial therapy

● Start early invasive therapy in case of- ❖ Recurrent/persistent ST deviation ❖ Ventricular Tachycardia ❖ Refractory angina ❖ Hemodynamically unstable ❖ Signs of pump failure

5.8.4.2 Low/ Intermediate risk Unstable Angina An unprovoked or prolonged chest pain raising suspicion of acute myocardial infarction (AMI), wthout definite ECG or laboratory evidence. Assess:

Normal ECG Abnormal ECG, but unchanged from previous ST segment deviation in either direction of less than 0.5 mm T wave inversion ≤ 2 mmConsider Management: Normal cardiac markers

Action:

● Serial cardiac markers (Troponin / CK-MB) at 0,6 hrs ● Repeat ECG at 1,3,6 hrs ● Continuous ST segment monitoring

Admission Following categories of patients with chest pain require admission or referral for proper management:

● Patients with documented MI, aortic dissection or pericarditis. ● Patients with history compatible with unstable angina or MI but with normal ECG. ● Patients with suspected pulmonary embolism, pericarditis or aortic dissection. ● Patients with hemodynamic instability, respiratory distress or altered mental status. ● Patients with chest trauma who were initially unstable or who have suspected

lung/heart contusion. ● Patients with chest trauma with multiple rib fractures who have pain severe enough to

cause respiratory compromise.


5.8.5.Nursing consideration in Drug Administration

Drug Presentation Action indication Dose Preparation Mode of administ

ration

Adverse effect

Nursing Responsibility

Nitr

ogly

ceri

ne

25 mg/5ml Vaso dilation

Hypertension

Acute MI

CHF

0.2 to 10 mg/kg/mt

25mg diluted in 250 ml of D5

IV infusion

Headache

Low BP

Administer through infusion

Do not stop abruptly

Stre

ptok

inas

e

1.5 million units

Powder form

Throm bolyic

Acute MI

Pulmonary embolism

Acute ,extensive thrombi of deep veins

1.5 millions units

2,50,000units(DVT)

1.5 mu diluted in 10 ml with 250 ml of normal saline to be given 60 mts.

30 mts

IV Infusion

Bleeding

Allergic reaction

Severe kidney disease

Blurred vision

Draw blood for PT before start therapy.

Continuous monitoring of vital signs.

Institute bleeding precaution watch for hyper sensitive reaction.

Not to be repeated within 6 month.

5.8.6 Scenarios Scenario1 A 50 years man came to the emergency with severe chest pain radiating to his left arm. How was he managed in your emergency?


Assessment:

History: Patient had diffuse, squeezing type of pain, was placing hand in the centre of chest for the last 30 min. The pain was radiating to left shoulder. The onset of pain was gradual which kept on increasing in intensity. The pain precipitated after exertion. Patient also complaint of sweating and nausea. He had the past history of Hypertension since 5 years on medications. No similar episode in the past.

Examination Patient was sweating, pulse rate 104/min, BP 180/96 mm Hg, oxygen saturation was 94% with no usage of accessory muscles and in respiratory and CVS Examinations no significant clinical finding was observed.

Action Supported his ABC, administered oxygen, attached cardiac monitor and started IV line, got 12 lead ECG immediately. Administered chewable Aspirin, Nitrates and Morphine. ECG showed ST elevation MI. Administered Chewable aspirin 325mg and sublingual nitroglycerine three doses, started clopidogrel 300-600 mg and high dose statins. Immediately shifted to a higher centre capable of doing Percutaneous Coronary Intervention(PCI) If it was not possible to shift to any appropriate facility for PCI within 120 min, we had alternatively planned to administer fibrinolytic within 30 min of arrival in ED.

5.9.0.Peri-Arrest Arrhythmias

5.9.1.Core Concepts:

Peri-arrest arrhythmias include rhythm disturbances (bradycardia or tachycardia rhythms) that immediately precede a cardiac arrest or follow a successful resuscitation. These rhythms may rapidly progress to arrest rhythms, if not treated

● Triage the patients based on the presence of danger signs and manage accordingly● Recognize the rhythm and follow the protocol for management

There are 2 main categories of abnormal peri arrest rhythms: Tachycardia (HR >100/min) and Bradycardia (HR < 60/min)


Management of a patient with Peri-arrest Arrhythmia(Algorithm)

Algorithm 6 : Management of a patient with Peri-arrest Arrhythmia

AssessABC

Oxygen, Monitors

YES

Patient is unstable

Urgent intervention is needed

No

Patient is stable

Does he have danger signs?• Pallor, Cold clammy skin, delayed

capillary refill time• Acute disorientation• Chest Pain• Low Blood Pressure• Acute heart failure

ECG Rhythm

Brady-Rhythm Tachy-Rhythm

Are there any Reversible causes???

Identify Rhythm Type

Follow protocolsNarrow complex Wide complex

If Yes

Treat them

12 lead ECG


5.9.2.0. Bradycardia It is defined as a heart rate less than 60 beats per minute (BPM) in adults. Bradycardia typically does not cause symptoms until the heart rate drops below 50 BPM. When symptomatic, it may cause fatigue, weakness, dizziness, and at very low rates may even cause fainting. Highly trained athletes and patient on β-blockers may also have low pulse rate.

5.9.2.1.Causes of bradycardia

· Aging- sick sinus syndrome · Myocardial Ischemia · Hypertension · Congenital heart defect. · Myocarditis · A complication of heart surgery · Hypothyroidism

· Electrolyte imbalance · Obstructive sleep apnea · Inflammatory disease, such as rheumatic

fever or lupus · Hemochromatosis · Medications - β blockers, drugs given for

rhythm disorders, high blood pressure and psychosis

5.9.2.2Management of a patient with Peri-arrestbradycardiarhythm(Algorithm 7)

Algorithm 7: Management of a patient with Peri-arrest bradycardia rhythm


5.9.3.0.Tachycardia It is defined as heart rate more than 100 beats per minute in an adult. Tachycardia increases the oxygen demand of the heart, which can lead to rate related ischemia.

5.9.3.1.Causes of tachycardia:

· Anaemia · Antiarrhythmic agents · Atrial fibrillation · Atrial flutter · Atrial tachycardia · AV nodal reentrant tachycardia · Caffeine · Cocaine · Exercise · Fear · Fever

· Hypoglycemia · Hypovolemia · Hyperthyroidism · Hyperventilation · Infection · Junctional tachycardia · Multifocal atrial tachycardia · Nicotine · Pacemaker mediated · Pain · Pheochromocytoma · Sinus tachycardia · Wolff–Parkinson–White syndrome

5.9.3.2.Management of a patient with Peri-arrest Tachycardia rhythm(Algorithm)

Algorithm 8 : Management of a patient with Peri-arrest Tachycardia rhythm


5.9.4. Heart Blocks

● These are due to defect in the conduction pathway between atria and ventricles. ● The three types of heart block are first degree, second degree, and third degree. First

degree is the least severe, and third degree is the most severe.

5.9.4.0.First-Degree Heart Block In first-degree heart block, there is prolongation of PR interval (>0.2 sec), but the PR interval does not vary and is constant. First-degree heart block may not cause any symptoms or require treatment.

5.9.4.1.Second-Degree Heart Block

● In this type of heart block, some electrical signals from the atria do not reach the ventricles. On ECG, every P wave is not followed by a QRS complex, as it normally would.

● Second-degree heart block is of two types: Mobitz type I and Mobitz type II. 5.9.4.1.0.Mobitz Type I

● In this type (Wenckebach's block), on the ECG, there is progressive lengthening of PR interval until a P wave is not followed by a QRS complex.


5.9.4.1.1Mobitz Type II

● In second-degree Mobitz type II heart block, the pattern is less regular than in Mobitz type I. Some signals move between the atria and ventricles normally, while others are blocked.

● On an ECG, PR interval is constant and some P waves are not followed by QRS complex. Ventricular rhythm is irregular because of some blocked impulses. Mobitz type II is less common than type I, but it's usually more severe. Some people who have type II may need pacing.

5.9.4.2.Third-Degree Heart Block

● In this type of heart block, no electrical signals reach the ventricles. This is also known as complete heart block or complete AV block.

● When complete heart block occurs, some areas in the ventricles may generate electrical signals to cause the ventricles to contract. This natural backup system is slower than the normal heart rate and is not coordinated with the contraction of the atria.

● On an ECG, both atrial and ventricular rhythms are regular but are dissociated and independent of each other. Complete heart block can result in sudden cardiac arrest and death. This type of heart block often requires emergency treatment. A temporary pacemaker might be used until a permanent pacemaker is implanted.


5.9.5. Nursing Consideration in Management of Peri arrest Arrythmias

Peri arrest Arrhythmias – Nursing Management

Assessment (Follow NELS approach)

Action as per ABCD priority Remarks

(Spl consideration)

Assess Airway ,Breathing , Circulation and Disability approach of assessment

Assess for danger signs associated with peri arrest arrhythmias

Nurse should assess for danger signs like –

Pallor, Cold clammy skin, Delayed capillary refill time >2seconds)

● Acute disorientation ● Chest Pain ● Low Blood Pressure ● Acute heart failure Rhythm Assessment

Assess the rate and rhythm of the ECG

Rate – increased >100 bpm is tachycardia and decreased <60 bpm is bradycardia

Rhythm – assess whether the ECG is regular or iriregular. Regular means each P wave is preceded

Initial Management: ● Follow NELS ABC

approach for management .

● Based on presence of warning signs and symptoms, triage the patient into hemodynamically stable or unstable

Specific Management: ● If patient is

hemodynamically stable: Observe.

● In case of 2nd Degree Type II or 3rd Degree Heart Block, transcutaneous pacer needs to be applied, on standby basis even if the patient is hemodynamically stable. Therefore, nurse has to prepare the pre procedure requirements like instrument, solutions, sutures etc.

Skills:

ECG Interpretation

(refer to peri arrest brady arrhythmia algorithm)


by QRS and then T wave If tachyarrhythmia (>100

bpm) – assess whether it is narrow complex (i.e. QRS is narrow) or broad complex (i.e. QRS is broad)

Example of narrow and broad complex tachyarrhythmias –

Narrow complex – Atrial Fibrillation, Atrial flutter, Supraventricular tachycardia (SVT)

Broad complex – ventricular tachycardia, ventricular fibrillation

● If patient is hemodynamically unstable:

❖ Loading and administration of drug as prescribed –

❖ Inj. Atropine: 0.6 I/V mg bolus, it may be repeated every 3 to 5 minutes to a maximum of 3 mg.

❖ If Atropine is ineffective, plan any one of the below mentioned modality:

❖ Inj. Dopamine (2 to 20 mcg/kg/min) infusion

❖ Inj. Epinephrine (2 to 10 mcg/min) infusion.

❖ Transcutaneous pacing (prepare the required articles)

❖ Seek expert consultation at the earliest.

(refer to peri arrest brady arrhythmia algorithm)

Assess the sign symptoms of Bradycardia

Observe the patient with

Fatigue Weakness Dizziness Fainting (with very low

rate)

Management

Monitor ABC Administer oxygen

Nurse should know initial and specific management related to condition.


A nurse should be aware of the causes of the bradycardia so that prompt action targeting the cause can be taking immediately on time.

· Aging- sick sinus syndrome

· Myocardial Ischemia · Electrolyte imbalance · Hypertension · Congenital heart defect. · Myocarditis · A complication of heart

surgery · Hypothyroidism · Obstructive sleep apnea · Inflammatory disease,

such as rheumatic fever or lupus

Hemochromatosis Medications - β blockers,

drugs given for rhythm disorders, high blood pressure and psychosis

Continuous Monitoring and response to treatment


approach of assessment and management as described earlier.

● Based on presence of warning signs and symptoms, triage the patient into hemodynamically stable or unstable

Specific Management: ● If patient is

hemodynamically stable: Observe.

● In case of 2nd Degree Type II or 3rd Degree Heart Block, transcutaneous pacer needs to be applied, on standby basis even if the patient is hemodynamically stable. Therefore, nurse has to prepare the pre procedure requirements like instrument, solutions, sutures etc.

● If patient is

hemodynamically unstable:

❖ Loading and administration of drug as prescribed –


❖ Inj. Atropine: 0.6 I/V mg bolus, it may be repeated every 3 to 5 minutes to a maximum of 3 mg.

❖ If Atropine is ineffective, plan any one of the below mentioned modality:

❖ Inj. Dopamine (2 to 20 mcg/kg/min) infusion

❖ Inj. Epinephrine (2 to 10 mcg/min) infusion.

❖ Transcutaneous pacing (prepare the required articles)

❖ Seek expert consultation at the earliest.

Assess the risk and causes of Peri arrest Tachyarrhythmia

Intervention

A nurse should be aware of the causes of the Tachycardia so that prompt action targeting the cause can be taking immediately

MANAGEMENT


approach of assessment and management as described earlier.

● Based on presence of warning signs and symptoms, triage the patient into hemodynamically stable or unstable.

Specific Management: If patient is hemodynamically stable:

● Obtain 12 lead ECG ● Categorize patient into

refer to peri arrest brady arrhythmia algorithm


on time.

Anaemia Antiarrhythmic agents Atrial fibrillation Atrial flutter Atrial tachycardia AV nodal reentrant

tachycardia Caffeine Cocaine Exercise Fear Fever Hypoglycemia Hypovolemia Hyperthyroidism Hyperventilation Infection Junctionaltachycardia Multifocalatrial

tachycardia Nicotine Pacemaker mediated Pain Pheochromocytoma Sinus tachycardia Wolff–Parkinson–White

syndrome

Continuous monitoring the Hemodynamic status

narrow complex or broad complex tachycardia

If patient is hemodynamically unstable: Do Cardioversion

● Narrow Complex, Regular: 50-100 J Biphasic

● Narrow Complex Irregular: 120- 200 J Biphasic

● Wide Complex Regular: 100 J Biphasic

● Wide Complex Irregular: Unsynchronised Defibrillation shock

NOTE: Get Defibrillator Ready For Cardioversion

Remember – 3 “C” for cardioversion

- CONSENT - CONSIDER

SEDATION - CRASH CART

Narrow Complex Tachycardia

● Vagal Maneuver: ● Adenosine: If regular

narrow complex present. Administer via wide bore IV cannula. 1st dose is 6 mg IV bolus push followed by flush of

Refer to Cardiac arrest


normal saline. 2nd dose is 12 mg IV push.

● Beta Blocker/ Calcium channel blocker

Broad Complex Tachycardia · Amiodarone infusion: 150 mg over 10 minutes followed by 1 mg/min over 6 hours · Seek Expert Consultation

Algorithm

5.9.6.Cardiac Arrest Rhythms (FATAL ARRITHYMIAS)

Cardiac arrest Rhythms may be either shockable (ventricular fibrillation or pulseless ventricular tachycardia) or non-shockable (asystole or pulseless electrical activity). [Figure 1]

Figure 1: Arrest Rhythms

Shockable rhythmsinclude ventricular fibrillation and pulseless ventricular tachycardia.

Pulseless ventricular

Tachycardia (VT ) • Ventricular tachycardia is

a rapid, regular heart

rhythm that originates in

the lower chambers of the

heart.

• In ventricular tachycardia

electrical impulses

Ventricular fibrillation(VF) • Ventricular fibrillation is an

abnormal heart rhythm that is

disorganized and irregular

• In ventricular fibrillation,

electrical activity in the heart

muscle becomes chaotic,

preventing the heart from

contracting.


Pulseless Electrical Activity (PEA):

Unresponsiveness and lack of palpable pulse in the presence of organized cardiac electrical activity.

Pulseless electrical activity has previously been referred to as electromechanical dissociation (EMD).

Asystole:

Asystole is cardiac standstill with no cardiac output and no ventricular depolarization, eventually occurs in all dying patients.

Ventricular fibrillation:

The rate or rhythm cannot be determined. The P waves, QRS complex or T waves are not recognizable. A pattern of sharp up and down deflections is seen. [Figure 2]

Figure 2: Ventricular fibrillation

Pulseless ventricular tachycardia (VT):The ventricular rate is more than 100/minute, typically 120 to 250/minute. The rhythm is regular ventricular rhythm. PR is absent, P waves are seldom seen but present. QRS complexes are wide and bizarre. It can be monomorphic (QRS Complexes with similar morphology) or Polymorphic (QRS Complexes with multiple morphology).

Figure 3: Monomorphic VT Figure 4: Polymorphic VT


Non- shockable Rhythmsinclude Asystole and Pulseless Electrical Activity (PEA)

Asystole: No ventricular activity is seen or there are ≤6 complexes/min.

Figure 5: Asytole

Pulseless electrical activity:There is some organized rhythm seen on ECG but there is NO carotid pulse palpable.

Figure 6: PEA with No Carotid Pulse


5.9.7.Nursing considerations in Emergency cardiac drug administration:

Drug Presentation Action Indication Dose preparation Mode of

administration

Adverse effect Nursing Responsibility

Dopamine 200 mg/5 ml

Vasopressor, BP support

Brady cardia

Septic shock

Cardiogenic shock

Severe CHF

2-20 mcg/kg/mt

200 mg=200,000 micro gram,

5ml +45 ml D5

200,000/50=4000 mcg/ml.

60 kgx 5mts =300 mics/mtx60 mts=18,000/hr = 4.5ml/hr

IV Infusion Headaches, dyspnea, arrhythmias,palpitation, nausea, Vomiting.

Monitor for tachycardia Administer through central line

Adrenaline 1 mg/ml Vasopressor 1mg stat IV Every 3-4 mts used in CPR

1ml + 9ml =10ml (1:1000) flushed by 20 ml saline and elevate the hand

IV infusion Arrhythmias Watch for arrhythmias


Nor adrenaline

2mg/2ml Potent Vaso constrictor

Severe hypotension

Sepsis

0.05-0.1/mcg/kg/mt

1-1.5 mcg/minute

1amp= 2 mg/2ml (2000 mics+48 ml)

2000/50=40 mics/ml . 60x0.05=3 mics/mt(3x 60 mts=180 mics/hr=4.5ml/hr)

IV infusion Hypertension which may associated with bradycardia

Extravasion

Monitor BP

Do not cease infusion abruptly

Discard dilated solution after 24 hrs.

Atropine

.6mg / 1ml Anti cholenergic

Brady cardia

AV Block

OP Poisoning

0.6 stat IV

Every 3-5 mts maximum dose 3 mg

2-4 mg or higher

Preparation 1mg /1ml –diute 10 mg of atropine (10mls =10 ampulse )in 40mls NS,50 mls. 5mls/hr=1mg/hr to titrate with effect

IV infusion Headache,Dizziness or light headedness, Weakness or nervousness,Blurred vision, large pupils, or sensitivity to bright light.

Decreased sweating

Continuous ECG monitoring

Overdose is poisonous.

Lignocaine

-2% without vasoconstriction (lignocaine plain)

Anti Arrythimic

Regional nerve block

Arrythimia

Status

7.0mg /kg for adult not to exceed 500

Dilute the 2% (20 mg/ml) Lidocaine 1:4 to get final concentration

IV infusion

Dermal patch,

Nasal

Drowsiness

Confusion

Tremors

Continuous ECG monitoring


-2% with Epinephrine (1: 50,000)

-2% with epinephrine 1,00,000

epilepticus

Neuropathic pain

mg.

4.4mg/kg of lignocaine without a vasoconstriction

of 0.5% (5 mg/ml)

instillation /spray /Tropical gel

Altered taste

Cordorone 150mg/3ml Antiarrythmic

VT,VF Initial dose 300 mg ,if no response , repeat at 150 mg IV

If rhythm converts 1mg/1mt or 450mg in 250 ml add with D5% (33ml/hr)

The standard recommended dose is 5mg/kg body weight given by intravenous infusion over a period of 20 minutes to 2 hours. This should be administered as adilute solution in 250mL 5% glucose.

IV infusion Increased ventricular beats,

Prolonged PR interval

Monitor ECG for bradycardia

Watch for signs of pulmonary toxicity ,dyspnea and cough.


5.9.8. Scenarios Scenario 1: A 60 years man with history of previous myocardial infarction was admitted 3 days back in the medicine ward. Suddenly, he started complaining of uneasiness and palpitation. How was he managed? Assess

● Airway was patent and he was talking ● Breathing: SpO2was 94%, oxygen supplementation was given via ventimask @ 6 L/

min, Breathing was normal ● Circulation: Pulse was 140/ min, BP 110/70, ECG showed broad complex

tachycardia, IV Line was secured. Looked for warning Signs/ Symptoms: There was no episode of chest pain/ Syncope/Altered mental status. Diagnosis: Broad complex tachycardia and it was stable Action

● Antiarrhythmic infusion with Amiodarone 150 mg IV over 10 minutes started followed by 1 mg/min infusion over 6 hours

● Patient became unstable, started complaining of light headedness and sweating with BP of 70/30 mm Hg

Diagnosis: Unstable broad complex tachycardia Planned cardioversion: In wide complex regular: Given 100 J Patient recovered with normal sinus rhythm and vital became within normal limits. Scenario 2: A 70-year man complained of heaviness in chest, uneasiness and sweating cam to the emergency department. How did you manage this patient?

Assessment: Identification of Peri-arrest rhythm

● A: Airway was patent and he was talking ● B: Breathing: SpO2 was 94%, oxygen supplementation given via ventimask @ 6 L/

min, Breathing was normal ● C: Circulation: Pulse was 40/ min, BP 80/40, ECG showed 2nd degree type II block,

IV Line secured Lookfor warning Signs/ Symptoms:

● Chest discomfort ● Uneasiness and sweating


Diagnosis: Bradycardia: unstable Action:

● Administered Atropine 0.6 mg IV, repeated up to max of 3 mg● Sent a call to cardiologist for pacer and expert help● When Pacer was available, attached pads for pacing and did transcutaneous pacing.● Given inj Dopamine (2 to 20 mcg/kg/min) as infusion.● Started Inj Epinephrine (2 to 10 mcg/min) as infusion

Bibliography: 1. Nicks BA, Gaillard J. Approach to Shock. In: Tintinalli JE, Stapczynski JS, Ma OJ,

Yealy DM, Meckler GD, Cline DM, editors. Tintinalli’s Emergency Medicine: AComprehensive Study Guide, 8th ed. McGraw-Hill Education; 2016. p. 63-69.

2. Advanced Trauma Life Support. Student course manual. American college ofsurgeons committee on trauma 9th ed. USA; 2012. p. 62-93.

3. Brock N, Williams BJ. Bleeding and shock. In: Gulli B, editor. Principles of ALSCare. American Academy of orthopaedic surgeons (AAOS). Sudbury, Massachusetts:Jones and Bartlett publishers; 2011.p.71-85.

4. Puskarich MA, Jones AE. Shock. In: Walls RM, Hockberger RS, Gausche-Hill M,Bakes K, Kaji AH, Baren JM et al. editors. Rosen’s Emergency Medicine: Conceptsand Clinical Practice, 9th ed. Philadelphia: Elsevier, Inc; 2018.p. 68-76.

5. Somand DM, Ward KR. Fluid and Blood Resuscitation in Traumatic Shock. In:Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, editors.Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8th ed. McGraw-Hill Education; 2016. p. 69-74.

6. Rowe BH, Gaeta TJ. Anaphylaxis, Allergies, and Angioedema. In: Tintinalli JE,Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, editors. Tintinalli’sEmergency Medicine: A Comprehensive Study Guide, 8th ed. McGraw-HillEducation; 2016. p. 74-79.

7. ASCIA Guidelines - Acute management of anaphylaxis 2017 updated. Availablefromhttps://www.allergy.org.au/images/stories/pospapers/ASCIA_Guidelines_Acute_ManManagem_Anaphylaxis_2017_Updated.pdf

8. Rhodes A, Evans LE, Alhazzani W, et al. Surviving sepsis campaign: internationalguidelines for management of sepsis and septic shock:2016. Intensive Care Med2017; 43: 304-77.

9. Levy MM, Evans LE, Rhodes A. The Surviving Sepsis Campaign Bundle: 2018update. Intensive Care Med 2018; Available from https://doi.org/10.1007/s00134-018-5085-0

10. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, etal. The Third International Consensus Definitions for Sepsis and Septic Shock(Sepsis-3). JAMA 2016;315:801-810.

11. Glass C, Manthey D. Cardiogenic Shock In: Tintinalli JE, Stapczynski JS, Ma OJ,Yealy DM, Meckler GD, Cline DM, editors. Tintinalli’s Emergency Medicine: AComprehensive Study Guide, 8th ed. McGraw-Hill Education; 2016. P.349-352.

12. American Heart Association –Advanced cardiovascular life support. Provider manual2016.

13. American Heart Association –Basic life support. Provider manual 2016.


14. Garg R, Ahmed SM, Kapoor MC, Mishra BB, Rao SC, Kalandoor MV, et al. Basiccardiopulmonary life support (BCLS) for cardiopulmonary resuscitation by trainedparamedics and medics outside the hospital. Indian J Anaesth2017;61:874-82.

15. Garg R, Ahmed SM, Kapoor MC, Rao SC, Mishra BB, Kalandoor MV, et al.Comprehensive cardiopulmonary life support (CCLS) for cardiopulmonaryresuscitation by trained paramedics and medics inside the hospital. Indian JAnaesth2017;61:883-94.

16. ACCF/AHA Guideline for the Management of Patients with UnstableAngina/Non-STEMI. Circulation. 2012


Lesson 6

Skills for maintaining circulation

Lesson 6 Skills for maintaining circulation Objectives Upon completion of the lesson the nurse would be able to perform

:

1. Assessment of capillary refill time 2. Pulse oximetery 3. blood pressure measurement 4. peripheral venous cannulation. 5. Central venous cannulation and pressure

monitoring 6. Setting up drug Infusion pumps 7. Blood transfusion 8. Carotid pulse check 9. Basic Cardiac Life Support (CCLS) 10. Comprehensive cardiac life support(CCLS) 11. Defibribrillation 12. AED(Automated External Defibrilator) 13. Infusion of Intra venous fluids 14. Setting up Devices and Equipments in ED 15. Setting up of Resuscitation cart for ault and child 16. Setting up of Resuscitation cart for trauma

To assist :

17. Cardioversion 18. Perform Transcutaneous pacing 19. Intraosseous Puncture (proximal tibia) 20. Vagal Manoeuvre/Carotid sinus massage 21. Internal Jugular Venipuncture 22. Subclavian Venipuncture: Infraclavicular Approach


Lesson 6

Skills for maintaining circulation Skill 1:Assesssment of Capillary refill time

Indication

To assess peripheral perfusion

Procedure

Light pressure is applied to the nail bed until it turns white (blanched). Pressure is removed and the time taken for blood to return to the tissue (indicated by the nail turning back to a pink colour) is noted. Normal capillary refill time is less than two seconds.

Skill 2: PULSE OXIMETRY

Pulse oximetry is a non invasive technique that measures the arterial oxyhemoglobinsaturation (Sa O2 or SpO2) of arterial blood. A sensor, or probe, uses a beam of red and infrared light that travels through tissue and blood vessels. One part of the sensor emits the light and another part receives the light. The oximeter then calculates the amount of light that as been absorbed by arterial blood. Oxygen saturation is determined by the amount of each light absorbed; unoxygenated hemoglobin absorbs more red light and oxygenated hemoglobin absorbs more infrared light.

The nurse should know the patient’s hemoglobin level before evaluating oxygen saturation because the test measures only the percentage of oxygen carried by the available hemoglobin. Thus, even a patient with a low hemoglobin could appear to have a normal SpO2 because emost of that hemoglobin is saturated.

Sensors are available for use on a finger, a toe, a foot( infants), an earlobe, and the bridge of the nose. Circulation to the sensor site must be adequate to ensure accurate readings. Pulse oximeter also display a measured pulse rate.

Pulse oximetry is useful for monitoring patients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk of hypoxia, and postoperative patients. Pulse oximetry does not replace arterial blood gas analysis. Desaturation indicates gas exchange abnormalities.


Purposes

1. To measure the capillary blood oxygen saturation. 2. To detect the presence of hypoxemia before visible signs develop. 3. To assess the response to therapy. 4. To assess the need to decrease the number of arterial blood gas specimens drawn.

Indications

1. Patients who may experience sudden change in blood oxygen level ( unstable conditions)

2. Patients who will need evaluation for home oxygen therapy. 3. Patients who need supplemental oxygen at rest and with exercise.

Procedure

Action Rationale 1. Explain what you are going to do

and why are you going to do it to the patient

Explanation relieves anxiety and facilitates cooperation.

2. Perform hand hygiene Hand hygiene deters the spread of microorganism.

3. Select an adequate site for application of sensor.

- Use the patient’s index, middle, or ring finger.

- Check the proximal pulse and capillary refill and pulse closest to the site.

- If circulation at site is inadequate, consider using the earlobe or bridge of nose

- Use toe only if lower extremity circulation is not compromised.

Inadequate circulation can interfere with the oxygen saturation reading. Fingers are easily accessible. Brisk capillary refill and a strong pulse indicate that circulation to the site is adequate. These alternative sites are highly vascular alternatives. Peripheral vascular disease is common in lower extremities.

4. Select proper equipment: - If one finger is too large for the

probe, use a smaller one. A pediatric probe may be used for smaller adult.

- Use probes appropriate for patient’s age and size.

- Check if patient is allergic to adhesive. A nonadhesive finger clip or reflectance sensor is available.

In accurate readings can result if probe or sensor is not attached correctly. Probes come in adult, pediatric, and infant sizes. A reaction may occur if patient is allergic to adhesive substance.

5. Prepare the monitoring site. Cleanse the selected area with the alcohol wipe or disposable cleansing cloth. Allow the area to dry. If necessary, remove nail polish and artificial nails after

Skin oils, dirt, or grime on the site, polish, and artificial nails can interfere with the passage of light waves.


Action Rationale checking manufacturer’s instructions.

6. Apply probe securely to skin.Make sure that the light-emittingsensor and the light receivingsensor are aligned opposite eachother ( not necessary to check ifplaced on forehead or bridge ofnose).

Secure attachment and proper alignment promote satisfactory operation of the equipment and accurate recording of the SpO2.

7. Connect the sensor probe to thepulse oximeter, turn the oximeteron, and check operation of theequipment (audible beep,fluctuation of bar of light orwaveform on face oximeter).

Audible beep represents the arterial pulse, and fluctuating waveform or light bar indicates the strength of the pulse. A weak signal will produce an inaccurate recording of the SpO2. Tone of beep reflects SpO2 reading. If SpO2 drops, tone becomes lower in pitch.

8. Set alarms on pulse oximeter.Check manufacture’s alarm limitsfor high and low pulse ratesettings

Alarm provides additional safeguard and signals when high or low limits have been surpassed.

9. Check oxygen saturation atregular intervals, as ordered bythe physician and signaled byalarms. Monitor hemoglobinlevel.

Monitoring SpO2 provides ongoing assessment of patient’s condition. A low hemoglobin level may be satisfactorily saturated yet inadequate to meet a patient’s oxygen needs.

10. Remove sensor on a regular basisand check for skin irritation orsigns of pressure ( every 2 hoursfor spring tension sensor or every4 hours for adhesive finger or toesensor).

Prolonged pressure may lead to tissue necrosis. Adhesive sensor may cause skin irritation.

11. Clean non disposable sensoraccording to the manufacturer’sdirections. Perform hand hygiene.

Each deters the spread of micro organisms and contaminants.

Documentation

Documentation should include the type of sensor and location used, the assessment of the proximal pulse and capillary refill, pulse oximeter reading, the amount of oxygen and delivery method if the patient is receiving supplemental oxygen, lung assessment, if relevant, and any other relevant interventions required as a result of the reading.

Conclusion

Pulse oximetry is a non-invasive method allowing the monitoring of the saturation of a patient's hemoglobin.A sensor is placed on a thin part of the patient's body, usually a fingertip or earlobe, or in the case of an infant, across a foot. Light of two different wavelengths is passed through the patient to a photodetector. The changing absorbance at each of the


wavelengths is measured, allowing determination of the absorbances due to the pulsing arterialblood alone, excluding venous blood, skin, bone, muscle, fat, and (in most cases) nail polish.

Skill 3: Blood pressure (BP) measurement

Equipment required

1. A stethoscope 2. An appropriately sized blood pressure cuff 3. A blood pressure measurement instrument such as an aneroid sphygmomanometer or an

automated device with a manual inflate mode.

Procedure

Prepare the patient: Make sure the patient is relaxed by allowing 5 minutes to relax before the first reading. The patient should sit upright with their upper arm positioned so it is level with their heart and feet flat on the floor. Remove excess clothing that might interfere with the BP cuff or constrict blood flow in the arm. Be sure you and the patient refrain from talking during the reading.

Select the proper BP cuff size: Most measurement errors occur by using not the proper cuff size. Length of cuff: 80% of arm circumference. Cover 2/3 of length of arm

Place the BP cuff on the patient's arm: Palpate/locate the brachial artery and position the BP cuff so that the artery marker points to the brachial artery. Wrap the BP cuff snugly around the arm.

Position the stethoscope: On the same arm that you placed the BP cuff, palpate the arm at the ante cubical fossa (crease of the arm) to locate the strongest pulse sound and place the bell of the stethoscope over the brachial artery at this location.

Inflate the BP cuff: Begin pumping the cuff bulb as you listen to the pulse sound. When the BP cuff has inflated enough to stop blood flow you should hear no sounds through the stethoscope. The gauge should read 30 to 40 mmHg above the person's normal BP reading or 180mmHg. If this value is unknown you can inflate the cuff to 160 - 180 mmHg. (If pulse sounds are heard right away, inflate to a higher pressure.)

Deflate the BP cuff : Begin deflation. The AHA recommends that the pressure should fall at 2 - 3 mmHg per second, anything faster may likely result in an inaccurate measurement.

Listen for the Systolic Reading: The first occurrence of rhythmic sounds heard as blood begins to flow through the artery is the patient's systolic pressure. This may resemble a tapping noise at first.


Listen for the Diastolic Reading: Continue to listen as the BP cuff pressure drops andthe sounds fade. Note the gauge reading when the rhythmic sounds stop. This will be the diastolic reading.

Record BP at least twice : The AHA recommends taking a reading with both arms andaveraging the readings. To check the pressure again for accuracy wait about five minutes between readings. Typically, blood pressure is higher in the mornings and lower in the evenings. If the blood pressure reading is a concern or masked or white coat hypertension is suspected, a 24 hour blood pressure study may be required to assess the patient's overall blood pressure profile.

Skill 4: Peripheral venous cannulation

Aims

1. Safe, effective delivery of treatment without discomfort or tissue damage2. Without compromising venous access especially if long term therapy is proposed.

Indications

1. Fluid and electrolyte replacement2. Administration of medicines3. Administration of blood/blood products4. Administration of Total Parenteral Nutrition5. Haemodynamic monitoring6. Blood sampling

Advantages

1. Immediate effect2. Control over rate of administration3. Useful in patients unable to tolerate drugs/fluids orally4. Some drugs cannot be absorbed by any other route5. Pain and irritation avoided compared to some substances given SC or IM

Veins of the hand:

1. Digital dorsal veins2. Dorsal metacarpal veins3. Dorsal venous network4. Cephalic vein5. Basilic vein

Veins of the forearm

1. Cephalic vein2. Median cubital vein3. Accessory cephalic vein


4. Basilic vein 5. Cephalic vein 6. Median antebrachial vein

Preparation and environment

Check and verify the physician’s orders Gather equipment Restraint the site in case of children Check vital signs and record Adjust the height of the bed for comfortable working Place the patient in comfortable position Select the site on the non-dominant arm Provide a good source of light

Identify a suitable vein

Bouncy Soft Above previous site Refills when depressed Visible A large lumen Well supported Straight Easily palpable

Veins to be avoided

Thrombosed/sclerosis Inflamed/bruised Thin/fragile Mobile Near bony prominences Areas or sites of infection Having undergone multiple previous punctures

Equipment

A tray containing

1. Sterile gloves 2. IV cannula of appropriate size and purpose 3. Tourniquet 4. Dressing to secure cannula 5. Alcohol swabs 6. Saline flush and sterile syringe or fluid to be administered


Procedure

Wash hands with antiseptic soap Strict adherence to hand washing and aseptic technique remains cornerstone of

prevention of cannula related infections Apply the tourniquet above insertion site Disinfect the selected site with skin prep and allow to dry Do not touch the skin with fingers after the preparation solution has been applied Inspect the cannula before insertion to ensure that the needle is fully inserted into

Athens plastic cannula and plastic tip is not damaged Do not touch the shaft or tip of the cannula Hold the cannula in your dominant hand, stretch the skin over the vein to anchor the

vein with non-dominant hand. Do not palpate the vein. Insert the needle at an angle of 15-30 degrees to the skin (depending on the vein

depth) Observe for blood in the flashback chamber Partially withdraw the needle and advance the cannula Remove the needle from the cannula and dispose into a sharp container Attach the white lock cap. Secure the hub of the cannula with clean adhesive tape Do not cover the puncture site Flush the cannula with normal saline or start IV fluid by connecting IV set to cannula Ensure that the insertion site and area proximal to the sure are visible for inspection

purposes If the site needs to be immobilized, use a well padded splint and strapping if

necessary.

Document the procedure including

Date and time Site and size of cannula Any problem encountered Clean up, dispose off rubbish

Complications

IV site infection: most common cannula related infection Cellulitis: warm, red and often tender skin surrounding the site of cannula insertion Infiltration or tissuing occurs when the fluid leaks into the surrounding tissue. It is

important to detect early as tissue necrosis could occur Thrombophlebitis: it occurs when a small clot becomes detached from the sheath of

the cannula or the vessel wall. Prevention is the greatest form of defence. Flush cannula regularly.

Extravasation: accidental administration of IV drug into the surrounding tissue becYse the needle has punctured the vein and the infusion goes directly into the arm tissue. The leakage of high osmolarity solutions or chemotherapy agents can result in significant tissue destruction.


Bruising: commonly results from failed IV placement, particularly in elderly andthose on anticoagulant therapy

Air embolism: occurs when air enters the infusion line, although it is very rare Haematoma: occurs when blood leaks out of infusion site. Commonest cause of this is

using cannula that are not tapered at the distal end. It will also occur if I’m insertionthe cannula has penetrated through to the other side of the vessel wall. Apply pressureto the site for approximately 4 minutes and elevate the limb.

Phlebitis: inflammation of a vein: common in IV therapy (redness and pain at theinfusion site. Prevention: aseptic technique, choosing the insertion, smallest gaugecannula, secure cannula properly.

Skill 5: Central venous cannulation and pressure monitoring

Definition

Central venous pressure (CVP) is a measure of the pressure within the right atrium of the heart. CVP can be measured using a manometer attached to the intravenous fluid line, in terms of fluid pressure in the column of manometer

Indication

Circulating blood flows into the right atrium via the inferior and superior vena cava. The pressure in the right atrium is known as central venous pressure (CVP). The condition of the patient and the treatment being administered determine how often CVP measurement should take place, for example, critically ill unstable patients may need hourly measurements

Site for insertion

Internal jugular veins

This site is chosen frequently as there is a high rate of successful insertion and a low incidence of complications such as pneumothorax. Internal jugular veins are short, straight and relatively large allowing easy access, however, catheter occlusion may occur as a result of head movement and may cause irritation in conscious patients.

Subclavian veins

This site is often chosen as there are more recognizable anatomical landmarks, making insertion of the device easier. Because this site is positioned beneath the clavicle there is a risk of pneumothorax during insertion. A subclavian CVC is generally recommended as it is more comfortable for the patient.

Femoral veins

This site provides rapid central access during an emergency such as a cardiac arrest. As the CVC is placed in a vein near the groin there is an increased risk of associated infection. In addition, femoral CVCs are reported to be uncomfortable and may discourage the conscious


patient from moving.

Articles

A tray containing, IV tubing Manometer set Stopcock if not included in the manometer set Indelible ink marking pen Normal saline Adhesive tape Facemask Sterile gloves

Procedure

S.No. Nursing intervention Rational

1 Inform patient what will be done Knowledge of what to expect will reduce anxiety

2 Wash hands and apply gloves Reduces transmission of microorganisms

3 Gather needed articles at the bedside Maximizes efficiency and minimizes chance of breaking sterility once started

4 Position client in supine or flat position with no pillows under the head (if this position is not tolerated have the client in semi-flowers position). Mark the level of right atrium (at the mid-axillary line about 1/3rd, of the distance from anterior to posterior chest wall) in the 4thintercostals space with an “X” mark indelible ink pen

The term phlebostatic axis may be used to identify the level of the atrium

5 Fix the manometer on the IV pole such that it is zeroed at the “X” mark

Helps minimize the variance in the measurement


6 Correct the IV fluid (usually normal saline) to a three-way stopcock and flush the other two ports

Forces air out the stopcock. Fluids with glucose are stickier than normal saline and may cause manometer to stick, thus glucose solution to be avoided

7 Apply sterile gloves and mask Aseptic technique minimizes chance of infection

8 Connect the CVP manometer to the upper port of the stopcock

9 Connect the CVP tubing from the client to the second side port of the stopcock

Establishes IV line from normal saline to CVP catheter

10 Turn the stopcock off to client and fill the manometer with normal saline to the 20 cm mark above the anticipated reading

The normal CVP reading varies 8 to 12 cm of water

11 Hold manometer at the phlebostatic axis and turn the stopcock off to the normal saline

System is open from the manometer to the client

12 Watch as the fluid falls in eth manometer take the central venous pressure reading when the fluid stabilizes

The fluid will stabilize at a level equal to the pressure in the right atrium or central veins. If the fluid level fluctuates with the clients respiration’s, take the reading at the end of the clients expiration

13 Turn the stopcock off to the manometer Reestablishges the flow from te IV to the client

14 Reposition the patient

15 Keep the manometer in an upright position (usually hanging from the IV pole) to prevent air bubbles from entering the fluid column or the client and to prevent contamination of the manometer

The top of the manometer remains open to the air. If manometer is not properly stored, contaminants or air can enter the manometer and be flushed in to the client

16 Wash and dry hands Prevents spread of microorganisms


Potential complications

Haemorrhage from the catheter site - if it becomes disconnected from the infusion. Patients who have coagulation problems such as those on warfarin or those will clotting disorders are at risk.

Catheterocclusion- by a blood clot or kinked tube -regular flushing of the CVC line and a well secured dressing should help to avoid this.

Infection- redness, pain, swelling around the catheter insertion site may all indicate infection. Careful asepsis is needed when touching a CVC site. Swabs for MC&S should be taken if infection is suspected.

Air embolus- if the infusion or monitoring lines become disconnected there is a risk that air can enter the venous system. All lines and connections should be checked at the start of every shift to minimize the risk of this occurring.

Catheter displacement- if the CVC moves into the chambers of the heart then cardiac arrhythmias may be noted, and should be reported. If the CVC is no longer in the correct position, CVP readings and medication administration will be affected.

Conclusion

Central venous pressure measurement is often associated with intensive and critical care settings. However, with increasing numbers of critically ill patients being cared for on medical and surgical wards, it is essential that clinicians are able to record central venous pressure measurement accurately and recognize normal and abnormal parameters.

Skill 6: Setting up Drug Infusion

Accurate fluid infusion and drug administration is crucial for the optimum management of a critically ill neonate. Controlled intravenous delivery of common medications, such as inotropic agents, vasodilators, aminophylline, insulin, heparin etc. via infusion pump is the preferred mode of therapy in acute care. This is especially true for drugs with short half-lives, so as to maintain a desirable constant serum concentration and in situations when constant infusion of glucose is needed. Infusion pumps are also indicated to infuse fluids in small

17 Document the reading obtained in the client’s medical record (Flow sheep and/ or Nurses record)

Provides continuity of care


babies with compromised renal, cardiac or pulmonary function in order to prevent fluid overload. The use of infusion pumps has been advocated over manual flow control system for assuring precise and accurate delivery of prescribed fluid volumes over a specified time and to help in better nursing management.

Desirable specifications

A good infusion device should be:

1. reliable and electrically safe

2. able to deliver the infusion accurately and consistently

3. easy to set up and use

4. able to lock the instructions

5. portable and robust

6. powered with both battery and mains

7. equipped with override rapid infusion facility

8. capable of alerting line occlusion and need to re-change syringe

9. able to display rate of infusion and volume infused clearly

Types of Pumps

Gravity Controlled

Drip rate regulators Drip rate controllers

Positive displacement pumps:

Drip rate pumps Volumetric pumps Syringe Pumps Multi-Channel Pumps Ambulatory Pumps

Types of infusion pumps

1. Gravity controlled devices

The simplest and cheapest systems are dial-a-flow/dosiflow, which solely rely on gravity to regulate intravenous infusions. Infusion rate is dependent on pressure difference across the valve i.e. height of fluid or venous pressure/obstruction. A drop sensor attached to the drip chamber senses the drip rate. This feedback system can adjust the drop rate to a preset value, but, it cannot account for variation in drop size. Although cheap and easily available, the


disadvantages of gravity controlled devices include difficulty to deliver small volume infusions, frequent cannula blocks and extravasations, difficulty in tight control of infusions such as inotropes and high pressure driven infusions such as arterial lines. These are overcome by positive displacement pumps.

2. Positive displacement pumps

Mechanism of action

These provide a positive displacement of fluid with the help of a motor. Positive displacement pumps have either a peristaltic or a piston mechanism. Linear peristalsis consists of finger like projections that sequentially compress the intravenous tubing against a stationary back plate, thus moving the fluid in one direction. Rotator peristaltic pumps have rollers on a wheel which compress the tubing and thus move fluid in the tubing towards the patient.

i) Drip rate pumps

These pumps use drip sensor attached to administration set to count drops in order to achieve control of infusion rate. The speed of pumping mechanism is under feedback control from a drip sensor/counter. With pumping mechanism, occlusion alarm pressure settings above 100 mm Hg are usual. The high occlusion pressure can distend the administration tubing to the point of bursting it and lead to extravasations.

ii) Volumetric pumps

These pumps overcome limitations associated with variation in drop size. They use either a piston type action or peristaltic pumping action on an accurately made section of tube which forms part of a special administration set.

These special administration sets increase the cost of each infusion. They also need special IV tubing of standard size which is 2-4 times more expensive than normal tubings. However, the pumps are calibrated in ml per hour and are capable of precise regulation of the set flow rates.

Volumetric infusion pumps are capable of calculating the volume of fluid with the microprocessor based calculations, taking into account the size of the drop produced and the standardized diameter of the tubing. It has capability of functioning on mains and on rechargeable batteries. The pump alarms if bubbles appear in the tube, when infusion is completed, the battery voltage is low and flow line is occluded.

(iii) Syringe pumps

The most commonly used pumps for the administration of intravenous drugs are positive displacement syringe pumps that utilize a gear reduction mechanism and lead screw. These pumps are extremely accurate and have the convenience of not requiring specialized tubing. The most significant advance has been the introduction of a calculator mode within the pumps so that clinician can set the weight of patient, the drug concentration and the infusion rate in the mg per kg per minute and the calculator in pump then calculates the infusion in ml per minute. The main parts of the syringe pump are the control panel, display panel and a driving


unit.

Specifications of syringe pump include

1. Microprocessor-controlled motor capable of accurate propulsion

2. It should be capable of functioning on mains and rechargeable batteries

3. It should have few controls upon power switch, start switch and reset/stop switch

4. It should have a range of 0.1-99.9 ml/hr with up-to 0.1 ml/hr increments

5. It should have a display for alarm/error messages, infused volume and infusion rate

6. It should give alarms for dis-engagements of syringe clamp, any occlusion, when syringe becomes empty or plunger is out, low battery and mains power failure

The performance of infusion pumps is generally adequate for clinical use, but the volume that can be infused is limited to a maximum of 100 ml. Their light weight and resistance to the effect of gravity and position makes them ideal during transport. These pumps can be mounted on an IV pole or on the operating table. Bolus doses can be easily and rapidly administered at any time during the infusion. They are able to accept all syringe sizes from 10-100 ml and have two independent microprocessors to monitor and control infusion processes for consistent delivery.

Advantages and disadvantages of syringe pumps

Advantages

Cheaper than drip rate pumps Precise control of total volume infused Suited for small volume Low cost of disposables Pressure maintains rate inspite of resistance Delivery of air impossible Portable

Disadvantages

Unsuitable for large volume Comprehensive alarm system not usually provided

(iii) Multi-channel pumps

These pumps permit simultaneous administration of 2 or 3 infusions. However, one potential problem with such a system is the possibility of incompatible mixing.

(iv) Ambulatory pumps

These are pocket size pumps, which use linear peristaltic mechanism and have a fluid


container in the form of a small floppy bag or cassette. The pumps are designed for users who need to wear them for long periods and they have good alarm and display systems.

(v) ‘Smart’ Infusion pumps

These are new generation infusion pumps that incorporate a software that includes a “drug library” where in hospital-defined drug infusion parameters, such as acceptable concentrations, infusion rates, dosing units, and maximum and minimum loading and maintenance dose bolus limits, for 60 or more medications can be preprogrammed. Though these are intended to prevent adverse drug events (ADE), clinical studies comparing them with conventional infusion pumps have not demonstrated a distinct advantage of these pump.

However, with rapid advancements in computer technology, these pumps are likely to be used in future along with computerized prescriber order entry (CPOE) and automatic medication dispensing systems.

SYRINGE INFUSION PUMP

Working

1. Connect the power cable to the power slot and fix the infusion pump on to the installation pole.

2. Press the On button for 1 second to switch on the syringe pump. All signals on the display unit will glow for a second.

3. Choose the appropriate size and type of syringe as per the need of the patient.

4. Set the syringe in the slot in the driving unit. To do this, lift up the syringe holder and place the drug filled syringe with the inner and the outer cylinders in their corresponding grooves and ensure good fixation.

5. The syringe should be connected to the appropriate tubing. Avoid cutting of the IV set tubing to fit the syringe nozzle.

6. Set the rate of infusion using the up and down arrow keys in the control panel.


7. Before starting infusion press the prime button to flush the tubings to remove all air bubbles.

8. Now connect to the patient after ensuring patency of the IV line.

Trouble shooting

Alarm message Possible problem Corrective action

“OUT OF INFU” Slider has moved inadvertently

Fix syringe again and restart infusion

“OCCLUSION” Tube occluded with >60 kPa pressure

Check and remove cause of occlusion;

P.N. Unnecessary pushing fluid into the IV line may cause extravasations

“AC FAILURE” Low internal battery Connect to AC power

“SYRINGE IN USE” Syringe removed from holder

Set syringe properly and resume infusion

“NEAR EMPTY” Infusate almost over Keep loaded syringe ready

Maintenance

Cleaning : In case of spillage wipe with soft cloth soaked in lukewarm water Disinfection : Disinfect with Benzalkonium chloride

Don’ts

i) Do not use alcohol based disinfectant

ii) Do not autoclave

iii) Do not clean with wet cloth while connected to mains

Skill 7: Blood transfusion

DEFINITION

Blood Transfusion is the intravenous administration of the whole blood or a component such as plasma, packed red blood cells or platelets to a patient.


PURPOSES OF BLOOD TRANSFUSION

-To increase circulatory blood volume.

-To increase the number of red blood cells and to maintain the hemoglobin level.

-To provide plasma clotting factors, help in controlling the bleeding.

INDICATIONS OF BLOOD TRANSFUSION

After surgery or trauma and hemorrhage

Severe anemia

Haemophilia

Leucopenia

Agranulocytosis

BLOOD GROUPS

There are four blood types: A, B, AB and O; type indicates antigens on or on the RBC membrane (e.g., type A blood has A antigens; type O blood has no antigens)

Blood can be either Rh-positive or Rh-negative; usually blood does not contain anti-Rh antibodies. However, Rh-negative blood will contain anti-Rh antibodies if the individual has been transfused with Rh-positive blood or has carried an Rh-positive fetus without treatment; Rh-positive blood never contain anti-Rh antibodies

TYPES OF BLOOD COMPONENTS

1) RED BLOOD CELLS

They are a blood product used to replace erythrocytes. Packed red blood cells are usually supplied in 250 ml unit bags. Each unit increases the haemoglobin by 1 gm/dl; the change in laboratory values takes 4 to 6 hours after completion of the blood transfusion.

2) WHOLE BLOOD

It is rarely used. Whole blood is used to resolve hypovolemic shock resulting from haemorrhage. It consists of red blood cells, plasma and plasma proteins. Each unit normally contains 500 ml.

3) PLATELETS

Platelets are used to treat thrombocytopenia and platelet dysfunction. The volume in a unit of platelets varies from 50 to 70 ml per unit. They are usually administered rapidly over 15 to 30 minutes.


4) FRESH FROZEN PLASMA

They may be used to provide clotting factors or volume expansion; it contains no platelets. A unit contains 200-250 ml.

5)CRYOPRECIPITATES

They are prepared from fresh frozen plasma and can be stored for 1 year. They are used to replace clotting factors.

BLOOD WARMERS

Blood warmers may be used to prevent hypothermia and adverse reactions when several units of blood are being administered. Special warmers have been designated for this purpose. Do not warm blood products in a microwave or in hot water.

Criteria for selecting donor

Should not be suffering from disease of heart, kidney, liver, lungs, cancer, jaundice, tuberculosis, hepatitis, AIDS, allergies etc

Should not have donated blood within the previous 90 days.

Should be healthy and in the age group of 18-65 years of age.

Should not be pregnant.

Should have Hb above 12 gm %.

Should have normal vital signs.

Should not be empty stomach.

Preprocedure Nursing interventions

Explain the procedure to the patient. Determine whether the patient has undergone prior blood transfusion reaction, if any

Obtain an informed consent from the patient or relatives.

Prior to administration, patient’s vital signs to be recorded.

Offer bed pan before starting the procedure.

Ask the patient to report chills, headache or rash immediately

Preparation of articles

A tray containing

A blood transfusion set


A mackintosh and towel

A tourniquet

Cotton swabs with antiseptic

Adhesive tape and scissors

Gloves

A kidney tray with a paper bag

I/V stand

Normal saline

Blood or any of its components with cover received from the blood bank with the name of the reciprocal

Procedure

STEPS RATIONALE

1. Verify the physician’s or qualified practitioner’s order for the transfusion.

2. Observe patent IV line.

3. Explain procedure to the client.

4. Review side effects (dyspnea, chills, headache, chest pain, itching) with client and ask them to report to the nurse.

5. Have the client sign consent forms.

6. Obtain baseline vital signs.

7. Obtain the blood product from the blood bank within 30 minutes of initiation.

8. Verify and record the blood product and

1. Blood must be orderd by a physician or quailified practitionor.

2. Ensures a patent and adequate IV for infuction of blood.

3. Ensures that client understands procedure and decreases anxiety.

4. Promot reporting of a side effect will lead to earlier discontinuation of transfusion and minimizis the reaction.

5. Some hospitals or agencies require the clientto sign a consent form.

6. Allows detection of a reaction by any changein vital signs during the transfusion.

7. Prevents bacterial growth and destruction ofred blood cells.

8. Strict verification procedures will reduce therisk of administering blood products to thewrong client. If there is an error during thisprocedure, notify the blood blank and do notadminister the product.


identify

the client with another nurse :

• Client’s name, blood group, Rh type

• Cross-match compatibility

• Donor blood group and Rh type

• Unit and hospital number

• Expiration date and time on blood bag

• Type of blood product compared with

physician’s or qualified practitioner’s order

• Presence of clots in bloodabnormal color, cloudiness and excess air.

9. Instruct client to empty the bladder.

10. Wash hands and put on gloves.

11.Open the sterile packing of blood transfusion set aseptically. Insert the infusion set into the bag of the blood to be transfused.

12. If the patient has an I/V infusion, check whether the needle and solution are appropriate to administer blood.

13. Place the tourniquet 10-12 cm above the insertion site, by asking the patient to clench the fist.

14. Insert the needle and start infusion with NS.

9. A urine specimen after initiation of the transfusion will be needed if a transfusion reaction occurs.

10. Reduces risk of transmission of human immunodeficiency virus (HIV), hepatitis, or bloodborne bacteria.

11. Prevention of micro-organisms.

12. The needle should be of no.18 or 19 gauge and the solution must be normal saline.

13. Allows the blood product to be infused intothe client’s vein.

14. Dextrose solutions are not used with blood transfusions since they can clot the donor blood

16. If any reaction is suspected, notify the physician and the blood bank.

17. If a reaction occurs, it generally happens during the first 15–30 minutes.

18. Changes in vital signs can warn of a transfusion reaction.


15. Begin transfusion after identifying theblood products and the patient thoroughly.

16. Adjust rate to 2 ml/minute for the first 15minutes and remain with the patient.

17. Monitor vital signs every 15 minutes forthe first 15 minutes and every hourthereafter.

18. Observe for flushing, itching, dyspnea orrash. Stop transfusion immediately if anyreaction is suspected.

19.Dismantle all the articles.

20. Remove and dispose off gloves and washhands.

21. Record administration of blood, date,time, blood group, any adverse reaction andthe amount of blood infused.

21. Ensures accurate records.

Skill 8: Carotid pulse check


Procedure

Maintain head tilt with one hand, use 2-3 fingers of other hand to locate trachea, slide fingers into groove between trachea and muscles of same side of neck. Palpate for five to ten seconds and count if palpable.

Skill 9: Basic Cardiopulmonary Life Support (BCLS) Core links in adult basic cardiopulmonary life support

To get an optimal outcome in people who suffer cardiopulmonary arrest outside the hospital, four essential core links need to be followed. These are Early recognition and activation; Early high-quality CPR; Early defibrillation and Early transfer.

Figure 1: Core links in adult basic cardiopulmonary life support

Basic cardiopulmonary life support (BCLS)

The BCLS approach is a simplified algorithm-based approach to be followed for a victim with cardiopulmonary arrest outside the hospital. Though the recommended algorithm of BCLS is in sequential series, when more than one trained rescuers are present, the steps may be done simultaneously.


Algorithm 1: Basic cardiopulmonary life support (BCLS)

Before approaching a victim always ensure that the scene is safe both for the rescuer(You) and the victim. Take standard precautions.

Next, check for responsiveness (tap on shoulders and shout). If the victim is unresponsive, activate the ambulance services (via mobile phone) and get an AED (automated external defibrillator) or tell someone to do it. To activate the ambulance services, you may dial your state/regional number. The number 108 has been proposed as the pan-India emergency contact number, and it has been accepted by many states of India. Remember to give full details, ask for AED and don’t hang up till told to do so.


Check for the carotid pulse and simultaneously observe the chest for breathing movements for five to ten seconds. By chanting 1001, 1002, 1003 ……. one is able to keep track of time, it takes around one second to chant a number each time.

During check of pulse and breathing, the three clinical situations that may be encountered are as follows:

A. If the victim is breathing normally and has a carotid pulse, he/she should be shifted in recovery position and assessed every 2 min or earlier to determine any change in condition till medical help arrives. Victim should be shifted to the nearest medical facility at the earliest.

B. If the victim is not breathing but has carotid pulse, then normal tidal volume breaths

every 5 s at the rate of 12 breaths /minute should be provided using mouth to mouth (with/without barrier device), mouth to mask or bag mask device ventilation. Each breath should be delivered over 1 s. The end point of the ventilation breath is visible chest rise. Check carotid pulse every 2 minutes or earlier to observe any change in condition of the victim. Wait for the medical team and shift the victim to the nearest medical facilities at the earliest.

C. If the victim is not breathing or is gasping and there is no carotid pulse, he is in

cardiopulmonary arrest and requires high-quality CPR including cycles of compression and breaths at the earliest. Start with chest compressions. Give cycles of 30 compressions and 2 breaths (CAB sequence: Chest compression- Airway- Breathing). CAB sequence: Chest compressions: Give 30 chest compressions. (refer to skill of chest compression)Push Hard (5-6 cm); Push Fast (120/min); Allow complete Chest recoil and Minimize interruptions. Airway: To open the airway, do head tilt–chin lift. If cervical spine injury is suspected give jaw thrust or chin lift. Breathing: Rescue breaths can be given mouth to mouth (with/without barriers device); mouth to mask or using a bag-mask device. Two breaths to be given each over 1 second; there should be a visible chest rise.

If there is more than one rescuer, then the chest compression and administration of breath can

be done by two different rescuers. The rescuer roles should be interchanged every five cycles of CPR (five cycles of 30 chest compressions and 2 breaths) to prevent exhaustion and maintain effective BCLS, especially chest compression. Reassess carotid pulse after every 5 cycles of CPR.

Use AED as soon as it is available. To use AED, power on the AED and follow the voice prompts. If shock is advised, give shock. After shock, immediately start CPR with chest compression for 5 cycles until prompted by AED for rhythm check. If no shock advised, continue CPR till victim starts to move or advanced life support providers take over.

Provide high quality BCLS to ensure optimal outcome. The various aspects enhancing the outcome include:

High-quality chest compressions Chest compressions speed, rate andrecoil:Ensure a chest compression speed of 120

compressions/minute to a depth of 5–6 cm. Allow complete chest recoil between compression without lifting hand from the chest (do not lean on the victim’s chest).

Avoid unnecessary interruption of chest compressions.\


Optimalventilation and airway management: Do not interrupt chest compression to secure the airway, apply ECG electrodes or

defibrillator pads/paddles. Do not hyperventilate End point for ventilation is visible chest rise; deliver normal tidal volume breaths.

Chest compressions

• Victim Position: Place the victim on firm, flat surface.• Rescuer Position: Rescuer to kneel by side of victim• Hand Position: Place heel of one hand on center of victim’s

Chest (lower half of sternum), place heel of other hand on top of 1sthand, and interlace fingers to keep them off the chest. Arms should be straight and shoulders above the victim chest.

• Push Hard (5-6 cm)• Push Fast (120/min)• Allow complete Chest recoil• Minimize interruptions • The rescuer should chant loudly 1, 2, 3, 4,….30 to maintain the

speed and number of chest compressions. The rescuer should allow the complete chest recoil between compression without lifting hand from the chest but without leaning on the victim’s chest.

•

Skill 10:- AED (Automated External Defibrillator)

Indication

It is used to provide defibrillation by layperson or healthcare provider. The device analyzes

the heart rhythm and identifies the rhythm if it is shockable or not.

Equipment required

AED, self-adhesive multifunction defibrillation pads


Procedure

1. Power ON the AED. (some devices power on when the case or lid is opened)

2. Follow AED voice prompts ( written in green):

Attach pads to patient’s bare chest (adult pads are applied on a person ≥ 8 years of age)

Peel off the backing of the pads and then attach the adhesive pads on bare chest, the pad

placement is depicted as a picture on the pads itself. Attach AED connecting cable to the

AED device.

Analysing rhythm (stop CPR, clear victim, allow the AED to analyse rhythm)

It may say shock advised, charging followed by stay clear and deliver shock,press the

flashing button.

Make sure no one including you is touching the patient when you press the shock button.

3. Resume CPR (5cycles or 2 min) after delivering the shock or in case no shock is advised

by AED.


Figure: Use of Automated External Defibrillator (AED)

Checklist to assess the BLS skills

Trainee Name __________________________________________________

S.No Skill Step Performed Not performed

Remarks

1. Checks for responsiveness

2. Activate emergency response system

3. Checks carotid pulse and breathing(not more than 10 seconds)

4. Gives high quality chest compression

Correct hand placement

Push hard (delivers compression at least 2inches in depth)


Push fast(compression rate at least 100 compressions/min)

Lets the chest recoil

Minimizes interruptions

5. Opens the airway using correct maneuver

6. Gives 2 effective rescue breaths

7. Gives 5 cycles of CPR

8. Checks pulse after 5 cycles of CPR

9. Changes role after 5 cycles of CPR

10 Attach with AED paddles at the appropriate place

11 Continue chest compression during application of AED paddles

12 Stay away from patient while AED is analysing rhythm

13 Continue CPR after the AED delivers the current

Trainer signature: Overall: Performed well/ Repeat


SKILL 11: Defibrillation

Indication

Patient is in cardiac arrest and ECG shows ventricular fibrillation or pulseless ventricular

tachycardia

Purpose

Defibrillation stuns the heart and briefly terminates all electrical activity. This allows the

normal pacemaker to resume electrical activity, if the heart is still viable.

Equipment required

Defibrillator monitor with paddles or self-adhesive pads, Conducting gel

Procedure

Power on the defibrillator

Select energy- In adults biphasic 120-200 Joules; monophasic 360 Joules (in children

2J/kg first shock, second at 4J/kg, subsequent shocks ≥ 4J/kg not to exceed 10 J/kg or

adult dose)

Apply gel to paddles.

Place paddles on patient’s chest (sternum-apex). Sternal paddle- placed to the right of victim’s upper sternum, below clavicle; Apical paddle - placed on the victim’s left chest, infero-lateral to the left breast

Press charge button on paddle (or monitor)


All clear! Ensure no one is touching the patient including yourself. Keep oxygen

away.)

Press the Shock button. Always face the patient when pressing the shock button.

Resume CPR, beginning with chest compression for 5 cycles, then recheck rhythm

(It is recommended to use self-adhesive pads if available for defibrillation)

Skill 12: Adult Comprehensive Cardiopulmonary Life Support (CCLS)

The early identification of pre-arrest conditions and appropriate management are essential to prevent cardiac arrest in the controlled environment of a hospital. If a patient develops cardiac arrest in hospital, an optimal outcome requires not only the basic resuscitation steps but also the incorporation of advanced steps including administration of drugs, airway management, correction of underlying aetiologies, advanced monitoring and post-resuscitation care.

Core links in adult comprehensive cardiopulmonary life support (CCLS) The five essential core links in adult CCLS for optimal outcome in a patient with cardiopulmonary arrest are [Fig 1] Early recognition and management of pre‑arrest conditions; Early recognition of arrest and activation of Code blue; Early high‑quality CPR; Early defibrillation; Early comprehensive life support and postresuscitation care.

Fig 1: Core links in adult comprehensive cardiopulmonary life support (CCLS)


Adult comprehensive cardiopulmonary life support (CCLS)

After ensuring scene safety, check responsiveness of patient. If unresponsive, activate code blue team or local team (as in Intensive care unit or other dedicated area). Check carotid pulse and breathing simultaneously for 5 to 10 sec.

A. If patient has normal breathing with definite carotid pulse, assess patient every 2 min or more frequently for any change in vital parameters.

B. If patient has abnormal or no breathing with definite carotid pulse, he/she is in respiratory arrest. Open airway and give normal tidal volume breath (causing visible chest rise) every 5 s. Airway adjuncts may be used. Reassess carotid pulse every 2 min or earlier for change in the vital parameters. Evaluate for the cause of respiratory arrest and manage accordingly.

C. If patient has abnormal or no breathing with no definite carotid pulse, he/she is in cardiopulmonary arrest. Initiate high-quality CPR with cycles of 30 chest compressions and 2 breaths. After 5 cycles of CPR, reassess carotid pulse and switch roles.

If patient’s airway is secured with an endotracheal tube, then chest compressions should be given continuously at a rate of 120 compressions/min without interruption, and 1 breath should be given every 6 s (10 breaths/min), instead of cycles of 30 chest compressions and 2 breaths. When cardiac monitor or defibrillator is attached to the patient, cardiac rhythm is checked on the monitor instead of pulse. If the rhythm is shockable (ventricular fibrillation [VF] and pulseless VT), defibrillation should be done at the earliest. Initial shock dose 120 J – 200 J (biphasic), subsequent shock may be same or escalated to higher dose with maximum of 200 J (biphasic). In case of monophasic defibrillator, the initial and subsequent energy for defibrillation should be 360 J. During cycles of CPR, other advanced aspects such as venous access, airway management, and drug administration should be integrated with cycles of CPR as early as possible. Simultaneously, cause of cardiac arrest should be identified and treated accordingly.

After vascular access is secured, give adrenaline (epinephrine) 1 mg diluted in 10 mL as bolus repeated every 3–5 min, irrespective of the type of heart rhythm. Drugs administered through peripheral venous access must be flushed with 20 mL of normal saline and whenever feasible, the limb should be elevated for 10–20 s after administration of the drug. Drugs should be administered during chest compression, so as to ensure their systemic distribution.

If arrhythmias persist, Amiodarone 300 mg should be administered intravenous as a slow bolus. A second intravenous dose of amiodarone 150 mg may be administered if arrhythmia persists. Lignocaine may be considered as an alternate drug in patients with persistent arrhythmia.

The underlying aetiology of the cardiorespiratory arrest needs to be assessed. The reversible causes of cardiopulmonary arrest may be remembered with the mnemonic: ‘HIT THE TARGET’ (H– Hypoxia, I – Increased H Ions [Acidosis], T – Tension Pneumothorax, T – Toxins/Poisons, H –Hypovolaemia, E – Electrolyte Imbalance [Hypo-/Hyperkalaemia], T–Tamponade Cardiac, A – Acute Coronary Syndrome, R – Raised Intracranial Pressure [Subarachnoid Haemorrhage], G – Glucose [Hypo-/hyperglycaemia], E – Embolism (Pulmonary Thrombosis), T – Temperature [Hypothermia]).


Following return of spontaneous circulation (ROSC), patient should receive post-resuscitation care. He should be shifted to a monitored area and further definitive management of the underlying aetiology should be started. Oxygen supplementation and ventilation support should be provided based on the post-resuscitation assessment. The haemodynamic monitoring is essential, and the mean arterial pressure should be maintained >65 mmHg.


Cardiac Arrest Rhythms: Cardiac arrest rhythms may be either shockable (ventricular fibrillation or pulseless ventricular tachycardia) or non-shockable (asystole or pulseless electrical activity).[Figure 1]

Figure 1: Arrest Rhythms

Shockable rhythmsincludeventricular fibrillation and pulseless ventricular tachycardia.

Ventricular fibrillation

The rate or rhythm cannot be determined. The P waves, QRS complex or T waves arenot recognizable. A pattern of sharp up and down deflections is seen. [Figure 2]

Figure 2: Ventricular fibrillation

Pulseless ventricular tachycardia (VT)

The ventricular rate is more than 100/minute, typically 120 to 250/minute. Therhythm is regular ventricular rhythm. PR is absent, P waves are seldom seen butpresent. QRS complexes are wide and bizarre. It can be monomorphic (QRSComplexes with similar morphology) or Polymorphic (QRS Complexes with multiplemorphology).


Figure 3: Monomorphic VT Figure 4: Polymorphic VT

Non- shockable Rhythmsinclude Asystole and Pulseless Electrical Activity (PEA)

Asystole

No ventricular activity is seen or there are ≤6 complexes/min.

Figure 5: Asytole

Pulseless electrical activity

There is some organized rhythm seen on ECG but there is NO carotid pulse palpable.

Figure 6: PEA with No Carotid Pulse


SKILL 13: Defibrillation

Indication

Patient is in cardiac arrest and ECG shows ventricular fibrillation or pulseless ventricular

tachycardia

Purpose

Defibrillation stuns the heart and briefly terminates all electrical activity. This allows the

normal pacemaker to resume electrical activity, if the heart is still viable.

Equipment required

Defibrillator monitor with paddles or self-adhesive pads, Conducting gel

Procedure

Power on the defibrillator

Select energy- In adults biphasic 120-200 Joules; monophasic 360 Joules (in children

2J/kg first shock, second at 4J/kg, subsequent shocks ≥ 4J/kg not to exceed 10 J/kg or

adult dose)

Apply gel to paddles.

Place paddles on patient’s chest (sternum-apex). Sternal paddle- placed to the right of victim’s upper sternum, below clavicle; Apical paddle - placed on the victim’s left chest, infero-lateral to the left breast

Press charge button on paddle (or monitor)


All clear! Ensure no one is touching the patient including yourself. Keep oxygen

away.)

Press the Shock button. Always face the patient when pressing the shock button.

Resume CPR, beginning with chest compression for 5 cycles, then recheck rhythm

(It is recommended to use self-adhesive pads if available for defibrillation)

Scenario practice of skill of BCLS and ACLS

A 70-year-old man is wheeled in the emergency department, who had suddenly collapsed outside the emergency gate. How will you proceed?

Scene safety is ensured, responsiveness is checked and found to be unresponsive Help is called, ask for vital sign monitor, defibrillator, emergency drugs and

equipment for resuscitation. Carotid pulse and breathing is checked and found to be absent.

CPR is started beginning with 30 chest compressions followed by 2 breaths;

compression: ventilation ratio is 30:2.

Oropharyngeal airway is inserted for keeping the airway open during breaths.

Breaths are given with the help of BVM device with reservoir bag and with

attached oxygen (12l/min)

Vital sign monitor is attached as soon as available. It shows ventricular fibrillation

(VF)

Defibrillation with 200 J Biphasic shock given and immediately CPR is started

beginning with chest compressions. IV line is secured. Investigations are sent to

rule out reversible causes of cardiac arrest.

On reassessment at 2 min, monitor again shows VF.

2nd Defibrillation with 200 J biphasic shock given followed immediately by 2 min

CPR


Inj. Epinephrine 1 mg IV (1 mg diluted in 10 ml NS) is administered, followed by

20 ml saline push and arm is raised.

On reassess at 2 min, monitor shows VF. 3rd Shock is givenfollowed immediately

by 2 min CPR

Inj. Amiodarone 300 mg IV is administered followed by 20 ml saline push and

arm is raised

On reassessment at 2 minutes, now monitor shows normal sinus rhythm

Carotid Pulse is checked which is present and BP is 80/50

Breathing is checked It is present with respiration rate of 14/min, SpO2 of 93%

Checked consciousness, patient is drowsy.

Oxygen administered via face mask and SpO2 improved to 96%

Fluids administered (RL), BP is 94/60

12 lead ECG showed STEMI

Plan and prepare for specialist referral and may be urgent coronary intervention

Skill 14 : Infusion of Intra venous fluids and Types of IV fluids

Crystalloids

Crystalloid solutions contain small molecules that flow easily across semipermeable membranes, from the bloodstream into the cells and body tissues. Crystalloid solutions are distinguished by the relative tonicity (before infusion) in relation to plasma and are categorized as isotonic, hypotonic, or hypertonic.

Isotonic solutions

They are the most commonly used fluids and have a concentration of dissolved particles similar to plasma, and an osmolality of 250 to 375 mOsm/L.

1. 0.9% NaCl (Normal Saline Solution, NS)

Composition

308 mOsm/L, Na+ 154 mmol/L, Cl- 154 mmol/L

Indication

Fluid of choice for resuscitation efforts.

• Used to replace fluid loss from hemorrhage, severe vomiting or diarrhea, heavy drainage from GI suction, fistulas or wounds.

• Use to treat shock, mild hyponatremia, metabolic acidosis, hypercalcemia.


• Caution in cardiac or renal disease, may cause fluid volume overload.

• The only solution that should be administered with blood products.

• Monitor for hyperchloremia with large volumes of fluid replacement with 0.9%NaCl.

2. Lactated Ringer’s Solution (RL, Ringer’s Lactate)

Composition

273mOsm/L, Na+ 130mEq/L, K+ 4 mEq/L, Ca++ 3 mEq/L, Cl- 109 mEq/L

Indication

First-line fluid resuscitation for burn and trauma patients. Used to treat acute blood loss or hypovolemia due to third-space fluid shift; GI loss and

fistula drainage; electrolyte loss; and metabolic acidosis. Contraindicated in patients who cannot metabolize lactate, (i.e. liver disease) or

experiencing lactic acidosis.

Special consideration

• Do not administer if pH > 7.5. (Normal liver will convert LR to bicarbonate worsening alkalosis).

• Caution in patients with renal failure (LR contains some potassium and hyperkalemia can occur).

3. 5% dextrose in water (D5W)

Composition

253mOsm/L, 5 g dextrose/100mL, 170 calories/L

Indication

Both isotonic and hypotonic. Initially dilutes osmolality of extracellular fluid (hypotonic); once cell has used dextrose, remaining saline and electrolytes act isotonic, expanding the extracellular compartment.

Provides free water for the kidneys, aiding renal excretion of solutes. May be used to treat hypernatremia. Should not be used alone to treat fluid volume deficit because it dilutes plasma electrolyte

concentrations. Contraindicated in resuscitation, early postoperative period, and patients with known or

suspected increased intracranial pressure (pressure). Provides some calories, but not enough nutrition for prolonged use.


General nursing considerations:

Document baseline vital signs, edema, lung sounds, and heart sounds, and continue monitoring during and after the infusion.

Monitor for continued signs of hypovolemia, including urine output < 0.5 mL/kg/hour, poor skin turgor, tachycardia, weak pulse, and hypotension.

Monitor for signs of hypervolemia such as hypertension, bounding pulse, pulmonary crackles, dyspnea, shortness of breath, peripheral edema, and jugular vein distension (JVD).

Hypotonic solutions

They have a concentration of dissolved particles lower compared to plasma and an osmolality < 250 mOsm/L. Eg 0.45% NaCl, 0.33% NaCl.


• May worsen existing hypovolemia and hypotension causing cardiovascular collapse.

• Monitor for signs of fluid volume deficit, such as confusion in older adult patients and dizziness.

Hypertonic solutions

They have a concentration of dissolved particles higher than plasma and an osmolality > 375 mOsm/L. Eg Dextrose 5% in 0.45%

NaCl (D5 ½ NS), Dextrose 5% in 0.9%

NaCl (D5 ½ NS), 3% NaCl, 5% NaCl.


• Administer only in high acuity areas. For short-term use to correct critical electrolyte abnormalities.

• Monitor electrolytes and assess for hypervolemia. May cause fluid volume overload and pulmonary edema.

• Avoid in patients with cardiac or renal conditions who are dehydrated, and in patients with diabetic ketoacidosis.

Colloids

Colloid solutions contain large molecules that do not pass through semipermeable membranes and therefore remain in the blood vessels. Also known as volume/plasma


expanders, colloids expand intravascular volume by drawing fluid from the interstitial space into the vessels through higher oncotic pressure.

Albumin (5%) 309 mOsm/L or Albumin (25%) 312 mOsm/L.

• Human albumin solution, used for moderate protein replacement, and to achieve hemodynamic stability in shock states.

• Considered a blood transfusion product, use the same protocols and nursing precautions when administering albumin.

• Contraindicated in severe anemia, heart failure or known sensitivity to albumin.

• Angiotensin-converting enzyme (ACE) inhibitors should be withheld at least 24 hours before administration due to risk of atypical reaction (flushing and hypotension).

Dextrans

Eg., Low-molecular weight dextran (LMWD) and High-molecular weight dextran (HMWD). They contain polysaccharide molecules that behave like colloids.

Used for volume expansion, fluid resuscitation. Contraindicated in thrombocytopenia, hyperfibrinogenemia, avoid with hemorrhagic shock.

Hetstarch (6%)

Used for hemodynamic volume replacement. Does not interfere with blood typing or cross matching.

Contraindicated in liver disease and severe cardiac/renal disorders.


• Before administering a colloid, take a careful allergy history.

• Use 18-gauge or larger needle for administration of colloid solutions.

• Monitor intake and output closely and for signs of hypervolemia: hypertension, dyspnea, crackles in lungs, jugular venous distension, edema, bounding pulse.

• Monitor coagulation indexes. I.V. Fluid Osmolarity.

Skill 15 : Setting up devices or equipment for emergency units

Universal precautions

• Gloves • face mask • eye protection


Monitoring devices:

ECG monitor/defibrillator with • monitoring electrodes, gauze and razor blade • conductive paste (or defibrillation pads) • adult and paediatric paddles (or hands-free pads) • transcutaneous pacing • cardiac arrest board) • Blood pressure device with • large, normal adult, child and infant cuffs • stethoscope • Doppler monitoring • Blood glucose testing equipment• Thermometer • hyper- and hypothermic readings • Pulse oximeter .

Airway and breathing devices

Oxygen delivery devices • rebreather masks • nasal cannulae • oxygen tubing .Oxygen supply with flow regulator • portable or fixed unit Pocket mask with • 1-way valve, O2 inlet and filter Bag-valve-device (self-inflating bag) with • O2 reservoir • adult, child, infant and neonatal masks ) • Oropharyngeal airways • Nasopharyngeal airways • 14 - 30F Suction devices • bulb syringe • electrical or mechanical Suction catheters • tonsil tip • flexible (6 - 14F) Laryngoscope handle • spare batteries and globes Laryngoscope blades • straight (no. 0 - 3) • curved (no. 2 - 4) Intubating stylets • 6 - 16F • articulating (Parker) Magill forceps • adult and paediatric Tracheal tubes • uncuffed (sizes 2.5 - 5.5 mm) • cuffed (sizes 3.0 - 8.0 mm) • water-soluble lubricant/KY jelly • syringe (10 ml) • bulb version Exhaled CO2 detector • adult and paediatric Tube holders • adjustable (adult and paediatric) • tape and bite block Laryngeal mask airway • sizes 1 - 5 Needle . cricothyrotomy • retrograde intubation Tracheostomy tubes • Nasogastric tubes • 5 - 18F Chest tubes • 10 - 40F

Circulatory access

IV cannulation • butterflies • catheter-over-needle cannulae (14 - 24G) • antiseptic wipes • rubber arm bands • securing tape • arm board • bandaging materials • sharps container • Central vein access • 3 - 5F catheters • Intraosseous needles • 15 - 18G Umbilical vein catheters • 3.5 - 5F • 5F feeding tube may be used Fluid administration sets • calibrated chamber (burette) • high-flow set • 3-way stopcocks • IV fluid/blood warmer IV fluids • normal saline • modified Ringer’s lactate • dextrose water • colloid Sample collection • needles and syringes (1 - 50 ml) • venous blood collection tubes • blood gas collection.

Skill 16: Setting up of Resuscitation cart for adult and child

Introduction:

The crash cart is the commonly used term to describe a self-contained, mobile unit that contains virtually all of the materials, drugs, and devices necessary to perform a code. The configuration of crash carts may vary, but most will be a waist high or chest high wheeled cart with many drawers. Many hospitals will also keep a defibrillator and heart monitor on top of the crash cart since these devices are also needed in most codes. Since the contents and organization of crash carts may vary, it is a good idea for you to make yourself aware of the crash cart that you are most likely going to encounter during a code.


What is in a crash cart?

The size, shape, and contents of a crash cart may be different between hospitals and between different departments within the same hospital. For example, an adult crash cart is set up differently than a pediatric crash cart or crash cart on the medical service may be different than the one on a surgical service.

Medications

Medications are usually kept in the top drawer of most crash carts. These need to be accessed and delivered as quickly as possible in emergent situations. Therefore, they need to be available to providers very easily. The medications are usually provided in a way that makes them easy to measure and dispense quickly.

The common set of first drawer medications might be:

Alcohol swabs Amiodarone 150 mg/3ml vial Atropine 1mg/10 ml syringe Sodium bicarbonate 50mEq/50 ml syringe Calcium chloride 1gm/10 ml syringe Sodium chloride 0.9% 10 ml vial Inj. 20 ml vial Dextrose 50% 0.5 mg/ml 50 ml syringe Dopamine 400 mg/250 ml IV bag Epinephrine 1 mg/10 ml (1:10,000) syringe Sterile water Lidocaine 100 mg 5ml syringes Lidocaine 2 gm/250 ml IV bag Povidone-Iodine swabstick Vasopressin 20 units/ml 1 ml vial

Pediatric:

Atropine 0.5 mg/ 5 ml syringe Sodium bicarbonate 10 mEq/10 ml syringe Saline flush syringes Sodium chloride 0.9% 10 ml flush syringe

The second drawer of the crash cart might also contain saline solution of various sizes like 100 mL or 1 L bags. A crash cart in the surgery department may include Ringer’s lactate solution.

Intubation

Many crash carts will also include most of the materials necessary to perform intubation. These may be contained in the third or fourth drawers depending on the setup of the particular crash cart.


The adult intubation drawer will contain:

Endotracheal tubes of various sizes Nasopharyngeal and perhaps oropharyngeal airways Laryngoscope handle and blades of different sizes A flashlight with extra batteries A syringe of sufficient size to inflate the cuff on it endotracheal tube Stylets Bite block Tongue depressors Newer setups may also include the materials needed to start quantitative waveform

capnography like a nasal filter line

Pediatric intubation materials may be in a separate cart or if they are included in the adult crash cart they may occupy their own drawer. The pediatric intubation supply drawer may contain the following:

2.5 mm uncuffed endotracheal tube 3.0 mm – 5.5 mm microcuff endotracheal tubes Pediatric Stylet (8 Fr) Neonatal Stylet (6 Fr) Nasopharyngeal and perhaps oropharyngeal airways, Laryngoscope blades Disposable Miller blades Disposable Macintosh blades Armboards of various sizes Vacutainers for blood collection Spinal needles Suction catheters of various sizes Bone marrow needles of various sizes Feeding tubes Umbilical vessel catheter Disinfectants (swab sticks) Pediatric IV kits

Procedure drawer

The bottom drawer on crash carts is usually devoted to keeping prepackaged kits available for various urgent and emergent procedures (or it is where the IV solutions are kept). In any case, the following kits may be found in the procedure drawer:

ECG electrodes Sterile gloves of various sizes Sutures of various sizes and materials Suction supplies Salem pump Cricothyroidotomy kit Adult and pediatric cut down pack Yankauer suction Drapes to create a sterile field


Large bore needle and syringe (for tension pneumothorax) Suction Cath Kit 14 Fr & 18 Fr Lumbar puncture kit

Skill 17: Setting up Resuscitation Cart for Trauma:

• Crash Cart • Vital Monitor • Defibrillator • AED • Central Oxygen and suction • Rapid fluid infuser and pressure bags • Adjustable trolley • Portable Ventilators • Pulse Oxymeter • Broselow’s Crash cart and tape • Fluid Warmer • Ultrasound Machine • Portable X-ray Machine • Patient display monitor


Maintenance of crash cart :

Skill 18: Cardioversion Indication Unstable re-entry supraventricular tachycardia, unstable ventricular tachycardia with pulse, unstable atrial fibrillation and unstable atrial flutter. Procedure

Ensure airway management equipment, emergency resuscitation drugs, short acting sedative drugs, and a cardioverter/defibrillator monitoring device is ready.

● Secure intravenous access. ● Sedate all conscious patients if possible, may use short acting sedative drug. Do not

delay cardioversion in an unstable or deteriorating patient, proceed without prior sedation.

● Turn on the defibrillator and attach monitor leads to the patient. ● Press the Synchronized “Sync” button on the defibrillator. This uses a sensor to

deliver a shock that is synchronized with peak of QRS complex (peak of R wave). ● Adjust monitor gain if required such that sync markers are seen with each R wave. ● Select the appropriate energy based on the abnormal ECG rhythm. ● Apply Jelly on the paddles. Charge the device and loudly say “Clear the patient”.

Paddle position is same as for defibrillation. ● Stay clear and press the shock button to deliver shock. There is a likelihood of a brief

delay before the cardioverter/defibrillator delivers a shock as the device will synchronize shock delivery with peak of R wave.


● Check monitor. May need to shock again with increased energy level if abnormal rhythm persists.

Caution:Activate the sync button after each synchronized shock as most defibrillators default back to unsynchronized mode after delivery of synchronized shock.

Skill 19: Transcutaneous pacing Indication

Haemodynamically unstable bradycardia; unstable clinical condition likely due to bradycardia; pacing readiness in high degree of heart block (Second degree Mobitz type 2 and third-degree heart block), new left, right or alternating bundle branch block or fascicular block; and in bradycardia with symptomatic ventricular escape rhythms. Procedure

Ensure airway management equipment, emergency resuscitation drugs, short acting sedative drugs, and pacemaker device is ready. Administer analgesia /sedation to conscious patients to reduce discomfort. Do not delay pacing in an unstable or deteriorating patient, start pacing without prior sedation.

Attach pacing pads to the patient’s bare chest as depicted on the pads. Turn the pacer on. Choose the mode: Demand mode Choose the rate: Set demand rate to 60/min. The rate is increased or decreased based

on clinical response. Start increasing the current: Initially there will be pacemaker spikes, then electrical

capture in the form of change in morphology of QRS complexes and then mechanical capture in the form of a palpable pulse. Set the current 2mA above the dose at which there is consistent capture.

The carotid pulse should not be assessed to confirm mechanical capture as muscle jerking due to electric stimulation may mimic the carotid pulse.

Contraindication Severe hypothermia, not recommended in asystole


Skill 20 : Intraosseous Puncture (proximal tibia) in children

Indication

To secure vascular access during circulatory collapse, when unable to secure peripheral venous access. It should be discontinued as soon as venous access has been established.

Material

Intraosseous needle, antiseptic solution, sterile drape, gauze pieces, IV fluid and IV infusion set, sterile dressing, injection lignocaine 2%, syringes, hypodermic needle.

Procedure Observe universal precautions, wear gloves. After placing the child supine, apply padding under the knee to flex the knee by 30 degree, allowing child’s heel to rest comfortably. Identify puncture site, locate a consistent flat area of bone on theanteromedial surface of the proximal tibia, approximately 2cm below the tibial tubercle, slightly medial to the tibial tuberosity. Under strict aseptic precautions, clean and drape the puncture site. Inject local anaesthetic to anesthetize the skin and periosteum.Support and stabilize the leg with the nondominant hand. Grasp the needle in the palm of the dominant hand and direct it perpendicular to the bone away from the joint space. Twist and apply constant pressure until resistance is abruptly decreased. Remove the stylet. Confirm correct needle placement by aspirating bone marrow into the syringe. In addition, proper placement of the needle is indicated if the needle remains upright without support and intravenous solution flows freely. Observe for signs of extravasation. Apply sterile dressing and secure the needle and tubing in place.

Complications

Iatrogenic fracture, epiphyseal plate injury, osteomyelitis, cellulitis, subcutaneous or subperiosteal infiltration, pressure necrosis of the skin, haematoma, fat embolism.


Skill 21: Vagal Manoeuvre/Carotid sinus massage Indication

Symptomatic but stable narrow complex tachycardia

Procedure

Prepare emergency drugs: Atropine, Epinephrine, Keep Defibrillator/ Pacer ready The vagal maneuver in the form of carotid sinus massage should be done on one side at a

time. Keep the patient neck in extended position with head turned away from site massaged. Massage in circular motion underneath the angle of the jaw,near carotid artery for 10

seconds.

Caution:It is not recommended in elderly and in carotid artery disease. Skill 22: Internal Jugular Venipuncture-Central venous access Indication: Volume resuscitation, venous access, nutritional support, administration of caustic medications (vasopressors), central venous pressure monitoring etc. Material: Antiseptic solution, gauze pieces, 2% lignocaine, hypodermic needle, 2 ml, 5 ml and 10 ml syringes, three-way cannula, heparin, IV fluid, IV infusion set, sterile transparent dressing, central venous catheter double or triple lumen set. Procedure: Observe universal precautions, wear gloves. Position the patient supine and turn his head away from the venipuncture site (if no cervical spine injury). Give 15° Trendelenburg tilt. Under strict antiseptic precautions clean and drape. If the patient is conscious, inject the local anaesthetic at the venipuncture site. Introduce needle attached to a 10 ml syringe loaded with 1 ml of saline, into the center of the triangle formed by the two heads of sternocleidomastoid muscle and clavicle. Ultrasound can be used as an adjunct for internal jugular vein identification, if available. Puncture the skin with the bevel of the needle upward, and direct the needle caudally, parallel to the sagittal plane, at an angle 30° posterior to the frontal plane. Advance the needle, gently withdrawing the syringe plunger, till free flow of blood is seen. Detach the syringe and insert the guidewire. Monitor the electrocardiogram (ECG) for rhythm abnormalities. Remove the needle over the guidewire. After dilating the vein using a dilator advance the catheter over the guide wire. After threading the catheter, attach a syringe to the catheter port and gently withdraw plunger, to check for free flow of blood. Do this for all the catheter ports and heparinize each of the ports. Affix the catheter in place to the skin with suture. Apply transparent sterile dressing. Obtain chest radiograph to confirm correct placement and to identify a possible pneumothorax.


Complications:

Pneumothorax, haemothorax, venous thrombosis, arterial or neurologic injury, infection, air embolism. Skill 23: Subclavian Venipuncture: Infraclavicular Approach Central venous access Material: Antiseptic solution, gauze pieces, 2% lignocaine, hypodermic needle, 2 ml, 5 ml and 10 ml syringes, three-way cannula, heparin, IV fluid, IV infusion set, sterile transparent dressing, central venous catheter double or triple lumen set. Procedure: Position the patient supine and turn his head away from the venipuncture site (if no cervical spine injury). Give 15° Trendelenburg tilt. Under strict antiseptic precautions clean and drape. If the patient is conscious, inject the local anaesthetic at the venipuncture site. Introduce needle attached to a 10-ml syringe loaded with 1 ml of saline, 1 cm below the junction of the middle and medial one-third of the clavicle. Ultrasound if available, can be used as an adjunct. Keep the bevel of the needle upward, hold the needle and syringe parallel to the frontal plane. Direct the needle medially, slightly cephalad, and posteriorly behind the clavicle toward the posterior, superior angle of the sternal end of the clavicle (toward the finger placed in the suprasternal notch). Advance the needle, gently withdrawing the syringe plunger, till free flow of blood is seen. Detach the syringe and insert the guidewire. Monitor the ECG for rhythm abnormalities. Remove the needle over the guidewire. After dilating the vein using a dilator insert the catheter over the guidewire to a predetermined depth. After threading the catheter, attach a syringe to the catheter port and gently withdraw plunger, to check for free flow of blood. Do this for all the catheter ports and heparinize each of the ports. Affix the catheter to the skin with a suture and apply a sterile transparent dressing. Obtain a chest radiograph to confirm correct placement and to identify a possible pneumothorax. Complications: Pneumothorax, haemothorax, venous thrombosis, arterial injury, infection, air embolism.


Chapter 7

Disability: Neurological Emergencies

(Stroke, Altered sensorium, Seizure and Acute headache)

7.1 Core concepts Neurologic emergencies happen quite frequently. These can be life threatening.

Delay in early recognition and management can have a devastating outcome.

Nurses play an important role in the early recognition of the symptoms and to

initiate the early management till the time expert/medical consultation is available.

The neurological emergencies can be traumatic (Head, spine); medical (stroke, altered sensorium, seizures, acute headache) or surgical (vascular/tumors) (Fig 7.1). In the current lesson role of nurses in the management of common medical emergencies including Stroke, Altered Sensorium, Seizures and Acute Headache is discussed.

Fig 7.1: Common Neurological emergencies

Neurological Emergencies

Surgical

Vascular/Tumours

TRAUMA

Head Spine

Medical

Altered Sensorium or COMA

Stroke Seizures Headache Neuro-muscular weakness

Objectives Upon completion of the chapter nurses should be able to:

Assess and identify the signs and symptoms of Stroke, Altered

Sensorium, Seizures and Acute Headache.

Prepare the patients for respective diagnostic tests.

Manage the patients as per the protocol.

Demonstrate skill regarding the use of

a. Assessment of symptoms of stroke using FAST.

b. National Institutes of Health Stroke Scale (NIHSS)


7.2 Stroke

7.2.1 Core Concepts

Early recognition and early CT Scan (non-contrast) and its interpretation for

differentiating the ischemic and hemorrhagic stroke is imperative for early appropriate

treatment of these patients. Early recognition of acute ischemic stroke and initiation of IV fibrinolytic treatment,

generally within 4.5 hours of onset of symptoms is crucial for a favorable outcome. Fibrinolytic therapy is contraindicated in hemorrhagic stroke. Anticoagulants and

antiplatelets are to be avoided. If facility for neuroimaging and fibrinolytic therapy is not available, patient should be

transported to Stroke center at the earliest possible. Central nervous system stroke is defined as brain, spinal cord, or retinal cell

death attributable to ischemia or bleeding based on neuropathological,

neuroimaging, and/or clinical evidence of permanent injury.

7.2.2 Types of stroke Stroke is also called acute brain attack. It may be caused by cerebral infarction (Ischemic

stroke) or cerebral haemorrhage (Haemorrhagic stroke). The Ischemic stroke represents 85%

of all strokes and the remaining 15% represents the haemorrhagic stroke.

Ischemic stroke occurs due to occlusion of an artery to a specific area of the brain

(symptoms persisting for more than 24hrs). Early recognition of acute ischemic stroke and

initiation of IV fibrinolytic treatment, generally within 3 hours of onset of symptoms (4.5 hours in selected patients), is crucial for a favourable outcome.

Haemorrhagic stroke occurs due to rupture of a blood vessel of the brain. There are

two main types of haemorrhagic stroke i.e. intracerebral haemorrhage and subarachnoid

haemorrhage. In intracerebral haemorrhage which is the most common type of

haemorrhagic stroke, the bleeding occurs inside the brain. In subarachnoid haemorrhage

the bleeding occurs between the brain and the membrane that cover it.


Fibrinolytic therapy is contraindicated in haemorrhagic stroke and anticoagulants and antiplatelets are to be avoided. Early CT Scan and its interpretation

for differentiating these two types of stroke is imperative for early appropriate treatment of these patients.

7.2.3 Management

As soon as the patient is brought in emergency, the patients suspected for neurological

emergency should be assessed for the symptoms of stroke. The Face Arm Speech Time

(FAST) is used to identify patients with acute stroke. The FAST test is an easy way to

remember and recognize the signs of stroke. (Table 7.1, Fig 7.2)

FAST is an acronym used as a mnemonic to assess the symptoms of stroke. The acronym

stands for Facial drooping, Arm weakness, Speech difficulties and Time. 1. Facial drooping: Usually one side of the face is drooping and hard to move.

2. Arm weakness: It is the inability to raise one's arm fully

3. Speech difficulties: It is inability or difficulty to understand or produce speech.

4. Time: Time is of the essence when having a stroke, and an immediate call to emergency

services or to the hospital is recommended

Table 7.1: Assessment of stroke symptoms

Face: Can the patient smile or does one side of the face droop?

Arm: Can the patient lift both the arms or is one arm weak? Speech: Is the patient’s speech slurred or muddled?

Time: What time the symptoms start?


Fig 7.2: Pictorial representation of FAST

The early recognition and treatment of stroke are crucial to minimize the damage it

causes. Just like the management for an acute myocardial infarction, treatment for an acute

stroke is given high priority by the emergency department personnel. Essentially, ‘time is

brain’; if time is wasted, brain tissue is lost. Every minute is precious when someone has

developed a stroke. It has been estimated that people who have had stroke lose approximately

1.9 million neurons and 14 billion synapses for each minute that they remain untreated. This

is the equivalent of 3.6 years of accelerated brain ageing per untreated hour.

NINDS (National Institute of Neurological disorders and Stroke) has defined critical-

in-hospital time goals for assessment and management of patients suspected of having a

stroke. These are as follows:

1. Patient to be assessed by the emergency physician or stroke team, within 10 minutes

of arrival to the emergency department (ED) and urgent non-contrast CT head to be

ordered .

2. Neurological assessment by the stroke team or neurologist and C.T. scan performed

within 25 minutes of hospital arrival.

3. Interpretation of C.T. scan within 45 minutes of arrival of patient in the ED.

4. Initiation of fibrinolytic therapy in appropriate patients and in those in which

fibrinolysis is not contraindicated, within 1 hour of arrival of patient in the ED


5. Door to admission time in stroke unit / Neurology department with facilities of

fibrinolytic therapy of 4.5 hours.

6. If facility for neuro imaging is not available, patient should be referred to the nearest

hospital where facilities for neuroimaging (CT scan) and fibrinolysis are available.

7.2.4 Assessment of impairment and severity of stroke in the patients In the first 24 to 36 hrs after stroke, patients’ neurological status should be assessed

frequently. To assess the impairment and stroke severity, the modified National Institutes of

Health Stroke Scale (mNIHSS) is a very good tool. It is a systematic assessment tool that

provides quantitative measure of stroke related neurological deficits. It takes less than 10

minutes to perform NIHSS. The scale assesses levels of consciousness, gaze, vision, facial

palsy, arm and leg strength, limb ataxia, sensory loss, neglect, dysarthria, and aphasia. The

score ranges from 0–31. Lower score indicates less impairment. (table 7.2)

Table 7.2: Modified National Institutes of Health Stroke Scale (mNIHSS)

Item Item Name Scoring Guide Patients’ Score

1b LOC Questions 0 = Answers both correctly.

1 = Answers one correctly.

2 = Answers neither correctly.

1c LOC Commands 0 = Performs both tasks correctly.

1 = Performs one task correctly.

2 = Performs neither task.

2 Gaze 0 = Normal.

1 = Partial gaze palsy.

2 = Total gaze palsy.



3 Visual Fields 0 = No visual loss.

1 = Partial hemianopia.

2 = Complete hemianopia.

3 = Bilateral hemianopia.

5a Left Arm Motor 0 = No drift

1 = Drift before 10 seconds

2 = Falls before 10 seconds

3 = No effort against gravity

4 = No movement

UN = Amputation or joint fusion, explain:

5b Right Arm Motor 0 = No drift




4 = No movement


6a Left Leg Motor 0 = No drift






4 = No movement


6b Right Leg Motor 0 = No drift




4 = No movement


8 Sensory 0 = Normal

1 = Abnormal

9 Language 0 = Normal

1 = Mild aphasia

2 = Severe aphasia

3 = Mute or global aphasia

11 Neglect 0 = Normal



1 = Mild

2 = Severe

Total Score (out of 31):

7.2.5 Administration of Thrombolytic Therapy

Recombinant tissue plasminogen activator (tPA) is the treatment for ischemic stroke if the

window period is <4.5 hrs and if there are no contraindications for tPA.

The neurologist checks all the inclusion and exclusion criteria on the thrombolysis check list for

ischemic stroke before administering tPA. Informed consent is very important. Because of the risk

of major bleeding, the risk and benefits of treatment should be discussed with the patient and/or

family prior to administration of tPA. The discussion should be properly documented.

Preparation of tPA: The nurse is responsible for administration of tPA to the eligible patients.

tPA is packaged as a 50 mg crystalline powder and reconstituted with sterile water. After

reconstitution, the preparation is 100 ml total. The total dose for an individual patient is calculated

by multiplying the patient’s weight per kilogram (up to 100 kg) by 0.9 mg. The total maximum

dose for a patient with AIS is 90 mg. (The remaining portion of the preparation that will not be

infused should be discarded to prevent accidental overdose.) tPA is administered in divided doses:

10% is given as a bolus over 1 minute, and the remaining 90% is administered as a continuous

infusion over the next 60 minutes. The infusion line should be flushed with 30mL 0.9% sodium

chloride after infusion is completed.

For Example: For a 70kg patient

Total dose = 0.9mg/kg bodyweight

= 0.9 x 70 = 63mg alteplase

Bolus dose = 10% of total dose

= 0.1 x 63 = 6.3mg = 6.3mL⇒ give as IV push over 1 minute

Infusion dose = total dose minus bolus dose


= 63 - 6.3 = 56.7mg = 56.7mL, add to 50mL sodium chloride 0.9% ⇒ infuse over 60 minutes.

Contraindications to thrombolysis

There are certain contraindications to thrombolysis. These are enumerated as follows:

1. Age of the patient is more than 80 years.

2. Blood pressure >185mmHg/110mmHg on presentation; blood glucose < 50 or

>400mg% at presentation; Glasgow Coma Scale score <8; on warfarin with

International Normalized Ratio of >1.7; on heparin in the past 48 hours.

3. Symptoms are minor and/or rapidly improving – patient must be reassessed ten

minutes after initial assessment.

4. Any evidence of intracranial haemorrhage.

5. Severe sudden-onset headache at onset of symptoms (suggestive of subarachnoid

haemorrhage).

6. Pregnant and lactating females.

7. Any history of brain or spine surgery, or of spontaneous intracranial haemorrhage.

8. Previous stroke or serious head injury within the past three months.

9. Gastrointestinal ulcer (for example, history of upper GI or colon bleeding) or urinary

tract haemorrhage within the past three months.

10. Major surgery or significant trauma within the past three months.

11. Lumbar puncture in the past ten days.

12. Presence of intracranial arteriovenous malformation or untreated aneurysm

(previously diagnosed or identified on computed tomography scan at this

presentation).

13. Pancreatitis, oesophageal varices, aortic aneurysm, active hepatitis or liver cirrhosis.

14. Bacterial endocarditis, pericarditis.

15. Neoplasm with increased bleeding risk.

16. Any evidence of active internal bleeding or recent unexplained fall in haemoglobin

(Hb <10).

17. Known (or suspected) iron-deficient anaemia or platelet count of less than

100,000/mm3.

18. Acute MI in the last 21 days.


7.2.6 Nursing actions for the management of Stroke

Assessment Actions Remarks

Assess signs

and

symptoms of

stroke

Recognize signs (FAST—Face,

Arm, Speech, Time) and inform

immediately to the physician.

Early recognition of signs of stroke

is very important for further its

management.

Perform

quick

baseline

assessment

of the

patient.

Monitor and record vital signs of

the patients.

Check and record SpO2

Check blood glucose levels.

Administer oxygen at the rate of 6

liters /min.

Insert oropharyngeal airway if

required.

Vital signs should be maintained

within normal limits to prevent

further complications.

Prepare the

patient for

CT.

Explain the patient/caregivers

regarding the procedure.

Establish 2-3 IV site lines. One

site is used for administration of

intravenous fluids, another for

administration of thrombolytic

therapy, and the third for

administration of intravenous

medications.

Send the blood sample for

complete blood cell count (CBC),

electrolytes, coagulation profile

such as prothrombin time,

activated partial thromboplastin

time, and fibrinogen. The other

tests include random blood sugar,

renal function tests, and liver

function tests.

Counsel the patient and the

family.

The initial scan is one of the

most important diagnostic tests

to diagnose whether stroke is

hemorrhagic or non-

hemorrhagic.

Rapid acquisition and results of

imaging help in deciding

treatment.

Notification to the CT deptt.

about the suspected stroke

patient will avoid delay in

carrying out CT.


Notify the CT department that a

patient with suspected acute

stroke is in transport.

Help transport the patient to the

CT room.

Prepare and

assist the

patient for

thrombolytic

therapy (if

indicated).

Explain the patient/caregivers

regarding the thrombolytic

therapy.

Insert nasogastric tube.

Insert urinary catheter.

Prepare all the articles for the

administration of thrombolytic

therapy

Counsel the patient and the

family.

To prevent bleeding, all invasive

procedures should be avoided.

Provide

ongoing care

to the patient

following

thrombolytic

therapy.

Elevate the head of the bed at 20-

30 degrees to promote venous

return and minimize cerebral

oedema.

Monitor and record vital signs

every 30 minutes.

BP should be monitored every 15

minutes during the first two hours,

every 30 minutes during the next six

hours and hourly for the next 15

hours.

Monitor the patients’ oxygen

saturation level using a pulse

oximeter regularly and maintain it

above 95% by giving appropriate

oxygen therapy.

Check and record blood glucose 4-6 hourly for at least 72 hours and maintain levels between 140-180mg/dl.

Ongoing care is extremely

important in the patients

receiving thrombolytic therapy

to prevent further complications.


Keep the patient NPO, including

no oral medications, until ability

to swallow can be assessed.

Administer normal saline that

maintains normovolemia (75 to 100

mL/h) to facilitate normal circulating

blood volume.

Provide alternating air

mattresses to prevent bedsores.

Avoid venepuncture for 12 hours

unless there is a clear clinical

indication.


7.3 Altered sensorium

7.3.1 Core Concepts

Finding the cause of altered sensorium is paramount for its management

Basic management of ABCD is always a priority

Evaluation and management of the patient with altered sensorium go hand in hand

7.3.2 Introduction

Altered sensorium is a very common medical emergency. There is change in cognition

or level of consciousness of the patients. They may exhibit the symptoms of coma,

drowsiness, confusion, irritability, aggressiveness, abnormal behavior etc.

7.3.3 Causes of altered sensorium

Finding the causes of altered sensorium is very important for the appropriate

management of the patient. Various causes of altered sensorium are depicted in figure 7.3 and

table 7.3.

Fig 7.3: Causes of altered sensorium


Table 7.3: Causes of altered sensorium

“TIPS” “AEIOU” Trauma/Temperature Infection (CNS or other) Poisoning/Psychiatric Space-occupying lesions/Stroke

Alcohol/Acidosis Epilepsy/Endocrine Insulin (hypoglycemia, hyperglycemia) Oxygen (hypoxia) Uremia

7.3.4 Nursing actions for altered sensorium


Assess and

manage

ABCD.

Assess level of consciousness by

using Glasgow Coma Scale.

Open the airway.

Maintain the airway patent.

Start oxygen therapy.

Elevate the head of the bed to 30

degree.

Check and record pulse and

blood pressure of the patient

accurately.

Attach probe to measure the

oxygen saturation.

Establish IV site lines and

administer the required type and

amount of IV fluids

Record intake and output

accurately.

Position the patient in a lateral or

semi prone position to promote

drainage of secretions.

Suction to remove secretions as

per need.

Use the Chin lift and head tilt

method or jaw thrust method to

open the airway in the patients

with trauma.

Ensure working of equipments

in emergency.

Protect the patient’s dignity

during altered level of

consciousness by providing

privacy and speaking to the

patient during nursing care

activities.

The type and amount of fluid to

be administered depends upon the


Hyper oxygenate and

hyperventilate the patient before

and after suctioning to prevent

hypoxia.

Examine the hydration status by

assessing tissue turgor and

mucous membranes.

Prepare and facilitate the patient

for various diagnostic tests.

cause of altered sensorium.

Maintain the

elimination

pattern of the

patient.

A catheter may be inserted

during the acute phase of illness

to monitor urinary output.

Assess the abdomen for

distention by listening for bowel

sounds and measuring the girth

of the abdomen with a tape

measure.

Monitor the number and

consistency of bowel

movements.

Stool softeners may be

prescribed. A glycerine

suppository or enema may be

prescribed to facilitate bowel

emptying.

Maintain strict aseptic

technique while catheterizing

the patient.

Prevent

bedsore.

Reposition the patient every two

hourly and carefully examine the

patients’ all the bony

prominences to prevent ischemic

necrosis over pressure areas.

While repositioning, do not drag

the patient up in bed because this

creates a shearing force and

The patients with altered level

of consciousness are more

prone for bedsores. These can

further increase their

complications.


friction on the skin surface.

Maintain correct body position

and provide passive exercise of

the extremities to prevent

contractures.

The patient should be positioned

that the arms should be in

abduction, the fingers lightly

flexed, and the hands in slight

supination.

Protect the patient by padded

side rails and raised at all times.

Maintain

communication

with the

patient.

Orient the patient to time and

place at least once every 8 hours.

Listen to and encourage

ventilation of feelings when the

patient has regained

consciousness.

Minimize the stimulation to the

patient by limiting background

noises, having only one person

speak to the patient at a time.

While providing any care always

touch and talk to the patient and

also encourage family members

and friends to do so.

Communication is extremely

important.

Do not speak any negative

things about the patient’s

condition or prognosis.

Keep the usual day and night

patterns for activity and sleep

to maintain routine of the

patients.


Scenario: Altered Sensorium in Diabetic Ketoacidosis (DKA)

A 17 year girl was brought to your ED with altered sensorium for the past 2 hrs, parents had given history of polydipsia, polyuria and rapid weight loss which started approximately one month ago and had worsened last week. The patient had not taken any thing orally since yesterday and was complaining of abdominal pain and vomiting. How did you assess and managed this patient?

Assessment and Actions:

Airway and Breathing: Quickly assessed her airway and breathing by talking to her, she was drowsy and confused, talking incoherently. Airway was clear as there were no secretions, blood or foreign body in the airway. There was increased rate and depth of breathing (Kussmaul breathing)

Respiratory rate was 24 breaths per minute, SpO2 93%, had breath with fruity odour. On auscultation of chest, there were crepts in the right lower chest. Started oxygen to maintain SpO2 above 94%

Circulation: Skin was pale and cold with poor skin turgor and dry mucus membranes

Pulse was 106/minute and NIBP 98/60mmHg

Started 2 large IV (18G) and infused normal saline 500 ml in each IV rapidly.

Took blood samples for blood sugar, S electrolytes, KFT, LFT, S. chloride, complete Haemogram and ABG/VBG, Urinalysis and ECG

Reassess vitals and found to be pulse rate 94/min, NIBP 110/70 mmHg, SpO2 97%

Blood glucose strip test showed blood sugar of 520mg/dl. Urine strip test for sugar +++ and Ketones ++

Disability /Neurological Disability: She was drowsy and confused, not talking coherently

GCS: Eye opening to painful stimuli (2), Verbal response was mumbling and not talking coherently (3)

Motor response was moving all four limbs and localizes to pain (5). Hence with GCS of 10/15

Pupils were normal size, normal reacting

Assess and Reassess GCS which improved with aggressive resuscitation & management.

Rapid hematology and biochemistry tests showed:


HCT 44%

Hb 13 g/dl

WBC 12,000/µl

RBS 520 mg/dl

Blood Urea 50 mg/dl

S. creatinine 0.8mg/dl

S.Na+ 148mEq/L

S. K+ 5.4 mEq/L

S.Cl- 112mmol/L

Diagnosis: Newly diagnosed diabetes mellitus with Diabetic Ketoacidosis

Differential Diagnosis: Any cause of a high anion gap metabolic acidosis likeAlcoholic ketoacidosis,

Starvation Ketoacidosis, Renal Failure, Lactic acidosis, Poisonin with methanol, salicylates or ethylene

glycol.

Diagnosis of DKA

Blood Glucose > 250mg/dl, Anion Gap >10, HCO3 levels <15 meq/l, pH< 7.3, Ketonuria

Reassessed vitals

Called the specialist physician & started definitive treatment. Monitored 2 hrly: Blood sugar, serum electrolytes (K+), Anion Gap, ABG, vitals,

level of consciousness and urine output

The order of treatment priorities is volume replacement first, correction of potassium deficit and then insulin administration.

Achieve blood glucose < 200mg/dl, HCO3- ≥ 18 and Venous pH > 7.3.

Fluid administration: As Hyperglycemia leads to osmotic diuresis, which leads to volume loss and loss of sodium, chloride, potassium, phosphorous, calcium and magnesium in the urine. Average water deficit in a patient of DKA is 100ml/Kg (5 to 10 litres), and sodium deficit is 7 to 10 mEq/Kg. Normal saline is the fluid of choice in these patients, with 0.45 % saline in the second IV line. In Patients without severe volume depletion only 500ml/hr is given.

ABG

pH 7.2

PO2 95mmHg

PCO2 25mmHg

HCO3 10meq/L

SpO2 98%


Continued with aggressive fluid therapy in our patient with Normal Saline and 0.45% saline

First 1 litre of Normal Saline in 30 mins

Next 1-2 litres of Normal Saline and 0.45% saline, administered within 2 hrs.

Next 2 litres of fluid over 2 to 6 hrs.

Next 2 litres of fluid over 6 to 12 hrs.

This replaces approximately 50% of total water deficit in 12 hours. When blood glucose was ≈250mg/dl, second IV line was changed to 5% dextrose. Fluid therapy was monitored with CVP. Potassium therapy: Profound total body potassium deficit of 3 to 5 mEq/Kg is present in patient of DKA due to insulin deficiency, osmotic diuresis & vomiting. Severe hypokalemia is potentially the most life-threatening electrolyte disorder which develops during treatment of DKA. Initial serum concentration of Potassium is normal or raised. Initial hypokalemia indicates severe total body potassium deficit and needs replacement urgently. During initial fluid and insulin administration, serum potassium may fall rapidly leading to fatal cardiac arrhythmias, respiratory paralysis, paralytic ileus and rhabdomyolysis.

If initial serum potassium >3.3mEq/L and <5.3mEq/L and urine output adequate, then give 10 mEq KCl per hour added to IV fluid for at least 4 hours.

Action: Assessed & reassess ECG, Serum potassium levels & urine output during resuscitation & treatment of DKA. Measured Serum Potassium every 2 hrly.

Measured urine output. When oliguria was present, evaluated renal function and withheld or decreased potassium administration.

When initial serum potassium was 4.6 mEq/L (> 5.3 mEq/L), indicating severe academia and volume depletion. Gave only IV fluids and Insulin till Serum potassium levels decreased.

(For each 0.1 decrease in pH, serum potassium concentration rises by 0.5 mEq/L, and vice versa).

If initial serum potassium would have been < 3.3 mEq/L. Aggressive potassium replacement had to be done before insulin therapy was started, as insulin pushes potassium inside the cells and will cause further life threatening hypokalemia.

Maintained serum potassium within normal range of 4 to 5 mEq/L. Started oral potassium as soon as patient could tolerate oral fluids.

(KCl 20mEq IV preferably in central vein is administered over one hour, under close monitoring of ECG and hourly Serum potassium levels. A Total of 100-150 mEq of potassium is required over 24 hours)


Insulin: was Administered as per guidelines written below

Low dose regular insulin IV. Infusion is safe, effective and flexible. After initial fluid bolus, once hypokalemia (Serum potassium < 3.3 mEq/L) is excluded. Insulin is started by making Insulin solution with 100 units regular insulin diluted in 100 ml of Normal saline. Infusion rate / hr can be calculated by a formula: (Bl Sugar-100)/ 100 equal to units/hr Insulin binds to plastic tubing hence flush IV tubing with 20 ml of insulin solution. Can administer insulin solution by syringe infusion pump or microdrip set. Reassess Blood Sugar levels at hourly interval and adjust the infusion rate. Blood glucose should decrease at 50 mg/dl/hr. The insulin infusion should be continued till ketones are absent in blood and anion gap has normalized. After stopping I.V. insulin infusion, switch to subcutaneous route with combination of short and long acting insulin. Consult an endocrinologist for further management. BICARBONATE:

Routine use of bicarbonate in treatment of DKA is not recommended.

I.V. fluids and insulin therapy inhibit lipolysis and correct ketoacidosis.

Bicarbonate may be given in titrated doses in the following situations

Severe academia (Ph <6.9) Decreased cardiac contractility and peripheral vasodilation Life threatening hyperkalemia. Com

Disadvantages of bicarbonate administration in DKA:

Worsening severe hypokalemia Paradoxical CNS acidosis Worsening intracellular acidosis Hypertonicity & sodium load Delayed recovery from ketoacidosis Increased lactate levels Cerebral edema

ACTION: REASSESS VENOUS pH every 60 minutes.

MAGNESIUM & CALCIUM: Assess Serum magnesium and serum calcium.



Assess for Airway

and breathing: Look for

Patency of

airway,

presence of

secretions/

frothing from the

mouth,

Snoring.

Check for

Injury to tongue.

SpO2 (if

available)

Call for help.

Remove eyeglasses if present

Loosen ties or anything around the

neck.

Turn the patient in lateral position.

(recovery position).

Do oral suction and clear the airway.

Administer Oxygen preferably by

nasal prongs.

Maintain airway patency.

If patient is unable to protect airway

or is hypoxic, assist in intubating the

patient.

Ventilate the patient if respiratory

efforts are inadequate.

Protect him from getting injured.

Any thing around the

neck may make

breathing difficult

Lateral position will

help avoiding the

aspiration as well as the

tongue falling back.

Check the availability

and working of all the

equipments such as

suction machine,

intubation articles etc.

Circulation

Attach monitors (if available)

Attach probe for SpO2

Check and record all the vital signs

accurately.

Secure an I/V line and start fluid as

prescribed.

Check and record the blood sugar

level.

Catheterize the patient to monitor for

urine output if indicated and maintain

intake and output.

This will help for the

further management of

the patient.

Disability

Perform GCS to check the level of

consciousness.

Look for new onset weakness in face or limbs.

Administer and document the

There could be

alterations in the vital

parameters because of

seizures.


Osmotic diuresis leads to depletion of magnesium from bone and hypomagnesemia. This inhibits parathyroid hormone secretion, leading to hypocalcemia and hyperphosphataemia

If S.Mg<2.0 mg/dl, magnesium to be given orally or parenterally as magnesium sulphate, 2 Gms IV over 1 hour.

prescribed anticonvulsant drugs

accurately.

Assess for the risk

of injury

Look for any injury

because of seizure.

Keep calm and reassure other people

who are nearby.

Protect the patient from injury by

removing any harmful objects from

nearby.

Cushion the head of the patient.

Look for an epilepsy identity card.

Ask the patient’s attendants to stay

with the person until recovery is

complete.

Aid breathing by gently placing them

in the recovery position once the

seizure has finished.

Reassure and orient the patient after

seizures.

Do not Restrain the patient’s

movements. Give any object in

his/her hands. Put anything in his/her

mouth Try to move them

unless they are in danger

Give them anything toeat or drink until theyare fully recovered.


7.4 Seizures

7.4.1 Core concepts

Seizure is another frequently occurring emergency.

The patient with seizure episode based on its presentation can be categorized as:o First seizureo Recurrent seizureso Status epilepticus

7.4.2 Causes of seizures Seizures are caused by abnormal electrical discharges in the brain. These may occur

because of various disorders or they may occur spontaneously without any apparent

cause. Seizures occurring because of metabolic disturbances such as acidosis,

electrolyte imbalances, hypoglycemia, hypoxia, dehydration etc. will cease when the

underlying problem is resolved.

7.4.3. Principles of nursing management of a patient with seizure:

To maintain the airway patent.

To maintain the adequate circulation level.

To prevent injury because of seizure.

7.4.5. Nursing Actions for the management of a patient with seizures

7.4.6 Status Epilepticus

Convulsive status epilepticus is defined as continuous convulsive seizure lasting for

more than 5 minutes, or two or more seizures during which the patient does not return

to baseline level of consciousness.

Summary of management of status epilepticus

Minutes of seizures

Actions

0-5 minutes Maintain airway, breathing and circulation

Administer oxygen

Insert an IV line

Obtain blood samples for glucose, urea, electrolytes, bilirubin,


hemogram, acid-base analysis, toxicology screen

Administer glucose (and thiamine) if hypoglycaemic

Elicit brief history and conduct brief examination

5-10 minutes Administer diazepam or lorazepam

5-20 minutes Administer phenytoin

Repeat diazepam or lorazepam if seizures persist

Evaluate for intubation

20-60 minutes Administer phenobarbital or levetiracetam or valproate or midazolam or

propofol

Support of respiration often required

Conduct detailed examination

>60 minutes Intubate and ventilate (if not done before)

Administer general anesthetic agents (e.g. thiopental) with EEG

monitoring

Admit in intensive care unit

7.5 Headache

7.5.1 Core Concepts

Identify life threatening and potentially serious causes

Appropriate pain management after initial stabilization in all patients is important

Response to pain therapy does not mean that the patient has a benign cause of headache

Failure to recognize a serious headache can have serious consequences, including

permanent neurologic deficits, loss of vision, and death.

7.5.2. Introduction Headache is the most common type of pain that human experience. Headaches can be

classified as primary or secondary headaches. Primary headache includes tension type,

migraine, and cluster headaches. Secondary headaches are caused by another condition or

disease such as sinus infection, neck injury or stroke. Acute headache is a common

presenting complaint in emergency. The most common cause of headache is tension


headache which occurs in nearly 50% .10% are due to migraines and 30% are due to non-

specific benign causes. 10% headaches are due to potentially serious causes. Only 1% are due

to a life-threatening causes.

7.5.3 Common underlying pathologies in headache (table 2) All red flags, general or specific, warn us the possibility of life-threatening disorders.

The term ‘red flag’ was originally associated with back pain and now lists of red flags are

available for other common presentations such as headache, red eye and dyspepsia as well.

The common underlying pathologies of headache in presence of a red flag are depicted in

table 7.4.

Table 7.4: Common underlying pathologies in presence of a red flag

First or worst headache CNS infection, intracranial hemorrhage

Focal neurologic signs AV malformation, intracranial mass

Triggered by cough/exertion Mass lesion, SAH Change in mental status CNS infection, intracerebral bleed, mass lesion

Neck stiffness/meningism Meningitis, SAH New onset in pregnancy or postpartum Cortical vein/cranial sinus thrombosis,

pituitary apoplexy Papilledema CNS infection, mass lesion Sudden onset (thunderclap headache) Bleedinginto a mass, subarachnoid hemorrhage New headache type in a patient with cancer, HIV or above 50 years

Metastasis, opportunistic CNS infections, mass lesion, temporal arteritis

7.5.4 History and physical examination A careful history and physical examination are the most important part of the assessment of

the patient with headache. (table 7.5)

Table 7.5: General questions for evaluation of headache

Questions Responses

Site and quality

What is the exact site of

pain

Describe the pain

Tension type headache: Bilateral, bandlike pressure at

the base of skull

Migraine: Unilateral, may switch to sides

Cluster: Unilateral, radiating up and down one eye.

Occipital headache with neurologic signs of dysarthria,

dysphagia, double vision, or ataxia are concerning for


posterior bleed, tumor, or stroke

Onset: • When did the headache start?

• What were you doing when it

started?

Sudden headache with exercise, coughing, straining, or

orgasm is concerning for SAH.

Provocation: • What makes the pain better orworse? Position? Exercise?Straining?

Pain exacerbated by supine position or cough

Radiation: • Does the pain move or

radiate?

Pain with radiation down the neck or neck stiffness is

concerning for SAH, meningitis, or carotid or vertebral

artery dissection.

Severity: • How long until your headache

reached its maximum?

Thunderclap headache (maximal pain within minutes of

onset) is concerning for secondary pathology including

SAH, venous sinus thrombosis, or intracranial

hemorrhage

Temporal: • Has the pain changed over

time?

Chronic, progressively worsening headaches are

concerning for possible structural mass or lesion.

Associated symptoms: • Are there any other symptoms

you have had?

Associated neurologic deficits, vision changes, or fever

are concerning for dangerous secondary etiology.

Migraine: Nausea, vomiting, irritability, sweating,

photophobia, phonophobia.


7.5.5 Nursing management Principles of nursing management of a patient with headache:

To relieve the headache.

To make the patient comfortable.

To help the patient identifying the triggering factors of headache.

Nursing actions for the management of a patient with headache

Assessment Intervention Remarks Assess Airway Breathing Circulation

Check and record respiration, pulse,

temperature and blood pressure of the

patient.

Start oxygen administration.

Attach pulse oximeter probe to check

oxygen saturation level.

Provide quiet, calm and comfortable

environment to the patient.

There could be alterations in the vital parameters because of headache.

Assess severity of headache

Ask history of headache

Assess the severity of headache.

The patient may be asked to rate the pain

on a scale of 10.

To take history of headache ask the

questions as depicted in table 7.5.

Administer the prescribed medication.

Prepare the patient for the further

diagnostic tests.

This will help for the further management of the patient.

For the patients getting discharge from the emergency after initial stabilization, assess the awareness level of the patients regarding triggering factors of headache.

Provide health education on

Daily exercise, relaxation periods and

socialization because each can help

decrease the recurrence of headache.

Alternative ways of handling headache

through techniques such as relaxation,

Help the patient identify precipitating factors and develop ways to avoid them.


meditation, and yoga etc.

To make written note of the drugs, dosage,

time and effectiveness for easy reference

of progress in treatment and avoid drug

overdose.

o To avoid food that triggersheadache.

o To avoid smoking and exposure totriggers such as strong perfume,volatile solvents etc.

o To maintain diary of headache andpossible precipitating events.

To contact care provider if any of thefollowing occurs:

o Symptoms become more severe,last longer than usual, or areresistant to medication.

o Nausea and vomiting (if severe ortypical), change in vision, or feveroccurs with the headache.

Problems occur with any drugs

Bibliography: 1. Lewis’s Medical Surgical Nursing: Assessment and Management of Clinical

Problems, Second South Asia Edition.

2. Singh A, Soares WE. Management strategies for Acute headache in the emergency

department. Emergency Medicine Practice 2012. www.ebmedcine.net. Retrieved on

31 July, 2019.

3. Meyer BC, Hemmen TM, Jackson CM, Lyden PD. Modified National Institutes of

Health Stroke Scale for Use in Stroke Clinical Trials: Prospective Reliability and

Validity. Stroke. 2002;33:1261-66.


Chapter 8:

Trauma: Head, Chest, Abdominal, Pelvis,

Musculoskeletal, Spinal and Burn

8.1 Head Trauma

8.1.1 Core concepts

Tracheal intubation is essential in patients of severe head injury with GCS <9.

Hypotension/haemorrhagic shock is very rarely caused by isolated head injury.

In head injury with hypotension, other associated injuries should always be ruled out

as they are responsible for causing hypotension/haemorrhagic shock.

Avoid hypoxia and hypotension in head injured patient to prevent secondary brain

injury.

Non contrast computerised tomography is the most important investigating tool used

for diagnosis of head injury.

Any trauma to the scalp, skull and brain is called Head Injury or Traumatic

Brain Injury. Head Trauma is associated with high rate of mortality and morbidity. Even a

mild head injury if neglected can progress into severe head injury and cause a life-threatening

injury. The nurse should be well informed and skilled enough to prevent head injury patient

from hypoxia and hypotension in emergency to prevent secondary brain injury. Primary brain

injury is caused by direct insult to the brain tissue during a traumatic event whereas

secondary brain injury is an indirect and delayed brain injury that occurs hours and days after

the primary injury. It is caused by various different process which include, intracranial, extra

cranial or systemic insults

Causes of secondary brain injury are, increased intracranial pressure, vasospasm,

convulsions, hypotension, hypoxia, hypocapnia, hypercapnia, hypertension, hypoglycaemia,

hyperglycaemia, acid-base disorders, hypothermia and hyperthermia.

The damage to brain during primary brain injury is irreversible, however the

secondary brain insults can be prevented.


8.1.2 Neuro Anatomy

Scalp: The scalp has a very rich blood supply. Scalp lacerations can cause significant blood

loss as the blood vessels do not retract. This can cause haemorrhagic shock especially in

paediatric age group. Application of a direct pressure on the wound and suturing with deep

sutures helps in control of bleeding.

Skull: The base of the skull is irregular and during acceleration and deceleration, the

movement of the brain against it can cause significant injury.

Meninges: The dura mater, arachnoid mater and pia mater form the three layers of meninges.

Superficial cerebral veins and the dural venous sinuses are connected by Bridging Veins and

trauma to these bridging veins result in formation of the Subdural hematoma. The injury to

the middle meningeal artery, dural sinuses and skull fracture are the important causes of

Extradural hematoma.

8.1.3 Neurophysiology

The normal Intracranial pressure (ICP) is maintained between 10-20 mmHg by various

autoregulatory mechanisms and ICP>20 mmHg results in poor cerebral perfusion.

In adults, normal cerebral blood flow is 50-55 ml/100 gm of brain tissue per min. The

Cerebral Perfusion Pressure (CPP) is the difference between Mean Arterial Pressure (MAP)

and Intracranial Pressure (ICP), i.e. CPP=MAP–ICP. The autoregulation of blood flow of

normal brain occurs between a MAP of 50-150 mmHg.

In head injury, this autoregulation is disrupted which results in the inability of the

brain to compensate for the changes in mean arterial pressure and cerebral perfusion pressure.

Thus the main principle in the management of head injury is to maintain cerebral perfusion

and blood flow.

The intracranial content comprises of arterial blood, venous blood, brain tissue and

Cerebrospinal Fluid (CSF). The Monroe Kelley Doctrine states that the total volume of

intracranial content, i.e. arterial blood, venous blood, brain tissue and CSF remains constant.

In head injury, the initial stage of the compensatory mechanism is achieved by a decrease in

CSF volume and venous blood. When this compensation is exhausted, there is a rise in ICP

and decrease in arterial volume, which further worsens the cerebral insult.


8.1.4 Classification of Head Injuries

There are various ways of classifying head injury, the commonest are on the basis of the

mechanism of injury, the severity of injury and morphology, and lesion can be focal or

diffuse. (Table 8.1)

Table 8.1: Classification of Head Injuries

Mechanism of injury

Severity of injury on the basis of GCS score

Morphology Intracranial lesions

Open: Penetrating/ Gunshot/Blast injuries

Mild: GCS 13-15 Vault skull fracture

Focal: Extradural hematoma, Subdural hematoma & Intracerebral hematoma

Closed: Blunt/Blast injuries

Moderate: GCS 9-12 Severe: GCS 3-8

Basilar skull fracture

Diffuse: Concussion, Multiple contusions, Diffuse axonal injury & Hypoxic ischemic insults

8.1.5 Diagnosis of Traumatic Brain Injury:

Glasgow Coma Scale

Information about mechanism of injury

How did the injury occur

Extrication time

Patients consciousness

Force of injury

ICP Monitoring

Speech and language test

Radiodiagnosis

CT Scan

MRI

PET


8.1.6 The NELS approach for Assessment and management of Head injury

In patients of head injury, the NELS approach of assessment and management of the

Airway, Breathing and Circulation is followed by Disability or Neurological

assessment. The primary goal of management is to prevent secondary brain injury.

The maintenance of adequate oxygenation and blood pressure ensures adequate

cerebral oxygenation and perfusion. Therefore, it is the cornerstone of treatment in

preventing secondary brain injury.

Airway: In patients of head injury, the association of cervical spine injury should

always be kept in mind. It is important to protect cervical spine by using any

immobilizing device such as a cervical collar or use of manual in line stabilization

before undertaking any procedures which involve any neck movement. Other

associated faciomaxillary injuries should always be excluded.

Unconscious patients may require tracheal intubation for airway protection, and it is

essential in all patients of severe head injury with GCS <9.

Breathing: Assess and manage breathing. Adequate oxygenation and ventilation

should be achieved in order to maintain SpO2>94% and normocapnia (PaCO2 35

mmHg approx) to prevent secondary brain injury.

Circulation: Prevent hypotension (maintain systolic BP ≥100 mmHg) by

haemorrhage control and adequate fluid, blood and blood products resuscitation. This

is the most vital step in preventing secondary brain injury and improving morbidity

and mortality in head injury. The fluids administered should be isotonic fluids such as

Normal saline and Ringer lactate.

Disability/Neurological assessment and management: The head injury is diagnosed

on the basis of history, signs and symptoms of head trauma and the presence of

decreased neurological function. The clinical features are decided by the severity of

injury, morphology and anatomical site of injury. Measurement of Glasgow coma

scale (GCS), pupillary signs and focussed neurological examination form an integral

component of examination of head injury. The signs of basilar skull fracture should

always be looked for.

Surgical Management: Depressed skull fracture, intracranial mass lesions

(extradural hematoma, subdural hematoma and cerebral contusions and hematoma)

and penetrating skull trauma require neurosurgical consultation and may require

surgical intervention.


8.1.7 Management of Head injury

All patients with Moderate and Severe head injury need neurosurgical consultation and

should be transferred to an appropriate neurosurgical facility for further management. These

patients should be transferred at the earliest after management of airway, breathing and

circulation and achieving adequate hemodynamic stability.

Mild head injury GCS 13-15

Assess and manage airway, breathing, circulation and undertake a focussed

neurological examination.

Rule out cervical spine injury.

Always rule out other associated injuries.

Elicit a history of the mechanism of injury, loss of consciousness, any episodes of

vomiting, headache and its severity and retrograde amnesia.

Always rule out alcohol or any drug intake.

If CT scan is available and it is indicated (as per the indications listed earlier), CT

scan can be done. However, if the clinical condition of the patient requires early

transfer to a higher centre, do not do CT scan. Transfer the patient at the earliest,

without causing any delay for doing CT scan.

Admit patient/transfer to a higher centre

GCS is less than 15.

GCS is deteriorating, consciousness level is worsening.

CT scan is abnormal.

Seizures

Moderate to a severe headache.

History of loss of consciousness of long duration.

Alcohol/drug intoxication.

Patients with penetrating head injury.

Skull fracture, especially close observation in a depressed and basilar skull fracture.

Discharge criteria

Rule out all the above mentioned conditions which require admission to the hospital.


Patient should be asymptomatic.

Patient should be fully conscious, alert, coherent and able to follow commands.

An attendant should be present with the patient.

Discharge instructions are explained to the patient and the caregiver.

Discharge instructions: 24 hours are most crucial and report to the hospital, if patient

develops any of these signs and symptoms.

8.1.8 Nursing considerations for Head Injury: The specific nursing considerations

for the management of head injury patients are as follows:

Assess Intervention Remarks

Assess for airway,

breathing, circulation,

disability and

environment.

Assess for patient’s level

of consciousness using

Glasgow Coma Scale

(GCS) as GCS is the best

indicator of

morbidity/mortality.

Assess for size of pupils,

equality, reaction to light.

Assess for any external

injury.

Assess the head, face and

scalp for:

o Abrasions,

contusions,

lacerations,

swelling,

haematoma,

presence of spinal

Administer 100% oxygen

irrespective of severity of

brain injury or any other

kind of trauma.

Assess GCS of the patient at

least once in each shift (six

hours) to assess the patient

for need of intubation (GCS

of 8 or less).

Monitor pupils for size and

reactivity changes.

Maintain PCO2 at 35mmHg

or above in ventilated

patient.

Keep systolic blood pressure

greater than or equal to

90mmHg to avoid episodes

of hypotension.

Provide calm and quiet

environment.

Do not elevate head of the

patient more than 30 degree.

One should know

how to check

GCS

application of

Cervical collar

Removal of

helmet


fluid, brain tissue,

stability of the head

and face, open

wounds, edema etc.

Continuous assessment of

vitals, Level of

Consciousness and

Glasgow Coma Scale

Assess for neurological

deficit, seizure, skull

fracture etc.

Assess for headache since

the injury, vomiting

episode, alcohol

intoxication, previous

history of brain surgery,

current medication,

amnesia, limb movement,

irritability and altered

behavior.

Avoid unnecessary and

multiple procedures.

Maintain head and neck in

neutral alignment.

Maintain euthermia and

euvolemia.

Monitor the temperature

(report any episode of

hypotension and

hypertension immediately),

pulse, respiration, blood

pressure, pulse pressure,

oxygen saturation after

every four hours and as per

need.

Prepare the patient for

surgical intervention if

indicated.

Maintain records of the

patient.

Report any changes

immediately to doctor on

duty.

Anticipate and administer

medications like antibiotics,

anti convulsive drugs, IV

Fluids, mannitol etc. if

advised.

Anticipate for a series of

diagnostic test and prepare

for transport of the patient.

Maintain and document all

assessment findings and


report if changes occur.

While taking and giving

over, neurological

assessment to be done

together at the bedside.

Cervical collar should

always be applied to head

trauma patient till cervical

injury is rule out. All trauma

patients are assumed to have

cervical injury as it is

difficult to diagnosed in an

unconscious patient.


Clinical Pearls

Tracheal intubation is essential in patients of severe head injury with GCS < 9.

Maintain SpO2>94% and start ventilation with 100% oxygen and then gradually

decrease it, to achieve the desired oxygen saturation and arterial blood gas values.

Avoid hyperventilation, do not decrease PaCO2< 32 mmHg.

Hypotension/haemorrhagic shock is very rarely caused by isolated head injury.

Intracranial haemorrhage does not cause haemorrhagic shock. If the head injury is

accompanied with hypotension, other associated injuries (chest trauma, abdominal

trauma, pelvic injuries, limb injuries) should always be ruled out. These associated

injuries are the primary cause of hypotension/haemorrhagic shock in these

patients.

Administration of isotonic intravenous fluids should be started at the earliest to

prevent and manage hypotension. Blood and blood products should also be

transfused, according to the requirement of the patient.

Focussed Assessment with Sonography in Trauma (FAST) should be done in all

comatose

patients to rule out any associated abdominal injury.

Do not administer glucose containing solutions as hyperglycaemia is harmful to

the injured brain and contributes to secondary brain injury.

Hyponatremia also causes secondary brain injury, so close monitoring of serum

sodium is

also important.

The presence of alcohol and drugs should always be ruled out in the evaluation of

a head

injury.

Mannitol, hypertonic saline and anticonvulsants can be given in consultation with

a

neurosurgeon. However, mannitol should not be given to a patient with

hypovolaemia.

There is no role of steroids in the management of head injury.


Scenarios

Scenario 1

Assessment

He is unconscious, not responding to vocal commands, has noisy breathing. His pulse rate is

110/min, BP 100/70 mmHg and respiratory rate is 32/min. He has not received any treatment

at the scene of accident. This hospital does not have a neurosurgical facility, however, CT

scan machine is available.

Action

Airway: Snoring and the gurgling sound are present. After applying mils , oral suction is

done and Oropharygeal Airway (OPA) is inserted. The patient tolerates an oral airway and is

not able to maintain the airway without it. Orotracheal intubation is done with application of

manual inline stabilisation. After intubation, a cervical collar is applied.

Breathing: Started mechanical ventilation after intubation as respi ratory efforts were

inadequate. Bilateral air entry is equal, SpO2 is 97%.

Circulation: Started Normal Saline with two 16 gauge IV cannula. Bleeding and deformity

of the right leg is observed. Compression bandage and splint are applied. No other source of

external bleeding was detected. Pulse is now 90/min with the blood pressure of 110/70

mmHg.

Disability: GCS is 8, Pupils are bilaterally equal and sluggishly reacting to light. X-ray chest

and pelvis are normal.

FAST is also normal.

CT head shows frontal and temporal lobe contusion.

Consultation from neurosurgeon is taken. The patient requires the neurosurgical care and

transfer to a higher centre for further management.

A 28 year male presents in an emergency with a history of motorcycle accident. He had a head on - collision and his helmet came off during the accident.


Scenario 2

Assessment

She is conscious, oriented and has active bleeding from left side of the scalp. Her pulse rate is

100/min, BP is 100/60 mmHg and respiratory rate of 18/min.

Action

Airway: Patent, she is talking coherently. Administered Oxygen using 12 L/min through non

rebreathing reservoir oxygen mask. Applied cervical collar.

Breathing: 18/min, regular, SpO2 is 99%.

No positive findings on inspection, palpation, percussion of chest and bilateral air entry is

equal.

Circulation: Pulse is 100/min, BP 100/60 mmHg.

Started two intravenous line of 16 G and infused 1 litre of Ringer Lactate.

Bleeding from the left side of scalp is seen with 3 cm laceration of the scalp Cleaned the

wound, there is no associated skull fracture. Sutured the lacerated wound.

Administered antibiotic. Abdomen, pelvis and lower limbs do not show any positive finding.

Neurologic Disability: GCS is 15, Pupils B/L equal and reactive.

Complains of nausea and headache. No history of seizures or retrograde amnesia.

CT scan is done which is normal.

She is kept under close observation for her symptoms of headache and nausea. After 8 hours

she is comfortable and nausea and headache have improved. She is fully conscious, well

oriented, responding coherently to commands. No new symptom has developed. She can be

sent home with the discharge criteria explained to her and her parents/care giver.

A 20 year badminton player slips while playing and hits her head on the floor. She

is brought to the emergency by her friends.


8.2 Chest Trauma

8.2.1 Core concepts

A chest injury or chest trauma, is an injury to the chest, heart, lungs including the ribs.

Chest injuries are usually caused by accidental like motor vehicle accident, intentional

injury like stabbing and also due to blunt injury.

Mortality is second highest after head injury, which implies the importance of careful

and prompt initial nursing assessment, intervention and management.

Chest injuries can impact the airway, breathing, circulation and neurological status of

the patient.

8.2.2 Types of Chest Trauma

Blunt: when the chest comes into contact with solid object which increased chest

cavity pressure

Penetrating: Piercing of the chest with foreign objects

Blast: Injury associated with explosions

Inhalation: Injury caused by gases, fumes, dust and liquid entering the chest cavity.

8.2.3 Effects of chest trauma Chest injuries can impact the airway, breathing and circulation of the patient.

a. Effects on the airway

Airway compromise can occur in any of the following conditions:

Swelling, bleeding, and aspiration of vomitus.

Laryngeal injury.

Posterior dislocation of the clavicular head.

Penetrating trauma of the neck or chest wall

Tracheobronchial tree injury

b. Effects on breathing: Significant Breathing problems are seen with the following life

threatening conditions:

Tension Pneumothorax.


Open Pneumothorax.

Massive Haemothorax.

c. Effect on circulation: Significant Circulation problems occur with the following

conditions:

Massive Haemothorax.

Cardiac Tamponade.

Tension Pneumothorax.

Traumatic Circulatory Arrest.

8.2.4 Triage in chest Injury

Red category: The following chest injuries are life threatening, requiring

immediate intervention

Laryngotracheal injury.

Tracheobroncheal injuries.

Tension pneumothorax.

Open pneumothorax.

Massive haemothorax.

Cardiac tamponade.

Traumatic Circulatory Arrest.

Yellow category

Fracture ribs with flail chest and pulmonary contusion.

Simple pneumothorax.

Simple Haemothorax.

Aortic disruption (contained).

Blunt cardiac injury.

Diaphragmatic injury.

Esophageal injury.


8.2.5 Life Threatening Injury in Chest Injury:

Injury Definition Presentation Management

Airway

Obstruction

Acute Airway

obstruction results

from Tracheal Injury

-haemoptysis

- Cervical Emphysema

- Cyanosis

- Tension Pneumothora

-Oxygen

administration

-Definitive Airway

Tension

pneumothorax

Tension

Pneumothorax

results when air is

forced into the

thoracic cavity

without any means

of escape,

completely

collapsing the

affected lungs. Here,

the Mediastinum is

displaced to the

opposite side,

caused decreased

venous return and

compression of the

opposite lung occur.

- Chest pain

- Air hunger

- Tachypnea

- Tachycardia

- Respiratory distress

- Hyperresonance

- Hypotension

-Tracheal Deviation

- Bilateral breath sound

absence

- Neck Vein Distension

- Cyanosis

- Oxygen inhalation

-Immediate

decompression by

inserting a large-

caliber needle over

the catheter into the

fifth intercostal

space slightly

anterior to the

midaxillary line.

- If needle

decompression fail,

finger

decompression

technique follows.

Open

Pneumothorax/ Sucking chest

wound

A large chest injury

which remains open

is an Open

Pneumothorax or

Sucking Chest

Wound.

- Pain

- Difficulty in breathing

- Tachypnea

- Decreased breath sound on

the affected side

- Noisy movement of air

through the chest wall

- Hypoxia

- Oxygen

administration

-Initial management

is to promptly close

the defect with

sterile occlusive

dressings. Tape it

securely on three


- Hypercarbia sides temporarily

and will prevent air

from entering the

pleural cavity while

taking breath. While

exhaling, air will

escape from the

pleural space.

- securing tape on

four sides will

prevent air

accumulation and

caused Tension

Pneumothorax.

- Chest Tube

Insertion will follow.

Massive

Haemothorax

Rapid accumulation

of more than 1500ml

of blood or one third

or more of the

patient’s blood in

the chest cavity

- Hypotension,

- Hypovolemia & Shock

-Hypoxia

- Pulseless Electrical Activity

Cyanosis

- Hypothermia

- Absence of distal pulses due

to depletion of volume - Flat

vein due to hypovolemia

-Oxygen

administration

- Chest Tube

Insertion

- IV Infusion

- Blood Transfusion

- Thoracotomy

Cardiac

Tamponade

Compression of the

heart by an

accumulation of

fluid in the

pericardial sac.

-Decrease cardiac output

- Dysrhythmia

- Muffle heart sound

- Hypotension

- Distended neck veins

- Kussmaul’s Sign(rise in

venous pressure with

-Oxygen

Administration

- FAST

- ECG

- Emergency

Pericardiocentesis

-Thoracotomy by


inspiration while breathing

simultaneously)

- Presence of bilateral breath

sounds

qualified Surgeon.

8.2.6 Potentially Life-Threatening Chest Injury

Injury Definition Presentation Management

Simple

Pneumothorax

Collection of air

within the pleural

space in between

the lung and the

chest wall that can

lead to partial or

complete collapse of

the lung.

-Shortness of breath

-Chest pain

-Sharp pain while inhaling

-Heaviness in the chest

-Tachycardia

-Rapid breathing

-Decreased breath sound on

the affected side

-Hyperresonance

-Chest X-ray

-Needle

decompression

-Chest tube Insertion

-Post insertion chest

x-ray

Hemothorax A type of pleural

Effusion in which

blood less than

1500ml accumulate

in the pleural cavity

due to laceration of

lung, great blood

vessels, an

intercostal vessel,

inter mammary

artery from the

impact of the injury.

-Chest Pain while breathing

-Tachycardia

-Hypotension

-Tense, rapid or swallow

breathing-

-difficulty in breathing

-Anxiety

-Dullness to the affected side

-Pain

-Oxygen

Administration

-Chest X-ray

-Chest tube insertion

Flail Chest

When a segment of

the chest wall does

not have bony

continuity with the

-Abnormal Chest wall

movement

-Pain

-Hypoxia

-Oxygen

Administration -

Chest x-ray

-


rest of the thoracic

cage i.e. two or more

ribs fracture, due to

trauma associated

with rib fractures.

-Paradoxical movement of

chest wall during inspiration

and expiration

-respiratory failure

-Adequate

ventilation

-Fluid resuscitation

-Administration of

analgesia

Pulmonary

Contusion Pulmonary

Contusion is bruise

of the lung due to

Thoracic Trauma.

Blood and other

fluids accumulate in

the lung tissue

causing hypoxia.

-Hypoxia

-Wheezing sound

-Cyanosis

-Cracking sound in the Chest

-Shallow breathing

-Cool and clammy skin

-Hypotension

-Respiratory failure

-Oxygen

Administration

-Pain management

Blunt Cardiac

Injury

Injury sustained due

to blunt trauma to

the heart,

-Pain

-Chest discomfort

-Chest wall contusion

-Fracture of Sternum or ribs

-Hypotension

-Cardiac wall rupture

-Hypotension

-Dysrhythmias

ECG Findings: -

-Sinus Tachycardia

-Atrial fibrillation

-Bundle Branch Block

-STsegment changes

-Transient arrythmias

-24 hours ECG

monitoring

-Oxygenation &

ventilation

-Fluid resuscitation

-FAST

-Pain management

Traumatic

Aortic

Disruption

Rupture Aorta

complete or

incomplete due to

traumatic blunt or

penetrating chest

trauma. It is a

-Hypotension

-widened mediastinum

-deviation of trachea to the

right

-depression of the right

mainstem bronchus

-Oxygen

administration

-IV Fluids

-Chest X-ray

-CT scan

-Aortography


common cause of

death after

automobile collision

or fall from height.

-Elevation of the right

mainstem bronchus

-Deviation of the esophagus

to the right

-Left Hemothorax

-Fracture of the first or

second rib or scapula

-Transoesophageal

Echocardiography

-Transfer to tertiary

care

-Primary repair or

resection of torn

segment with graft

Traumatic

Diaphragmatic

Injury

It is a condition in

which the Aorta is

torn or ruptured due

to motor vehicle

collision or fall from

great heights.

Survivors of this

trauma often recover

if promptly

identified and

treated immediately.

-Dyspnea

-Dysphagia

-Back pain

-Hoarseness

-Contained Hematoma

-Persistent or recurrent

hypotension

-widened mediastinum

-deviation of trachea to the

right

-depression of the right

mainstem bronchus

-Elevation of the right

mainstem bronchus

-Deviation of the oesophagus

to the right

-Left Haemothorax

-Fracture of the first or

second rib or scapula

-Oxygen

administration

-IV Fluid

resuscitation

-Pain Management

-Chest x-ray

-CT Scan

-Reffered to

qualified Surgeon

-

Blunt

Esophageal

Injury

Traumatic

perforation of the

Esophagus due to

blunt trauma.

-Dysphagia

-Dyspnea

-Chest pain

-Cervical Edema

-Subcutaneous Emphysema

-Fever

-Oxygen

administration

-IV Fluids

-Pain management

-Surgical Repair of

injury


8.2.7 Assessment of a Chest Injury victim:

Assess Airway, Breathing and Circulation and attach monitors (SpO2, EtCO2, NIBP and

ECG). Examine the neck and chest and consider mechanism of injury in anticipating the type

and nature of injuries.

Look for:

Distended neck veins signifying raised jugular venous pressure.

Neck and chest injury, swelling, bruising, contusion, penetrating wound and hematoma

Symmetry of chest movements, respiratory rate and depth of respiration.

Signs of laboured or abnormal breathing, chest deformity and any flail segment

Cyanosis

Capillary refill time

Listen for:

Talk to the patient; If the patient is talking in a clear voice it is an indication that the

airway is patent. A change in voice like hoarseness or noisy breathing like stridor,

snoring or gurgling sound, signifies obstructed breathing.

Percuss the chest bilaterally to observe whether the percussion note is hyper-resonant,

dull, or normal.

Auscultate the chest to check for bilateral air entry if present or not, whether breath

sounds are equal on both sides and if any adventitious sounds like crepts or Ronchi can

be heard.

Auscultate the heart for heart sounds and note if well heard or muffled.

Listen for carotid bruit over the neck.

Feel for:

Position of trachea; ascertain if it is central or deviated to one side.

Palpate chest wall for any crepitus or subcutaneous emphysema signifying underlying

injury to the bony rib cage.

Palpate chest wall for tenderness or bony fragments


Action

Airway: Maintain a patent airway by chin lift and jaw thrust techniques or using the

OPA/NPA in unconscious patients.

Administer oxygen, monitor SpO2 and maintain SpO2 ≥94% by ensuring a patent

airway, adequate ventilation and providing supplemental oxygen.

Breathing: If patient has rapid, shallow ineffective breathing or is apneic, assist

ventilation with bag valve mask with a reservoir bag (BVM) with oxygen at high

flows of 12-15l/min. Rule out tension pneumothorax before assisting ventilation.

Secure definitive airway with cuffed endotracheal tube/ cuffed cricothyroidotomy

tube and maintain an EtCO2 of 35 to 45mmHg

Procedures: Needle decompression followed by intercostal drain in Tension

Pneumothorax, and ICD in Simple Pneumothorax and Hemothorax,

Apply occlusive three sided chest wound dressing in open pneumothorax,

Perform ultrasound guided Pericardiocentesis in Cardiac Tamponade.

Reassess: SpO2, ETCO2, blood pressure, electrocardiogram, capillary refill time,

temperature, urine output, skin color and level of consciousness.

Judicious use of I/V fluids, blood and blood components is needed as excess volume

replacement can compromise the respiratory status.

Investigations required will be e-FAST and chest X-ray, preferably in the upright

position if patient is conscious and hemodynamically stable.


8.2.9 Nursing considerations for Chest Injury Assessment Actions Remarks

Access for

ABCD Administer oxygen.

Patient should be kept in supine position

Cannulate the patient and ensure its

patency.

Attach patient to monitor for vitals

monitoring and cardiac changes.

Continuously monitor for anything which

can lead to complication like tension

Pneumothorax.

Administer analgesic, sedatives and any

other medications as advised.

If an object is still present at the wound

site, do not remove it.

Remove patient’s clothing and any object

covering the wound but not clothing that

is stuck in the wound.

Keep one hand over the wound or take

help of others while removing clothing or

any object covering the wound. If no help

is available ask help from the patient if he

is able to do so.

Seal the open chest wound with sterile

dressing pads.

Put pressure on wound to control

bleeding.

Place tape, plastic or chest seal over the

wound that is open where air enters and

exit and not to allow any entry of air

Universal

precaution.

Prepare the

equipments and the

patient for chest

tube insertion and

drainage

Maintain aseptic

condition

throughout the

procedure.

.

8.2.8 Chest injuries: Management


further.

Use occlusive dressing to seal the wound

or any material for a water and airtight

seal with one sided open for exit of air.

Remove the seal from the wound if

tension pneumothorax developed.

Place the patient on side lying position to

let the air move as much as possible.

Maintain room temperature or provide

warm clothing to prevent hypotension.

Keep patient NPO.

Prepare for Chest Tube Drainage.

8.2.10 Nursing Considerations for Cardiac Tamponade:

Cardiac tamponade develops when there is an accumulation of fluid/blood in the

pericardial sac resulting in compression of the heart, thus preventing it from functioning

effectively and leading to the low cardiac output state. The pericardium is a fibrous structure

and therefore even a small amount of blood can restrict action of the heart. Commonest cause

of cardiac tamponade is penetrating trauma, though blunt trauma may also be a cause. The

source of blood collection in the pericardial sac may be from the heart, great vessels or

epicardial vessels.

The three typical signs of cardiac tamponade are muffled heart sounds, low blood pressure

due to a decrease in stroke volume and jugular-venous distension due to impaired venous

return to the heart – these form the Beck’s triad.


Assess for

ABCD Administer oxygen.

Provide supine position to the patient.

Cannulate and ensure its patency.

Attach patient to monitor for vital signs’

Maintain sterile

technique while

providing care and

assisting in


8.2.10 Nursing interventions in Flail Chest

Signs and symptoms of Flail chest

Chest pain

Pain and tenderness of the affected area.

Difficulty in breathing

Uneven chest rise.

monitoring and cardiac changes.

Continuously monitor and documented fluid

withdrawal and withdrawal of needle during

the procedure, changes in the vitals, heart rates

and immediately inform doctor for any

changes.

See for the comfort level of patient and inform

doctor for any discomfort.

Administer analgesic or any other medications

as advised.

Continuously monitor for anything which can

lead to complications like hypotension,

ventricular puncture, cardiac arrest,

pneumothrax and injury to adjoining organs

and inform doctor of any changes.

See for resolution of cardiac tamponade and

hypotension due to removal of blood or fluid.

Pericardiocentesis.


Assess for

ABCD

Assess for pain

in the injured

side of the chest,

Humidified Oxygen by a facemask with

a reservoir bag and high flows of

oxygen > 12 l/min to maintain SpO2 of

more than 94%.

Ensure adequate ventilation. Re-assess

o check for

working

condition of

equipments

and prepare

for


more so during

breathing.

Assess for

abnormal chest

wall movement

(asymmetrical,

unco-ordinated

and shallow).

Assess &

reassess:

Respiratory rate,

SpO2, EtCO2,

Heart Rate,

ABG, pain,

NIBP, X-ray

chest etc.

R/R, SpO2, EtCO2, sweating, color of

patient and ABG if possible.

If inadequate ventilation and patient not

responding then drug assisted

endotracheal intubation, and mechanical

ventilation to be started and adequate

I/V analgesics to be administered.

Judicious I/V fluids to be administered

with goal of maintaining euvolemia.

Fluid overload adds to edema of lung

parenchyma and impairs gas exchange

further. Hypovolemia results in hypo

perfusion of the lung tissue leading to

activation of the inflammatory cascade,

acute lung injury, ARDS and may cause

multiple organ failure.

Pain of chest injury causes inadequate

ventilation and ineffective clearing of

secretions. Effective multimodal

analgesia is mandatory and maybe

administered by:

o I/V Narcotics, NSAIDS &

Paracetamol in appropriate doses

by bolus or by patient controlled

analgesia

o Local anesthesia by intermittent

intercostal block or Intrapleural

block

o Extra pleural or continuous

thoracic epidural analgesia by

isometric pumps, patient

controlled analgesia pumps or

endotracheal

intubation.


Scenario 1

NELS Approach to the patient

Airway: Airway is patent as the patient is talking, SpO2 is 85%. Administer oxygen through

high flow non-rebreathing oxygen mask.

Breathing: Respiratory rate is 40/min, shallow and patient is distressed. Neck veins appear

distended and trachea is shifted to the left. There is hyper-resonant percussion note and no

breath sounds on the right side of the chest. In E-FAST, look for seashore, barcode or

stratosphere sign in M mode.

Patient has tension pneumothorax in the right side of chest so immediately a right sided

needle

thoracentesis is done with a large over the needle catheter in the 5th Intercostals Space (ICS)

just anterior to the mid axillary line in adults (2nd ICS in midclavicular line for children) is

performed and a gush of air comes out. It is followed by ICD on the right side of chest with

28–32 Fr chest drain tube, which is connected to an underwater seal and bubbling of air is

seen.

On re-assessing, there is an improvement in breathing, the patient feels comfortable, SpO2

increases to 95% and air entry significantly improves on the right side of the chest.

Circulation: Initial BP was 80/40 mmHg, Pulse 120/min. After chest tube insertion, Pulse is

95/min and BP is 110/70 mmHg.

Other management: Secure vascular access and administer crystalloids. Get blood grouping

and cross matching. Administer antibiotics and an I/V analgesic. Take surgical consultation.

Perform investigations if the patient is stable and time permits for X-ray chest or CT.

top ups through the epidural

catheter.

Two friends were driving a car at midnight after a booze party. The car was found by the

passing villagers in a ditch with the driver dead and the passenger without a seat belt. On

arrival in the hospital, the patient is clutching his chest, struggling to breath and looking

distressed.


8.3 Abdominal trauma and Pelvis Trauma

8.3.1 Core Concepts

Abdominal and pelvic injuries can be diagnosed in the majority of patients by the

mechanism of injury, systematic abdominal examination & simple diagnostic tests

(FAST/X-ray pelvis).

Early haemorrhage control is mandatory in abdominal trauma victim with

haemodynamic instability.

Positive FAST with signs of peritonitis mandates urgent laparotomy.

In any penetrating wound of the chest below 4th Intercostal space, one should always

look for injuries to intra abdominal organs.

FAST should be performed to rule out abdominal trauma in suspected spinal injury

and unconscious patient.

Never catheterize a patient with a suspected urethral injury.

8.3.2 Introduction Abdominal and pelvic trauma continues to be a significant cause of morbidity and

mortality. If not recognized and treated promptly, it can be disastrous for the patient.

Associated brain and spinal cord injury, use of illicit drugs, alcohol intoxication etc. may

make it difficult to assess abdomen and pelvis properly. The abdominal injury should be

suspected in any patient who is involved in a high speed motor vehicle accident, has had a

fall from a height, has penetrating wounds between nipple and perineum and who has been

exposed to explosions. A high index of suspicion based on the injury mechanism, systematic

thorough examination, and diagnostic investigations can help the clinician in arriving at the

correct diagnosis in a majority of the patients.

8.3.3 Types of trauma

It may be categorized as blunt or penetrating trauma depending on mechanism of

injury.

Blunt Trauma:

Trauma caused by blunt force is called Blunt Trauma. It can be difficult to recognize if the

patient has no signs of obvious external injury and normal vital parameters but can cause

severe blood loss without any change in the appearance of the abdomen but which may lead


to imminent cardiovascular collapse. In a blunt trauma, the skin is not broken but impact can

be seen externally. A direct blow to the abdomen can lead to severe internal organ rupture

and visceral damage leading to haemorrhage, contamination with the visceral organs and

peritonitis.

Penetrating Trauma:

In Penetrating Injury or trauma, an object directly pierces the skin, enters the tissue and leave

an open wound. The most common penetrating injuries are high velocity gunshot and stab

injury.

8.3.4 Signs and Symptoms:

Blunt Injury

Abdominal pain

Tenderness

Rigidity

Organs injured:

Spleen

Liver

Retroperitoneum

Small bowels

Kidneys

Pancreas

Diaphragm

Causes

Falls

Motor vehicles

collisions

Pedestrian event

Assault with

blunt object

Crush injuries

Explosions

Assessment findings

Decreased level of

consciousness

Tachypnea

Tachycardia

Decrease mean arterial

pressure & pulse

pressure

Abrasions on

abdominal wall, flank,

peritoneum

Penetrating Injury

Abdominal Pain

Tenderness

Rigidity

Organs injured:

Liver

Small & large bowel

Intra-Abdominal

Causes

Stab injury

Gunshot injury

Other missiles

Findings

Pain

Tenderness

Hypovolemia

Internal hemorrhage

Peritoneal irritation

Open wound,

lacerations,


Organs eviscerations,

puncture wounds,

gunshot wounds

Impaled objects

Healed incisions or old

scars

8.3.5 Examination of Abdomen:

Inspection:

Abrasions

Bruish

discoloration

Ecchymosis

Bruit

Evisceration

Entry & exit

wound, in case

of gunshot

injury

Penetrating

wound

Palpation:

Crepitus

Abdominal

mass

Guarding

Rigidity

Tenderness

Pain

Rebound

tenderness

Percussion:

Free fluid

Obliteration of

liver dullness

Auscultation:

Bowel

sounds

Abdomina

l bruits

8.3.6 Indications of Laparotomy in Abdominal Trauma

Peritonitis

Free air under diaphragm

Positive FAST with haemodynamic instability

Evisceration

Gunshot wounds

8.3.7 Complications

Hematoma rupture


Peritonitis

Intraabdominal abscess

Biliary leakage

Abdominal compartment syndrome

Bowel obstruction

Incisional hernia

Post operative multiple organ failure and death

8.4 Pelvis Injury

Break of bony structure of the Pelvis is called Pelvis Fracture. This include the break of

sacrum and innominate bones (ilium, ischium, and pubis). There are Stable and Unstable

Pelvic Fracture. In stable fracture, the broken bones are still lined up and the pelvic ring still

maintains its shape and one bone is usually affected. In Unstable Pelvic Fracture, two or more

bones are broken and the ends of the pelvic bone move apart. It occurs with high impact

injury and causes more bleeding from the broken bones and might even damage internal

organs. In both the cases, there are open and closed fractures. In open fracture, the skin is

open and the fractured bones are visible and chances of infection is much higher. While in

close fracture, the skin is intact and broken bones are not visible.

8.4.1 Signs and Symptoms

Pain and tenderness in the groin, hip, pelvis and lower back

Bruising and swelling over the pelvic bones, over the perineum, groin and lower back

Numbness in the upper thigh

Pain which can be felt while sitting and during bowel movement.

Vaginal bleeding in women and bruise in male scrotum

Hematuria

8.4.2 Mechanism of Injury

Pelvic trauma occurs from fall from height or direct injury to the pelvis. Four patterns of

force leading to Pelvic Fracture are:-


AP compression:

Injury caused by a

collision of auto-

pedestrian and motor

cycle crash. Direct

crush injury to the

pelvis or fall from

height of more than

12 feet.

Lateral

Compression:

It occurs from motor

vehicle accident and

caused the internal

rotation of the

involved hemipelvis

from the sides. The

rotation pushed the

pubis into

genitourinary system

and injured the

bladder or urethra.

Vertical Shear:

Here, there is a high

energy shearing

force involved

which causes

disruption to the

pelvic ring, joints,

ligaments, blood

vessels and leads to

internal bleeding.

Complex Pattern Injury:

Combination of both

compression and shear

force leads to complex

pattern of injury, which

causes major bleeding.

8.4.3 Pelvic injury should be suspected in any trauma patient with

o Unexplained hypotension

Blood at the urethral meatus

Mechanical instability of the pelvic ring

Limb length discrepancy

External rotation of lower limb in the absence of obvious fracture

Fig: X- Ray Fracture Pelvis


8.4.4 Assessment of pelvis fractures

Assessment of pelvis stability is done by an expert only once by compression

distraction manoeuvre and translational motion.

Urethral, Perineal and rectal examination: Look for any blood at external urethral

meatus, scrotal/ perineal ecchymosis. Per rectal examination should be done to

assess sphincter tone, high riding prostate, mucosal integrity or blood on

withdrawing finger.

Vaginal examination in females: Should be done if mechanism of injury suggests

vaginal involvement.

Gluteal examination: Important because it, may be associated with

intraabdominal injuries in penetrating injuries.

It is important to remember that associated injuries e.g. injuries to the ribs or

spine, may distract the clinician

8.4.5 Actions

Assess for ABCD

Insert two wide bore IV cannula and infuse crystalloid and transfuse blood.

Apply Pelvic binder

Perform internal rotation of lower limbs.

Longitudinal traction through skin or skeleton by an expert.

Definitive care should involve Trauma Surgeon, Orthopaedic Surgeon,

Interventional Radiologist if available

Angiographic embolization is the best option

Otherwise operative intervention


8.4.6 Nursing considerations: Nurses have got an important role to play in managing

the patients with abdominal and pelvis trauma.

The specific nursing considerations are as follows:

Assess Actions Remarks

Verbalization

Obstruction in

airway

o Secretions

o Tongue

falling

back

o Foreign

body

Proper position (semi fowler’s with

face towards one side).

Check Respiratory rate

Suctioning

C Spine Immobilization C Spine

Immobilization

Skills

Breathing pattern

Respiratory rate

Chest movements

Use of accessory

muscles

Administer oxygen

Auscultate for air entry

Check for oxygen saturation

Check Respiratory rate

Oxygen

administration

Oxygen saturation

External bleeding

Signs and

symptoms of

internal bleeding

Signs and

symptoms of

shock

Do not remove any object if found

impaled.

Remove clothing to assess presence of

any external injury.

Check vital signs

Perform IV Cannulation with wide bore

cannula in both hands.

Take blood samples and send to lab for

routine investigations and cross

Vital sign

checking

IV cannulation

Capillary refill

IV fluid/blood

transfusion

Application of

pressure bandage

Wound dressing


matching.

Check capillary refill

Administer IV fluids/ blood products

Apply pressure bandage on the open

wound.

Maintenance of

I/O chart

Neurological disability

GCS

Assessment and documentation of GCS Assessment of GCS

Pain assessment Assess pain

Administer analgesic

Provide comfortable position

Use of pain

assessment scale

Overcrowding.

Panicky

situation

Environment

Temperature

Control crowd.

Maintain environmental temperature

Reassure patients and their caregivers

Decision making

ability

Regularly

review the

patient’s

treatment

chart.

Administer antibiotics and tetanus

toxoid.

Keep patient NPO if indicated or

advised.

Insert nasogastric tube to decompress

the stomach, to prevent aspiration and

vomiting and see for the content of

gastric for presence of blood

Anticipate for surgical procedure and

prepare patient and relatives.

Catheterize the patient.

NG Insertion

IV injection

Pre and post op

nursing care

Insertion of

urinary catheter.

Assess for injury Wrap a sheet/binder around the pelvis Pelvic binder


at the pelvic

region, laceration,

bleeding,

abrasions,

contusions.

Look for both

lower limbs

length, isolated

rotation of lower

limb.

Look for blood at

the meatus, rectum

etc.

to stabilize the pelvis and decrease the

blood volume.

Examine the pelvis stability only once to

avoid further trauma.

Carefully handle the patient while

positioning and shifting for any other

radiological investigations to avoid further

harm.

Check for bowel movement, urine

output

distal nerves.

application

Scenario 2

Assessment

He was conscious, RR: 18/min, pulse rate: 90/min, BP: 110/70 mmHg.

Per-abdominal examination: Urinary bladder was palpable, Rest was normal.

Pelvic compression test was positive.

Blood was present at the external urethral meatus.

Provision diagnosis made was a pelvic fracture with a urethral injury.

Action

Infused IV fluids and blood.

X-ray pelvis AP view was performed.

A 35 year gentleman was hit by a car from the side while crossing a road. He complained of pain in the pelvis and inability to pass urine.


Applied pelvic binder.

Immediate Orthopaedic/Surgeon’s consultation obtained for further definitive management.

Highlights of the Case Mechanism of injury, complaint of pain in pelvis and inability to pass

urine with blood at the external urethral meatus suggestive of pelvic injury with a urethral

injury.

Scenario 3

Assessment

She was conscious with RR 18/min, Pulse rate: 90/min, BP: 110/76 mmHg.

On per abdominal examination, there were bruises over the anterior abdominal wall,

guarding/

rigidity abdomen present, tenderness/rebound tenderness was present, liver dullness was

obliterated, bowel sounds were absent.

Provisional diagnosis was bowel trauma abdomen with peritonitis. Bowel perforation.

Action

X-ray chest including domes of the diaphragm showed free air under the right dome of

the diaphragm.

FAST was positive.

The patient was kept nil orally and infused IV fluids.

Her bladder was catheterized and urine output was measured.

Clinical Pearls

Never catheterize a patient with a suspected urethral injury. Retrograde urethrography is mandatory to assess a urethral injury and if present, the

patient needs suprapubic catheterization by the surgeon.

A young lady was brought to the ED after being involved in a road traffic accident. She was not wearing a seat belt appropriately. She complained of pain in the abdomen.


Broad-spectrum antibiotics covering gram negative antibiotics and anaerobes were

administered.

Arranged adequate blood and blood products after grouping and cross- matching.

An urgent surgical consultation was taken.

Highlights of the case

Mechanism of injury with features of peritonitis suggested bowel injury. Surgical

consultation with urgent laparotomy was mandatory in such a case.

Clinical Pearls

Inappropriately worn seat belt with bruises over the abdominal wall is highly suggestive of “Bucket handle” injury of the bowel.

Positive FAST with signs of peritonitis mandates urgent laparotomy.


8.5 Musculoskeletal Trauma

8.5.1 Core Concepts Multiple musculoskeletal injuries imply that the patient has sustained an injury with a

considerable force and other life-threatening associated injuries should be ruled out.

Pelvic and long bone fractures are frequently associated with major blood loss.

The crush injuries of the limbs may affect the renal system due to myoglobinuria.

Inappropriate management of compartment syndrome may be limb threatening.

Long limb fractures may be associated with fat embolism which may be life- threatening.

Many musculoskeletal injuries may not be detected in the initial evaluation of the patient.

A repeat assessment and high index of suspicion based on the mechanism of injury is

warranted.

In compartment syndrome, the absence of a pulse is a usually a late finding and thus

presence of a pulse may not rule out occurrence of compartment syndrome.

8.5.2 Introduction Trauma patients with multiple injuries are often associated with musculoskeletal injuries. These injuries may appear devastating but if managed appropriately are not an immediate threat to life or limb. Musculoskeletal injuries may present as crush injuries, fractures, dislocations, sprain, and stress fractures. Irrespective of the etiology, the musculoskeletal trauma is associated with bleeding, pain, psychological stress and inflammatory response depending on the severity of the trauma and traumatized tissue vascularity. The primary goal in the management of such injuries includes prevention of further disability, anticipation, and prevention of further complications and optimization and maintenance of physiology.

8.5.3 Signs and symptoms: Pain

Instability

Disfunction around the joints or internal derangement in joints

Swelling with no injury

Deformity

Asymmetric limbs

Limited movements of limbs


8.5.4 NELS approach to musculoskeletal injuries The initial management of musculoskeletal injuries remains the same, i.e. following the

assessment and action approach of Airway, Breathing, Circulation and Disability. The

management is based on the detection of life threatening injuries as per NELS protocol.

The primary end point during the management is optimization and maintenance of

physiology and anatomy.

8.5.4.1 Assessment

A simple and quick way of assessment of musculoskeletal injuries involves “Look, Listen

and Feel”. approach. Take standard precautions. Use the ABCDE approach and ensure

oxygenation, obtain vascular access, administer IV fluids, get blood grouping and cross-

matching of blood. Enquire about the mechanism of injury, the time taken to reach the

hospital and prehospital status.

Look for swelling, open wound, bruises, laceration, blood loss, any deformity of limb, the

colour of the limb which will be pale if there is a vascular compromise, the position of the

limb (radial nerve injury causing wrist drop, peroneal nerve injury causing foot drop) and

inability to move the limb.

Listen to complaints of pain, paraesthesia, and numbness or inability to move a limb.

Perform Doppler to assess pulse and ankle/brachial systolic pressure ratio (N<0.9) and

auscultate for bruit.

Feel for temperature, tenderness, swelling, and any crepitus. Palpate muscles for tension,

pain on a passive stretch to rule out compartment syndrome. Check any asymmetry, distal

pulses bilaterally, capillary refill time, sensory or motor deficit, tendon reflexes, able to

move other limbs or not, joint stability and tendon reflexes and test for any sensory and

motor loss.

8.5.4.2 Action

Hemorrhage due to musculoskeletal injury may be life-threatening and needs to be

taken care. There may not be obvious external hemorrhage, but underlying extensive

soft tissue injury or long bone fractures may be associated with significant blood loss.

Pelvic trauma may also be associated with major blood loss in the pelvic cavity and

may be missed if not assessed for pelvic complex stability.


The long bone fractures require splinting and pelvic fractures require the application of

pelvic binders to prevent further ongoing blood loss along with adequate fluid and

blood resuscitation.

The splinting helps in the realignment of the fractured bone. This reduces the blood

loss, pain and prevents further injury that may occur due to the fractured ends. The

open fracture should be cleaned, covered with sterile dressing, antibiotics and tetanus

toxoid injection. The most important aspect of first aid is to stabilize the arm. All

injuries should be splinted before the person is moved to minimize further injury

unless the scene is not safe for the victim and the responder. If sensation or pulses are

impaired and limb is deformed due to fracture, a trained person should straighten the

limb prior to splinting. To protect the fracture site, splinting is done one joint above

and below the fractured bone. Distal pulses and sensation should be checked before

and after splinting frequently. If the person complains of tightness, tingling, or

numbness, then remove bandages completely, and then reapply the splint.

The external bleeding must be controlled with external pressure, irrespective of the

type of bleeding vessels. However, in extreme situations like amputation, a tourniquet

may need to be applied to control the bleeding.

The time for tourniquet application should also be noted.

In the case of dislocations, either it may be reduced or may be splinted in the position

in which initially found and subsequently patient is transferred to a higher centre with

the requisite available facility.

After management of life and limb-threatening injuries, the patient should be

reassessed for the presence of any occult injuries, small joints or further worsening of

existing injuries.

A detailed history should include mechanism of injury, pre-hospital condition, and

management of the patient.

The physical examination should include a detailed head to toe examination including

small joints of hands and feet.


8.5.5 Nursing considerations for musculoskeletal trauma


Assess for airway,

breathing,

circulation and

disability.

Start oxygen administration.

Regularly monitor the vital signs.

Connect patient to monitor and pulse

oximeter.

Record the vital signs

accurately.

Assess for external

injury, swelling,

redness, tightness

for compartment

syndrome, muscle

spasm and distal

pulses.

Assess for pain,

location, duration

and character of

pain.

Assess the

movement of limbs.

Assess for skin

color and sensation.

Identify and intervene in the

treatment of limb threatening

injuries.

Compare the affected extremity with

the unaffected extremity and lower

extremity to upper extremity.

Control external bleeding by

applying pressure bandage/dressings.

Evaluate neurovascular (Pain, pallor,

pulse, paresthesia, and paralysis)

after applying splint and tractions.

Anticipate timely reduction of

fractures or dislocation.

Facilitate Orthopedics consultation

Always remember for rest, ice

application, compression and

elevation.

Immobilize fracture limbs or

dislocations.

Immobilize the joint above and

below injuries.

Apply skin traction splint

Prepare the patient for diagnostic

tests like x-rays, CT scan etc.

Administer antibiotics for open

Make sure

regarding the

availability and

working of

Orthopedic

equipments and

devices.


wounds and analgesic for pain as

advised.

Prepare for transfer of patient to

higher centre.

Restrict movements of the patients in

order to allow injured areas to heal

reduce pain, swelling, muscle

spasms.

Dress any of the obvious open

wound.

8.5.6 Compartment Syndrome

Compartment syndrome occurs after trauma when the pressure increases in the osteofascial

compartment of a limb leading to compromised perfusion to the muscle. This is seen in areas

having closed fascial space. This is usually seen with tibia or forearm fractures, tight plaster

cast, crush injuries, reperfusion injuries, burns etc. The usual features include

disproportionate pain in the affected limb, asymmetry of limbs, tense and tender limb, pain

on passive stretching, the presence of paraesthesia and intra-compartment pressure of > 35-45

mmHg. The absence of a pulse is an important finding but is usually very late and thus the

presence of a pulse may not rule out the occurrence of compartment syndrome. If not

appropriately managed, this may lead to the neurological deficit, muscle necrosis, ischemic

contracture, infection, delayed healing of a fracture and possible amputation. The

management includes removal of tight dressings or casts and reassessment. If symptoms and

signs persist, fasciotomy is required to release the pressure.

8.5.6.1 Signs & Symptoms

Pain out of proportion which sometimes does not go with pain medications and pain

with movement

Throbbing and burning pain

Decrease sensation and weakness

Pallor or cyanotic look

Swelling and tightness


Paresthesia or numbness feeling (non localized burning sensation distal to injury

Pulseless is a very late and ominous sign.

8.5.6.2 Management

Once the compartment syndrome is diagnosed, measure the compartment pressure

Analgesic for pain control

The only option available to treat compartment syndrome is surgery. Faciotomy is

done by cutting open the skin and facia to relieve the pressure.

Physiotherapy

Anti-inflammatory medications

Orthotist inserts, it is done by putting the orthotics inside the shoe which can correct

abnormal foot posture and relieve muscle pain while walking and running.

8.5.7 Crush Injury

Trauma may lead to crush injuries of the limbs. It results from compressive forces on the

limbs leading to impaired tissue perfusion and metabolism. The tissue injuries lead to the

release of products from tissue damage into the circulation. This leads to acidosis,

hyperkalaemia and at times renal dysfunction, especially with the release of myoglobulin in

the circulation by muscle damage. This is the predominant cause of posttraumatic renal

failure and also Disseminated Intravascular Coagulopathy (DIC). Crush injuries should be

managed on priority; once life-threatening injuries have been managed. Apart from wound

care, crush injuries should be attended by fluid resuscitation to flush the kidneys. The use of

diuretics to maintain high urine output at least more than 2ml/kg/hr is warranted.

8.5.7.1 Management

Stop bleeding by applying pressure

Cover the area with bandage or wet cloth

Raised the area above the affected

8.5.8 Pain Management The patients with musculoskeletal injuries have severe pain and require immediate

treatment. Though the management like splinting and thus movement reduction may

itself reduce pain, but any residual pain requires analgesic administration. Multimodal

management approach for pain management is an acceptable approach for patient

comfort and deleterious effects of pain. The use of narcotics in titrated and controlled


administration is very effective in pain management, use it with caution keeping in

mind its sedative and respiratory depression effects.

The Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are helpful for reducing

inflammatory pain. However, these may be cautiously used in bleeding patients. The

sedation should be used very cautiously as it may hamper reassessment.

The use of interventional nerve blocks in expert hands are well-accepted pain

management tool. The continued pain management require pain assessment using

appropriate tools like visual analog scale or numerical rating scale.

Scenario 1

Assessment

In the above scenario, the injured patient complained of severe pain and had tenderness, open

wound, deformity of left mid-thigh and there was no neurovascular deficit. Fracture of left

mid femur was suspected.

Action

The ABCDE approach was followed and life-threatening injuries were treated first. Watch,

rings and all constricting devices were removed from the limbs. Open wounds were cleaned

and covered with a sterile dressing. Taking all precautions, left limb was immobilized with

Thomas Splint for temporary management.

Longitudinal traction to align left limb was applied. Neurovascular status was checked before

and after splinting. Analgesics, tetanus prophylaxis and antibiotics for an open wound were

administered. The neurovascular deficit was checked, there was no neurovascular deficit.

However, if neurovascular deficit is present, then splint should be removed and limb re-

positioned and recheck.

A 20 year young man was hit by a motorcycle while crossing the road. He complained of severe pain in the left thigh and there was an obvious deformity. He was brought to the emergency by his friends. How did you approach?


Scenario 2

Assessment and Action

Compartment syndrome was suspected due to disproportionate pain, pain on passive

stretch, tense muscles, asymmetry, and altered sensations. Pulse was also weak.

As there was clinical suspicion of compartment syndrome, immediately cast was

removed and compartment pressure was checked, delta P <30 mmHg [diastolic

pressure-compartment pressure]

Compartment pressure was > 35-45 mmHg which is high.

As there was no improvement in 30 minutes, fasciotomy was done to save the limb.

Scenario 3

Assessment and Action

It was observed that his left leg was swollen, deformed and the patient had intense pain. His

initial assessment of vitals included the blood pressure as 130/76 mmHg, heart rate 118

beats/min, and respiratory rate 26 breaths/min. Glasgow Coma Scale score was 15.

His initial management as per NELS approach of the ABCDE assessment and management

revealed no life-threatening abnormality. He was found to have severe pain. His distal pulses

of all the four limbs were palpable. He could move his toes on verbal command. His sensory

perception in all the limbs was intact.

Radiographic imaging (X-ray) of left lower limb revealed commuted fracture of the femur.

His cervical X-ray was normal. His left lower limb was splinted with Thomas splint and

In a 30 year man with a fracture tibia, a plaster cast was applied. He complained of severe pain after 8 hours. What happened?

After a thunderstorm, a wall collapsed on a 28 year male sleeping on the floor. He was brought to the ED at midnight. How was he managed?


distal pulse was re-checked. He was provided with analgesics and injection tetanus toxoid

and subsequently transferred to the higher center for further management.

Conclusion

The musculoskeletal injuries are associated injuries in poly-trauma patients. These patients

require management of life-threatening injuries as per NELS concept and musculoskeletal

injuries need to be assessed and managed.

The clinician should be suspicious of vascular injuries, crush injuries and compartment

syndrome which are limb threatening and require immediate action.


8.6 Spinal Trauma

8.6.1 Core Concepts

Anticipate and suspect spine trauma in all trauma patients.

Follow the principle of PROTECTION BEFORE DETECTION and restrict the

movement of the WHOLE spine to prevent further damage to the spinal cord.

Manage Airway, Breathing, and Circulation which will prevent secondary injury to

spinal cord due to hypoxia and hypotension.

Once resuscitation is complete, neurological and radiological examination is done to

detect spine trauma.

If definitive treatment is unavailable in the hospital then arrange for transfer while

maintaining ABC and restricting the spinal movement.

Spinal Cord Injury (SCI) causes intense and dreadful functional, psychological, economic

and social disability in the patient and has long-term impact on the family and society.

Most common cause of spinal injury is fall from height (unprotected roof, trees, and wells).

Motor vehicle accidents are the second most common cause. Other causes include sports

injury (diving, wrestling, gymnastics etc,), heavy weight falling on the head, direct trauma

(blunt or penetrating) to the spine. The spinal injury

should be suspected in all head injury patients.

The spinal cord protection should begin at the scene of the injury with proper immobilization

of the spine. However detailed neurological and radiographic evaluation is done after

stabilization of the ABC.

8.6.2 Neuroanatomy and Neurophysiology

Bony vertebral column consists of 33 vertebrae (7 Cervical, 12 Thoracic, 5 Lumbar, 5

Sacral, 4 Coccygeal)

The spinal cord extends from medulla oblongata to first Lumber Vertebra.

The spinal cord has a complex network of neurons that functions along with the rest of

the CNS, to achieve control of sensory, autonomic and motor functions.

There are 31 pairs of spinal nerves (8 Cervical, 12 Thoracic, 5 Lumbar, 5 Sacral, 1

coccygeal)


The sympathetic system is localized in the thoracic and lumbar part whereas the

parasympathetic ganglia are located in the sacral region of the spinal cord.

The spinal cord has three main tracts. Lateral Spinothalamic tract (transmits contralateral

pain and temperature), Corticospinal tract (Ipsilateral Motor power), Dorsal column

(Ipsilateral proprioception, vibration sense and light touch). Any injury to these can

easily be assessed clinically.

The cervical spine is most susceptible to injury because it is most mobile and

unprotected.

The thoracolumbar junction is the next part to be commonly injured because of

excessive mobility at 12th thoracic and first Lumber junction.

Spinal cord segmental levels are denoted by the spinal nerve roots innervating them but

are not situated at the corresponding vertebral levels. For example, the C8 cord segment

is situated in the C7 vertebra while the T12 cord is situated in the T8 vertebra. The

lumbar cord is situated between T9 and T11vertebrae. The sacral cord is situated

between the T12 to L1 vertebrae.

A myotome is the group of muscles that a single spinal nerve innervates.

A dermatome is an area of skin that a single spinal nerve innervates.

8.6.3 Pathophysiology of Spinal Cord Injury (SCI)

Primary injury to the spinal cord is a result of direct biomechanical injury to the neural

components of the spinal cord.

Secondary injury is a damage due to vascular and biochemical effects of the primary

injury. Systemic factors like hypoxia and hypotension and local factors like tissue oedema

contribute to the development of secondary injury. It develops in the hours and days after

primary injury. Lack of oxygen supply due to impaired perfusion at the cellular level is

the main pathological process underlying all of these mechanisms, leading to ischemia

and eventually tissue death.

8.6.4 Effect of Spinal Cord Injury

Respiratory system: The level of injury is an important determinant of effect on the

respiratory system. The higher the level, more is the level of insufficiency. The cervical and

thoracic spine injury cause respiratory embarrassment:


Higher injury (C3, C4) may paralyze the phrenic nerve.

Lower Cervical injury (C5-C8) and lower level will paralyze the accessory muscles of

respiration and muscles of upper and lower limb.

Higher thoracic (T1-T6) will paralyze the intercostals.

Lower thoracic (T7-T12) and below will paralyze the intercostals, abdominal

musculature and lower limb with involvement of bladder and bowel sphincters.

Hypoventilation and inability to cough, lead to complications such as aspiration,

hypostatic pneumonia, atelectasis and even death.

Cardiovascular system

Higher spinal lesions i.e., above T5, cause interruption of descendent sympathetic

pathways resulting in unopposed parasympathetic activity.

Vasodilatation and parasympathetic stimulation cause a decrease in cardiac output and

total peripheral resistance, while central venous pressure remains unchanged.

The patient develops bradycardia and hypotension.

The vasodilatation and muscle paralysis contribute to the development of

hypothermia.

8.6.5 Neurogenic Shock

Neurogenic Shock is a disruptive type of shock which results from impairment of the

descending sympathetic pathways in the cervical or upper thoracic spinal cord. It can occur

due to damage to central nervous system such as spinal cord injury above T6 and traumatic

brain injury.

This condition results in loss of vasomotor tone and sympathetic innervation to the heart.

Vasomotor causes vasodilation of visceral and lower extremity blood vessels, pooling of

blood, and consequently hypotension.

Loss of cardiac sympathetic tone may cause bradycardia in response to hypovolemia. In this

condition, hypotension may not be restored by fluid infusion alone, instead massive use of

fluids may result in fluid overload and pulmonary edema. The role of judicious use of

vasopressors is indicated after moderate volume resuscitation.


8.6.5.1 Signs and symptoms of Neurogenic Shock:

Hypotension

Hypovolemia

Irregular blood circulation

Bradycardia

Slow heart rhythm/decrease cardiac output

Faint pulse

Cyanosis

Dry extremities

Cold body

8.6.6 Spinal Shock

Spinal Shock occur when there is loss of muscle tone(flaccidity)and reflexes(areflexia) after

spinal cord injury and involves a reversible loss of all neurological functions including

reflexes, rectal tone below the injury. It is not a circulatory shock but a state of depressed

spinal reflexes due to cord injury.

The initial loss of reflexia occur due to loss of both cutaneous and tendon reflexes below the

level of injury accompanied by loss of sympathetic outflow which results in hypotension and

bradycardia.

8.6.6.1 Signs and Symptoms of Spinal Shock:

Difficulty in walking

Involuntary bladder or bowel movements

Dry and pale skin

Excessive sweating

Depressed genital reflexes

Increased blood pressure and slower heart rate

Loss of sensation and reflexes

Numbness or tingling sensation in the extremities


8.6.7 Spinal vs Neurogenic Shock

SPINAL SHOCK NEUROGENIC SHOCK

Definition Immediate temporary loss of total

power, sensation and reflexes

below the level of injury.

Sudden loss of sympathetic

nervous system signals

BP Hypotension Hypotension

PULSE Bradycardia Bradycardia

Reflexes Absent/decrease/sensation Variable, unable to maintain

body temperature

Motor Flaccid Paralysis Variable

Time 48-72 hours immediate after spinal

cord injury

48-72 hours immediate after

spinal cord injury

Mechanism Peripheral neurons become

temporarily unresponsive to brain

stimuli

Due to acute spinal cord injury

Loss of sympathetic tone,

vasomotor tone and vasodilation

Management/

duration

Lasts days to months(transient) Airway support, fluid support,

atropine for bradycardia,

vasopressors for BP support

8.7.8 Classification of Spinal Cord Injury

1. Complete Spinal Cord Injury:

A complete Spinal Cord Injury causes permanent damage to the affected area of the spinal

cord. There is complete lost of motor and sensory functions from below the affected area of

the spinal cord.

2. Incomplete Spinal Cord Injury:

Incomplete spinal cord injury partially impedes the spinal cord which can be caused by spinal

cord contusion, compression of the spinal cord and pressure against the spinal cord. Here,

there is a lessened sensory and motor functions below the injury site of the spinal cord.


Spinal Cord Injury may be categorized as:

1. Incomplete paraplegia (incomplete thoracic injury)

2. Complete paraplegia (complete thoracic injury)

3. Incomplete quadriplegia (incomplete cervical injury)

4. Complete quadriplegia (complete cervical injury injury)

8.7.9 Management of Spine trauma Management of Spine trauma has three components: Prehospital, In-hospital, and Transfer to

an appropriate facility.

A. Pre hospital Management

PROTECT BEFORE DETECT! Anticipate and suspect Cervical spine trauma in

all patients.

The pre-hospital management of a spine trauma patient follows the principle of

whole spine immobilization, management of the ABC and immediate transfer to

the hospital. Pre-hospital personnel need to use the following devices to restrict

the spinal movement:

o Semi-rigid cervical collar

o Supportive blocks on the side

o Spine board with straps

B. In-hospital management The priority of management remains the same i.e., stabilization of the

ABC, along with restriction of the spinal movement.

1. Airway management with restriction of spinal movement

Spine trauma rarely causes airway compromise as a result of the spinal injury.

However, immobilization devices, in patients with spine trauma, may pose

difficulty in airway management. Due to this restriction in the movement of the

neck, the intubation is difficult and hence the involvement of an expert early on

is highly recommended. At the time of airway management, the collar should be

removed and Manual In-Line Stabilization should be applied instead.

Indications for endotracheal intubation in spinal cord injury are:

o Acute respiratory failure.

o Glasgow score < 9.


o Increased respiratory rate.

o Hypoxia (PaO2 < 60 mmHg).

o Hypercarbia (PaCO2 >50 mmHg).

o Vital capacity less than 15 ml/kg body weight.

2. Breathing: Positive pressure ventilation should be initiated to manage breathing;

periodically measuring respiratory parameters.

3. Management of circulation:

Circulatory compromise in acute spinal cord injury may be hemorrhagic and/or

neurogenic.

Hypotension, in spinal cord injured patients, may be because of a high incidence of

associated injuries.

These signs of hypovolemia are also mimicked by spinal shock. This leads to

confusing vital signs.

Hence, an active search for occult sources of hemorrhage must be made.

After occult sources of hemorrhage have been excluded, judicious fluid replacement

with an isotonic crystalloid solution to a maximum of 1L is the initial treatment of

choice. Overzealous crystalloid administration may precipitate pulmonary edema.

Vasopressors may be used if a haemorrhagic shock is ruled out:

o Dopamine or Nor-epinephrine is required rarely for ionotropic support.

o Prevent hypothermia (infuse warm fluids, cover the patient, keep high

ambient temperature).

The following parameters form the therapeutic goals for adequate perfusion for

the treatment of neurogenic shock:

o Systolic Blood Pressure (BP) of 90-100 mmHg.

o Heart rate should be 60-100 beats per minute (bpm) in normal sinus

rhythm.

o Treat bradycardia associated with hypotension with atropine.

o Placement of a Foley catheter is required to monitor urine

output(>30ml/hr) and to decompress the neurogenic bladder


4. Radiographic examination

It is not recommended in patients who are awake, alert, not intoxicated and are

without neck pain or tenderness on a full range of movement.

The patient should not have any significant associated injuries that distract them at the

time of evaluation. Such patients may be cleared of cervical spine trauma with

instructions to report if they have pain, tenderness, paraesthesia, numbness or any

other sign of neurological injury.

Radiographic evaluation involves X-ray of Cervical Spine Lateral, AP and Odontoid

view.

Supplement with CT Scan or MRI of suspicious areas.

5. Neurologic deterioration

Despite optimal treatment, the neurologic deficit of Spinal Cord Injury (SCI) often

increases during the hours to days following acute injury.

The extension of the sensory deficit cephalad to the initially detected neurologic level

is one of the first signs of neurologic deterioration.

Careful repeat neurologic examination may help in detecting the rise in sensory level

by 1 or 2 segments.

Repeat neurologic examinations to check for progression are mandatory and should

always be documented.

8.7.10 Transfer to Secondary Units

Patients may require transfer to a higher center for definitive treatment of spine

trauma or other injuries once the ABC are stabilized. The transfer should not be

delayed for un-necessary diagnostic tests and procedures that will not alter initial

management. This includes radiological imaging of the spine. The movement of the

whole spine should be restricted during the transfer to prevent secondary injury.

The log-roll is the standard procedure to allow examination of the back; to allow

placement of X-ray plates and for transfer on and off spine board. The number of rolls

should be kept to an absolute minimum.


8.7.11 Nursing considerations: The specific nursing considerations are as follows:

Assess ACTIONS Remarks

Assess for airway,

breathing, circulation

and disability.

Assess for

consciousness,

confusion or

uncooperativeness.

Assess the limbs for

weakness, loss of

sensation, numbness

and tingling sensation.

Assess for rectal tone,

bowel and bladder

movement whether

decrease or absent

Inspect the spine for

presence of trauma or

injury.

Palpate the spinal

column for pain,

tenderness, crepitus

and abnormality

Immobilize the patient to prevent further

injury to the spine.

Oxygen administration

If intubation is indicated, intubate the

patient by immobilizing the cervical

spine and put the patient on ventilatory

support.

Maintain adequate ventilation and lung

function in patients with high cervical

injury.

Check and document vital signs very

meticulously. Maintain blood pressure

and document it to keep a track on

hypotension.

Provide adequate IV Fluids to prevent

hypotension and shock.

Vasopressors for BP support if indicated

Bowel and bladder movement should be

monitored closely and notify to

physician immediately for any changes.

Regularly assess for motor and sensory

changes. Duration of assessment may be

Application of

cervical

collar.

Manual In-

line

Stabilization

(MILS)

Log rolling of

the patient.

(Annexure 1)

Sensory and

motor

evaluation.

Clinical Pearls

Full spinal movement restriction should be maintained till spinal injury is ruled out by an expert.

Once the patient is on a firm trolley, the spine board should be removed. Prolonged use of spine boards (>2 hrs) can lead to pressure injuries. A baseline skin assessment should always be performed on the removal of the backboard.


Observe the patient for

spinal or neurogenic

shock

Reassess the patient as

required to avoid

secondary damage.

changed as per need.

Patient should be catheterized initially

and later on intermittently according to

the condition of the patient.

Dress any open wound under aseptic

technique to prevent infection.

Anticipate respiratory and

heamodynamic compromised and

support the patient accordingly as

advised.

Administer adequate pain killer as

advised

Anticipate neurogenic shock and manage

with fluid resuscitation and vasopressors

as advised.

Prepare and immobilize the whole body

while transporting for diagnostic studies

like X-rays, CT Scan etc. to prevent

further injury to the spine.

Reduce friction and rotation of patient

while positioning and transporting

Document all positive and negative

findings.


Scenarios

Scenario 1: Isolated spinal injury

Assessment: The NELS approach (Assess and Manage) applied to this patient would be the

following:

Airway: Talked to the patient. He is talking, his airway is clear. Applied semi-rigid cervical

collar, placed him on a long spine board with supportive blocks and strapped him on the

board to immobilize the whole spine. Given oxygen by high flow oxygen by mask.

Breathing: Assessed his breathing. Only abdominal breathing is present, it is jerky because

of high spinal injury causing paralysis of resiratory muscles. Kept watch on his oxygen

saturation and end tidal CO2.

When tidal volume became inadequate, intubated the trachea with a limitation of spinal

movement and assisted his ventilation.

Circulation: BP is 70/40 mmHg, Pulse is 60/min and has cold extremities.

Hypotension and bradycardia indicate sympathetic block due to spinal cord injury. Inserted

two wide bore I/V cannula. Infused 1L of warm Ringer Lactate. No response was seen so

started vasopressor infusion.

Disability: Patient was alert, talking, following commands, GCS is 15, pupils are normal so

he may not have a head injury. There is a loss of sensation and movement in the upper and

lower limbs.

Performed FAST to rule out occult injury as the patient may not have symptoms (pain

abdomen) due to a sensory loss which was negative.

Once the ABC were stable, did a detailed neurological examination for sensory and

motor functions.

Got X-ray of C-spine AP and Lateral films, only when the patient was stable and time

permitted before transfer for the definitive care.

Restrict the movement of the whole spine.

A boy dives from a height into shallow water, hitting his head first at the base of the

swimming pool, unable to move all four limbs. He is rescued by the lifeguard.


As the facility for definitive treatment is not available, arranged for transfer to a

higher centre while maintaining the ABC with restriction of spinal movement.

Scenario 2: Polytrauma with spinal injury

The NELS approach (Assess and Manage) to this patient would be the following:

Airway: Assessed the airway with cervical spine immobilization. Used OPA as airway was

obstructed.

Facial injuries caused blood in the airway, cleared with suction, trachea intubated as the

bleeding was continuous, keeping a low threshold for the surgical airway. Once a definitive

airway was established, gave oxygen by high flow mask.

Breathing: Assessed breathing. The possibility of pneumothorax, haemothorax, fracture ribs

with flail chest was kept in mind. Managed as per the findings and optimized the ventilation.

Circulation: Assessed circulation. Looked for signs of haemorrhagic shock. Looked for the

site of bleeding by clinical examination and FAST. BP is 70/40, Pulse is 140/min. Treated

with warm isotonic crystalloid and blood products as per protocol.

Disability: Assessed GCS, pupils and looked for obvious lateralizing signs. Complains of

back pain hints towards the possibility of spinal injury. Restrict the movement of the whole

spine.

Maintain high suspicion as masking of spinal injury due to distracting injuries or

masking of other injuries due to spinal injuries is common in polytrauma patients.

Once the ABC, are stable, did a detailed neurological examination for sensory and

motor functions.

Since the patient is not responding, the sensory examination is not possible. Got X-ray

of C-spine AP and Lateral films, when the patient was stable and time permitted

before transfer for definitive care.

Kept the whole spine immobilized.

A car driver without seat belt sustains multiple injuries over his face and torso when

his car has a head-on collision and brought to the ED.


As the facility for definitive treatment is not available, arranged to transfer to a higher

centre while maintaining the ABC with the whole spine immobilization.

Scenario 3: Exclusion of spinal injury

Airway & Breathing: The patient is talking comfortably and responding to verbal

commands.

A & B are stable.

Circulation: P- 96/min; BP- 118/78 mmHg. C is stable.

Disability: Conscious, moving all the four limbs. Complains of pain in the right wrist.

Patient already has the restriction of spinal movement device in place.

Spinal injury needs to be excluded before the restrictions in place are removed.

The patient is conscious, cooperative, alert, able to focus attention on neck and spine,

not intoxicated, has no distracting injuries (only a minor wrist injury).

Rule out neck or spine pain, bony tenderness on palpation, any bruising, step down

deformity, a neurological deficit.

Assess to rule out pain, tenderness or tingling with gentle voluntary movement (side

to side; flexion extension). Before eliciting this step, the patient needs to be explained

clearly; stressing on the need to be very soft and cautious with the movements and to

stop at the slightest suspicion of the above symptoms.

Cervical collar and long spine board can be removed if the above criteria are met.

Further evaluation or X-ray is not required.

The patient needs to be directed to follow up at the onset of the slightest of symptoms.

A nursing student slips on the staircase of a nursing hostel and has a fall. His paramedic

friends apply a cervical collar and shift him to the hospital on a spine board after properly

restricting spinal movements.


8.8 Burn Injury

8.8.1 Core Concepts

Airway, breathing and circulation are the priority in the assessment and management

of Thermal Injury

One must clinically suspect Inhalational injury and treat it by securing the airway and

improving oxygenation at the earliest.

Chemical and electrical burns need special care.

8.8.2 Introduction

Burn injuries occur when energy from a heat source is transferred to the tissue of the body.

These are a form of traumatic injury to the skin and underlying tissue caused by thermal,

electrical, chemical and radioactive agents. The depth of injury is related to the temperature

and the duration of exposure or contact. The first priority of burn patient in the hospital is not

the treatment rather it is important to implement the ABCD approach. The first few hours

after burn injury are very important and critical for positive outcome between life and death

of these patients. Burns vary in size i.e. the area or surface burned and severity or depth

depending on the temperature and time duration of exposure to burn source.

8.8.3 First Aid

Contact with a source of heat, i.e. fire or hot liquid should be stopped. Fire should be

doused with water, drop and roll, covering with a blanket. Stop contact with hot liquid

and pour water on the scalded area to cool down. Remove clothes and jewellery from

the burnt area. Wash with cold water till pain subsides. It may take 10-15 minutes. Ice

should be avoided. The wound should be covered with clean cloth and transported to

specialised centre.

Water by mouth should be encouraged till patient reaches a hospital.

Paracetamol should be given for pain management.

Blister if any should be left intact.

Avoid application of toothpaste, mud, cow dunk, oil, ghee or unsterile ointment or

powder. If available antibiotic ointment may be applied.


8.8.3.1 Shift burn victim to a hospital for appropriate care in the following circumstances

Almost all the burn patients except for very small superficial burn, should be taken to

specialised burn centre. No burn patient should be ignored. Especially in the

following circumstances they should be shifted to the hospital very expeditiously:

Facial burn with inhalational injury

Burn in closed space with likely hood of Carbon Monoxide poisoning

Full thickness burn anywhere in the body

Chemical and electrical burn injury

Pregnant women

Children < 5yrs or elderly >60yrs of age.

Suffering from co morbidity

Immune deficiency due to HIV or AIDS, on chemotherapy

All burn victims should be given tetanus toxoid prophylaxis (Tetanus toxoid and

Human Tetanus Globulin).

8.8.4 Assessment of a burn victim

Apart from general condition of the patient following important parameters should be

assessed which are relevant for the management:

1. Degree of burn

2. Body surface Percentage of burn

3. Weight of the patient

8.8.4.1 Degree of Burn

Epidermal burn (1st degree): Only epidermis is burnt. Skin is red and tender with no

blisters. Does not require calculation of burn area and IV fluids. It is treated with

topical creams and emollients.

• Partial-thickness burn (2nd degree): Involves the epidermis and part of the dermis,

looks wet and weepy, edematous, usually have blisters. It is painful due to the

exposed nerve endings. It requires aggressive management to avoid morbidity and


mortality. This is again divided into superficial partial thickness and deep partial

thickness depending upon the involvement of dermal thickness.

• Full-thickness burn (3rd degree): It involves burn of epidermis and full thickness of

dermis. It may also involve the deeper tissues e.g. fascia, fat, muscles or even bones.

There are no blisters, looks dry, leathery and insensitive. Mortality and morbidity is

very high.

8.8.4.2 Body Surface Percentage of Burn (Adults)

• Only second and third degree burns are calculated. Mostly there is mixture of all the

degrees of burns in one victim.

• Rule of NINE: It is used in adults to calculate % of total body surface burn area for

calculation of fluid therapy. Body areas are divided into different regions equal to 9 or

multiples of 9. Smaller burnt area is considered 1% of body surface area of the victim.

Head, Neck and face =9%

Front of trunk- 18%

Back of trunk – 18%

Each upper limb 9% x 2=18%

Front and back of each thigh - 9% x 2 = 18%

Front and back of each leg and foot - 9% x 2 = 18%

Perineum= 1%


8.8.4.3 Body surface % of burn calculation in children: Pediatrics calculation is different

from adults. Lund and Browder chart is used for calculating the TBSA burn area in children

as follows:

Front and back of Head- 9% each=18%

Front and back of each Arm- 4.5% each=18%

Front and back of each leg-7% each=28%

Front of Trunk=18%

Back of Trunk=13%

Buttocks- 2.5% each


Scenario 1

30 yr old female sustained burns in kitchen due to LPG gas leak and suffered burns on face, chest, abdomen and both arms. She is conscious, coughing and crying with pain.

Assessment and action

Airway and Breathing

There is potential threat to airway and breathing due to suspicion of inhalational injury, Carbon monoxide poisoning and burns to face and circumferential neck.

High percentage of oxygen Administration Secure airway at the earliest as there is

suspicion of inhalational injury Ventilation Calculate TBSA (Body surface area) burnt

Circulation

• Maintain organ perfusion • Monitor Oxygen saturation, Pulse rate, Non Invasive Blood pressure, temperature and

urine output. Keep patient warm. • Start two big bore IV access and infuse Ringer Lactate

• 2-4 mL warmed Ringer’s lactate / wt (kg) x total BSA burnt in first 24 hours • Administer ½ calculated fluids volume in first 8 hours • Administer the remainder during next 16 hours

• Reassess fluid requirement as per urine output Adult -0.5 – 1 ml/kg/hr Pediatric- 1ml/kg/hr

Disability

Examine for any associated Injury

Exposure and Environmental control

• Expose the patient for complete examination • Keep patient covered without touching burnt area. • Prevent Hypothermia • Catheterize for assessment of urine output.

How do I identify inhalation injury?

• Cough • Hoarseness • Stridor • Singed nasal or facial hair • Facial burns • Carbon in the sputum • Soot in oropharynx • Inflamed oropharynx • Hypoxia • Wheezing/Labored respiration


• Get baseline blood analysis and X ray chest • Administer pain relief with IV narcotics in low dose, tetanus prophylaxis and

infection control with broad coverage of antibiotics as per the protocol of the burn unit.

• Do wound care as per protocol • Detail documentation in detail • Information to police and medico legal aspects need special attention in burn injury

Carbon mono-oxide poisoning History of Burn in enclosed space With increasing levels of CO poisoning following sign and symptoms are seen

• Head ache, nausea • Confusion • Coma and Death

Management High flow of oxygen thro’ non breathing mask, ventilation with higher % of Oxygen, Hyperbaric Oxygen


8.8.5 Chemical Burn Removal of chemical by flushing with copious water for 20- 30 mins

Brush off powder before washing.

Prevent spillage of chemical over normal areas while washing

Care giver should take safety precaution and avoid chemical injury

Alkali burns go deep and cause necrosis, so alkali burn should be irrigated

with water for longer period. Alkali is more hazardous.

Loosely apply a bandage or gauze.

Transfer to burn Hospital

Fig: Chemical burn

Chemical burns of Eye, Assessment and management

Flush with copious amounts of water.

If the patient wears contact lenses, remove it.

Patch the eyes with lightly applied dressings.

8.8.6 Electrical Burn

Electrical burns may produce severe internal injuries with little external evidence.

Current passes through least path of resistance via blood vessels and nerves causing

arrhythmia and sometimes cardiac arrest. Can disrupt the nervous system, cause

spinal injuries, associated skeletal and muscular damage leading to rhabdomyolysis

and renal failure.

Assessment and Management of electrical burn

• Remove from source of current, protect victim and yourself for further harm

• Take care of Airway, Breathing and Circulation


• Maintain tissue perfusion and urine output of 2ml/kg body wt/hour with IV fluids to

prevent myoglobinuria and acute renal failure

• ECG monitoring to detect and treat arrhythmia

• Appropriate management of associated injuries

8.8.6 Nursing considerations:

Assessment Intervention Remarks

Assess for airway,

breathing and

ventilation,

circulation

Assess for cyanosis,

extremities burn,

distal circulation, and

capillary refill, and

peripheral pulses.

Assess whether the

burn happen within a

closed place to rule

out possible

inhalation injury.

Oxygen administration

Assist in intubation if required.

Attach patient to monitor, SPO2,

and continuous monitoring of

vitals.

Any patient with suspected

smoke inhalation injury must be

started on high-flow oxygen (15

L/min at 100%) using a non-

rebreather oxygen mask.

Inform immediately in

case of any changes in

patients’ condition.

Assess for severity of

burns injury, time,

and duration.

Assess for patient’s

body surface area-

Rule of nine.

Insert two large bore IV cannulas

for fluid infusion.

Calculate requirement of fluids to

be infused.

Maintain very strict I/O record.

Insert Nasogastric tube if indicated

Catheterize the patient.

Fluid resuscitation

should be accurate by

using PARKLAND FORMULA 4ML X

%burn X kg body

weight in 24 hours (4

X 50 X 60=12000ml

in 24 hours).

Half this volume is

given in the first 8


hours

Second half is given

in the subsequent 16

hours

Assess for patient

tetanus status

Assess for pre-injury,

disease, medication,

allergies and drug

sensitivities.

Anticipate for

baseline blood

investigations, cross

matching etc.

Assessed the burn area

in a controlled

environment to avoid

hypothermia.

Administer Tetanus injection after

confirming tetanus immunization

status.

Administer prescribed treatment

(pain management, antibiotics,

sedation)

Routine blood investigations

including blood grouping and

cross matching.

Carefully remove all the

patients’clothings, jewelleries and

hand over to the relatives.

Rinse the burn surface with cold

tap water but avoid using ice cubes

or refrigerated

water as this may cause further

vasoconstriction and tissue

damage.

Avoid hypothermia by providing

warm, clean and dry linen.

Blisters small in size should be left

Pain should be assessed

upon arrival to hospital

and then continued at

regular intervals (1-4

hourly minimum) with

the help of pain scales.

Monitor the lab parameter

also mainly CBC count,

electrolytes, RFT and

LFT.

Follow universal

precautions while

providing care to the

patients.

Never use ice or cold

water because it will

restrict peripheral

circulation locally

increasing the depth of

the burn, and it may

decrease body

temperature.


as it is to avoid infection but large

blisters can be aspirated under

aseptic condition.

Anticipate excision and grafting

and prepare accordingly as

advised.

Wound care: Dressing/wound

care should be carried out under

strict aseptic condition to prevent

infection. Cover minor burns with

dressings dampened with sterile

normal saline and keep the patient

warm. Patient with major burn

injury should be covered with dry

clean or sterile sheet.

Anticipate formation of contractors

and prevent formation of it by

giving proper wound care.

Clinical Pearls

Ten Commandments of Burn management

1. Maintain Airway

2. Maintain Circulation (Shock management)

3. Increase body resistance

4. Avoid bacterial toxemia

5. Avoid auto toxemia

6. Watch for renal complications and multiorgan dysfunction

7. Maintain nutrition

8. Abide by principals of biomechanical physiotherapy and rehabilitation

9. Attend to psychological, emotional aspects and counseling

10. Analyze factors for reducing mortality


Bibliography: 1. Advance Trauma Life Support, Student Course manual 9th and 10th Edition.

2. Practical Hand Book of Burn Management for NPPMRBI under Min of H and FW,

GOI


Chapter 9:

Trauma Skills (Cervical collar application, Helmet removal, Splints, Pelvis binder)

Objectives Upon completion of the chapter nurses should be able to demonstrate skill for:

Application of cervical collar Removal of helmet Use of Glasgow Coma scale Application of splints Application of Pelvic binder


APPLICATION of CERVICAL COLLAR

Cervical collar is a device used to support the neck of the patient having traumatic head or

neck injury. Application of cervical collar can be done in supine position as well as

ambulatory position.

Purpose:

To support the head and neck and provide inline immobilization.

Equipment:

Cervical collar

Application of Cervical Collar in Supine Position (fig 1):

Explain the procedure to the patient if he or she is conscious and request him/her to

co-operate during the procedure.

Check the neck for stiffness, wounds and any other abnormalities.

Clean the wound before collar application.

Choose collar of appropriate size

Measure with fingers from top of shoulder to bottom of chin.

Keeping patient in neutral position, slide the back panel of the collar under the neck

until the panel is placed/centred under the neck.

Again, with proper head alignment, fix the front portion of the collar uptill the

patient’s neck and properly maintain chin support.

Hold the front and back panel firmly with one hand fix up the collar.

Minor adjustment can be done if necessary, of the straps and both the front and back

panel for more comfort fittings, support and immobilization.


Fig 1: Applying cervical collar

Application of Cervical Collar in upright position (ambulatory patient):

Position the patient in neutral head alignment, measure the vertical distance from

tip of the chin to top of the shoulder using size guide.

With the patient in neutral head position, slide the front panel of the collar up the

patient’s neck and properly position the chin support.

Hold the front panel firmly with one hand and place the back panel under crevice

of the neck until the panel is centered at the back and attach both sides to the front

panel.

Minor adjustment can be done if necessary

Complication:

Application of hard and wrong size cervical collar can cause occipital pressure

ulceration.

Documentation:

A nurse should document the patient

a) Details, parameters.

b) Time and duration of cervical collar applied

c) Types of collar

d) Patient’s response


HELMET REMOVAL

Following trauma careful removal of helmet is of great importance. The rescuer who

removes the helmet improperly may cause further cervical injury. Two persons are

required for removing the helmet. One rescuer maintains inline immobilization while the

other cut the straps and moves the helmet. At no point of time both the rescuers should be

moving simultaneously.

Purpose:

Helmet removal requires a very basic training which is safe and gives quick

access to health care providers to access the patient’s airway and provide them

opportunity of stabilizing the patient’s head and neck to prevent further cervical

injury.

Requirements:

Two persons

Procedure:

Check and provide safe environment for victims and rescuer.

Explain the patient what you are going to do to the patient and ask for his/her cooperation

during the procedure if conscious.

The first rescuer positions himself above the patients’ head and provide inline

immobilization by placing his hands on each side of the helmet and placing his fingers on

the victim’s chin. This position prevents slippage if the straps are loose.

The second rescuer positions himself at one side of the victim by kneeling down and

opens the face shield, removes glasses if present and cut the straps of the helmet.

The victims’ mandible is grasped by placing between the thumb and the first two fingers

are at the angle of the mandible. The other hand is placed under the neck on the occiput of

the skull of the victim to provide inline immobilization. The rescuer forearms should be

resting on the floor for additional support.


The first provider pulls the sides of the helmet apart, away from the victim’s head, and

rotates the helmet with up-and-down /forward and backward slightly rotating while

pulling it off the head. He takes care till the helmet crossed the nose and head.

Once the helmet is removed, paddings should be kept behind the patient’s head to

maintain an inline position. As manual immobilization is maintained, a correct sized

cervical collar is applied on the patient.

Fig 1: Steps of helmet removal.

Precautions: Always ask for symptoms of pain, numbness and paresthesia. If patient

complaints of any of these symptoms, abandon the above mentioned technique. The

helmet should then be removed by cutting it.

Complications:

Improper helmet removal or a rescuer without knowledge of helmet removal skills

may cause secondary head and neck injury to the victim.

Documentation:

A nurse should document the time at which helmet was removed

Whether the helmet was intact or broken to know the impact of accident.

Patient response at the time of removal and after.

Vital signs

Any findings on the head and neck of the patient after helmet removal.


Glasgow Coma Scale

Glasgow Coma Scale (GCS) is a common scoring scale used to assess the level of

consciousness in an accident victim following a Traumatic Brain Injury. The GCS assesses

three major brain functions: eye opening, motor response, and verbal response. The patient

receives a score for best response in each of these areas, and the three scores are added

together. The total score will range from 3 to 15; the higher the number, the better.

Purposes:

To assess the level of consciousness.

To identifying any minor or major changes in alteration in the level of

consciousness.

Steps:

Eye opening response:

Go near the patient. If the patient opens eyes spontaneously, he/she is given a

score of 4, even if he can open only one eye, as it is the best response that we

assess.

If the patient does not open eyes spontaneously, ask the patient to open his

eyes give a score of 3.

If the patient does not respond to a verbal stimulus, a painful stimulus such as

nail bed pressure with a pen, squeezing the axillary tissue, supraorbital nerve

pressure or sternal pressure can be applied. Give a score of 2 if the patient

opens his eye with these stimuli.

Try all the above three, if no response then score the patient as one.

Verbal response

Go near the patients and as the questions like “what happened to you?” If the

patient answers correctly and coherently he scores 5.

If the patient is confused (talking in sentences but disoriented in time and

place) then give a score of 4.


If the patient respond inappropriately (utters occasional words rather than

sentences) then give a score of 3.

If the patient groans or grunts but no words or absent then give him a score of

2.

No verbal response, score 1

Category Response Score Eye opening Spontaneous 4

To speech 3 To pain 2 None 1

Verbal response Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 None 1

Motor response Obeys commands 6 Localizes pain 5 Flexion withdrawal 4 Abnormal flexion 3 Abnormal extension 2 None 1

Motor Response:

No motor response---Score 1

Decerebrate posturing accentuated by pain (extensor response: adduction of arm,

internal rotation of shoulder, pronation of forearm and extension at elbow, flexion of

wrist and fingers, leg extension, plantar flexion of foot)—Score 2

Decorticate posturing accentuated by pain (flexor response: internal rotation of

shoulder, flexion of forearm and wrist with clenched fist, leg extension, plantar

flexion of foot)---Score 3

Withdrawal from pain (absence of abnormal posturing; unable to lift hand past chin

with supraorbital pain but does pull away when nail bed is pinched)—Score 4

Localizes to pain (purposeful movements towards painful stimuli; e.g., brings hand up

beyond chin when supraorbital pressure applied)—Score 5

Obeys commands (the patient does simple things as asked)---Score 6


Documentation:

Documentation of the GCS score every time the score is checked.

Patient’s response to treatment, changes in the GCS score reflected through the GCS

score

Vital parameters to be documented

SKILLS for MUSCULOSKELETAL TRAUMA

Splints are applied in suspected or fractured lower and upper limbs and where transport is indicated. They immobilized and reduce bleeding, fat emboli, blood vessel and nerve damage and relieve pain.

Purposes:

Splints in Musculoskeletal Trauma helps to mobilize and protect the joints,

reduce pain, reduce swelling and helps in healing process of acute injury.

They are also useful in injury prevention, chronic pain reduction and can

change the function of the joints.

Devices for Musculoskeletal Injury:

Splints, bandages, casts, and braces are used to support and protect broken bones, dislocated joint and injured tissues

In some cases, splints and casts are used after surgical procedures to repair bones, tendons or ligaments

Main equipments of orthopedics and immobilization:

Cast and splints

Slings

Braces

Collars


Nursing skills:

Application of traction splint in Musculoskeletal Trauma:

Thomas Splint Cremer Wire Bohler Braun Splint

Fig 1: Thomas Splint

Fig 2: Bohler Braun Splint

Splints are applied in suspected or fractured lower and upper limbs and where transport is indicated. They immobilized and reduce bleeding, fat emboli, blood vessel and nerve damage and relieve pain.

1. Two people are always needed while applying any kind of splints. 2. Explain the procedure to the patient before and after applying explain again how

to take care of the splint and follow advised physical activity advised. 3. Remove clothing, jewellery, footwear and any other object seen in the limbs

before applying the splints. 4. Assess distal pulse, sensation, movement and motor movement before applying.


5. Clean the open wound if any before applying under aseptic condition and cover with sterile dressings and secure it.

6. Measure the unaffected limb with the traction splints, splints should be measured, cut/adjust before being applied.

7. If patient is critical, splinting should be limited to securing the fractured limb and the long spine board and transport it.

8. While lifting the limb, it should be lifted so as the splint can be slide below the fractured limb.

9. Immobilize and stabilize the joint or bone above and below the injury. 10. Patient should be always on supine position and limb elevated to prevent swelling. 11. Pad all bony prominences and extremity in the splint. 12. Reassessment of the patient and the splints should be done atleast every fifteen

minutes for stable patient and more frequently for critical patient or as advised. 13. Any change in vitals or abnormal findings should be reported immediately and

documented.

Wound Care in Musculoskeletal Injury:

Equipments:

Gauze Sponges Bandages and Dressings Cotton Tipped Applicators. Cotton Balls. Sterile gloves Antiseptic Solutions Suture set (for suturing if required) Medical Adhesive Tape Sterile drapes Gauze rolls

Steps:

1. The wound is irrigated with saline and the skin is clean with antiseptic solution.

2. Remove loose foreign materials, dirt or clothing from the wound. 3. Wound closure or suturing should be done immediately after cleaning the wound

provided the wound is clean. 4. Contaminated wound should be clean thoroughly and left open in the wound for

secondary healing. 5. If wound debridement is done, the wound should be left open in the air after the

debridement for healing.


Pain Management:

1. Reassurance, immobilize and administer pain to alleviate the pain. 2. Encourage the patient to monitor own pain and intervene accordingly. 3. Position the patient in proper body alignment to reduce pain. 4. Medication before any procedure like wound dressings and debridement will help

reduce pain.

Complications of Splint Traction application:

Respiratory problems General weakness Skin abrasions and ulcers Allergy Constriction of circulation Infection at pin site if skeletal traction is present Thromboembolism Nerve palsy due to adhesive tapes.

CHEST TUBE DRAINAGE

Chest tube drainage is a procedure where fluid, blood, air and pus which are collected at the chest cavity or the area surrounding the lung cavity are removed by using a flexible plastic tube.

Purposes:

Chest tube drainage system helps and permits drainage of air and blood and fluid

from the pleural space.

It helps re-expand the lung tissue by re-establishing normal pressure in the pleural

space.

It prevents mediastinal shift and lung tissue collapse by equalizing pressure on

both the sides of the thoracic cavity.

Indications:

Pneumothorax(spontaneous, tension, iatrogenic, traumatic)

Pleural Collection

Hemothorax


Articles/equipments required:

Antiseptic solution Sterile gauze Sterile drape Sterile gloves Suture material Syringe and 22 and 25-gauge needles for local anesthetic injection Chest tube insertion set (sterile) 70% ethyl alcohol to clean the area Povidine iodine to clean the area 2% Lidocaine/xylocaine to provide local anesthesia Silk suture to secure the chest Large Kelly clamp Scalpel Normal saline 0.9% Chest tubes of appropriate size Chest tube drainage system

Preparation:

Make sure that all the instruments required to insert a chest tube are available

before commencing the procedure.

Supplemental oxygen and monitoring equipments should be instituted.

Optimal room temperature to be maintained.

All documentation like vitals, consent to be completed

The site selected is cleaned with an antiseptic solution with full aseptic

precautions. The site is covered with sterile drapes, except the insertion site

which is left opened.

Procedure explained to the patient I the language to him/her and request for full

cooperation during the procedure.

Position:

In trauma situations, emergency chest tube insertion is usually performed in

supine position as part of the primary survey; however it is preferable to place the

patient in a 45 degree head up position if there are no contraindication.


Site (Fig 1):

Site for chest tube insertion is at level of the nipple , just in front of the mid-

axillary line on the involved side. This corresponds to the 5th intercostal space.

This area is lies within “triangle of safety”, which is bounded anteriorly by lateral

border of the pectoralis major, posteriorly the anterior border of latissimus dorsi,

base being a horizontal line at the level of nipple and the apex is below the

axilla.

Fig 1: Site of chest tube insertion

Role of a Nurse before Chest Tube Insertion:

Assess for ABCD Remove extra cloths to assess chest injury.

Do not remove the obstructed object which has caused the chest injury if any.

Administer 100% Oxygen. Attach monitors, SPO2, NIBP, ECG and Etco2 for continuous

monitoring of vital signs. Cover the chest wound with sterile dressings. Position the patient in semi fowler’s position or on the injured side if

breathing is not impaired and after cervical injury is ruled out. Secure IV line and administer fluids Administer antibiotics, analgesic, send routine blood test, blood

grouping and cross matching, chest X-ray if advised. Continuous assessment and monitoring of vital signs, response of the


patient, oxygen saturation, ECG, intake and output etc be taken care of.

Ensure the availability and working of equipments for Chest Tube Insertion.

Remove patient’s clothing and any object covering the wound but not clothing that is stuck in the wound.

Keep one hand over the wound or take help of others while removing clothing or any object covering the wound. If no help is available ask the help of the patient if he is able to help.

Seal the open chest wound with sterile dressing pads. Put pressure on wound to control bleeding. Ask the patient to breath out excess air accumulated inside the chest

if he can. Place tape, plastic or chest seal over the wound that is open where air

enters and exit and not to allow any entry of air further. Use occlusive dressing to seal the wound or any material for a water

and airtight seal with one sided open for exit of air. Remove the seal if tension pneumothorax developed. Place the patient on side lying position to let the air move as much as

possible. Maintain room temperature or provide warm clothing to prevent

hypotension. Keep patient NPO. Prepare for Chest Tube Drainage. Prepare for chest tube insertion to relieve tension pneumothorax.

Role of a Nurse during Chest Tube Insertion:

Continuous monitoring of all vital parameters and to inform any changes in the vital stats.

After chest tube insertion, secure the tube, tubings and monitor its functionings and inform the doctor if it is not functioning as desired.

Once the chest drain is in proper place with all holes inside the skin, then it is connected to the underwater seal. This underwater seal will act as a one-way valve which will allow egress of intrapleural air whereas the atmospheric air will be prevented from entering into pleural cavity during inspiration

Look for fogging of the chest tube with expiration. Check and make sure that the chest tube is fixed with a suture at the site of

incision. The ends of the suture are left loose so that they can be tied when the chest tube is removed.

One should not raise the drainage bottle above the level of heart to prevent reverse flow of fluid from the collection bag to the pleural cavity

To check the flow of fluid into the drainage bottle and any blockage in the drainage system.

Monitor the volume of pleural fluid in the drainage bottles periodically. See for the comfort level of patient and inform doctor for any discomfort. Administer analgesic or any other medications as advised and required.


Continuously monitor for anything which can lead to complications like hypotension, cardiac arrest and injury to adjoining organs and inform doctor of any changes.

See for presence of hypotension due to removal of blood or fluid and follow up for its resolution.

Role of Nurse after Chest Tube Insertion:

Continuous assessment of ABCD Continuous monitoring of vital parameters Monitor the volume of pleural fluid in the drainage bottles periodically. See for the comfort level of patient and inform doctor for any discomfort. Administer analgesic or any other medications as advised and required Chest-drain connection is secured with tape and an occlusive dressing is applied

and tube fixed to the chest wall. Make sure that the drainage tube is underwater for at least 2cm in collection bag.

This will ensure proper seal. Check that the tip of drainage tube does not slip out of the water otherwise atmospheric air will enter pleural cavity causing pulmonary collapse.

Obtain a chest Xray to see correct placement of tube. Reassess the patient and obtain an ABG and pulse oximetry readings Patient teaching about the care of chest tube

Complications:

Surgical emphysema, Injury to intrathoracic or intra abdominal structures (this can be prevented by

placing the gloved finger in the incision site before placing the chest tube) Bleeding, Nerve injury, Blockage/kinking/ not functional due to drain holes outside the pleural cavity, Problem of drainage system. Pleural infection Intercostal neuritis/neuralgia

Documentation:

Vital parameters to be documented every two hourly Document patient’s symptoms, such as shortness of breath and chest pain,

physical assessment findings such as asymmetrical chest wall movement; dyspnea; tachycardia; hypotension; decreased or absence of breath sounds; neck vein distension; and tracheal distension.

Written record of consent be documented


Any pre-medication advised and given Position of the patient during the procedure Patient tolerance level of pain during and after the procedure The type, size and length of the chest tube The site of insertion and type of dressing used Whether the tube is in the right place or not Presence of air or fogging The amount/quantity of fluid, blood drained out and the presence of air in the

drainage bottle. Any investigations advised and carried out after the procedure Patient’s response post tube insertion Intake and output chart IV therapy and lab values Use of ultrasound guidance Patient education about the care of chest tube and response to the teachings.

Source: Nursing 2019, Documenting Pneumothorax, ATLS 10th Edition Manual


PERICARDIOCENTESIS

Pericardiocentesis is also called a pericardial tap, is an invasive procedure that involves using a needle and catheter to remove fluid (called a pericardial effusion) from the sac around the heart (the pericardium).

Purposes:

Pericardiocentesis is done to remove fluid from pericardium, a sac around the heart using a needle and a catheter.

To prevent buildup of fluid in the pericardial sac. It is also performing under strict aseptic condition and precautions for diagnostic

purpose by sending the fluid to find out the presence of infection, inflammation and presence of blood and cancer.

Equipment/items required for Pericardiocentesis:

Antiseptic solution Sterile gauze Sterile drape Sterile gloves Suture materials Syringe and 22 and 25-gauge needles for local anesthetic injection Local anesthetic agent 18-gauge over-the-needle catheter Large syringe (35 to 60mL) for aspiration of pleural fluid 3-way stopcock 2-3 50cc of syringes with luer lock Sterile occlusive dressing Specimen tubes 1 or 2 large evacuated containers


Echocardiography with a cardiac probe Sterile probe covers and sterile echo gel Central Venous Catheter Kit for Seldinger Technique, triple lumen (16, 18 &

18G). Drainage catheter Haemostat One way Heimlich valve or a three way stop cock for the end of the

pericardial tube if left indwelling.

Nursing Skills required during Pericardiocentesis:

Explain the procedure to the patient and relative and give them support. An IV line is placed for administering fluids and sedatives. Vitals signs like temp, pulse rate, breathing, heart rate, spO2 are monitored before,

through out and after the procedure. Patient should be placed in supine position. Connect patient on cardiac monitor and inform about any ECG changes. Echocardiogram is done to guide the cardiologists/Trauma Surgeon/Emc Physician to

insert the needle. Local Anaesthesia is administered as advised. Assist doctor under aseptic condition while needle is inserted in the chest wall and

pericardial space to be replaced with catheter. Nurse assisting should monitor cardiac monitor during the whole procedure for any

changes. Monitor for patient’s comfort, response and inform to doctor if patient is feeling any

discomfort and pain and administer analgesic as advised. Administer emergency drugs as prescribed. Carefully assess for hypotension, ventricular puncture, cardiac arrest, pulseless

electrical activity, Pneumothorax. Fluid or blood is drained out and the catheter is left for hours under continuous

monitoring. After the removal of fluids, the catheter is removed and pressure bandage is applied. After the procedure obtain ECG and X ray again. Document vitals, ECG changes any

during the procedure. Document the amount of fluids drained out and specimen send to lab. Document pain, anxiety, discomfort etc. and complications arising out of the

procedure.

Complications:

Cardiac Arrest Perforation leading to tamponade Laceration, thrombus formation at the pericardium Injury to the intercostal vessels, Pneumothorax, Pulmonary edema, ventricular tachycardia and injury to the adjoining vessels.


Documentations:

Document the patient’s general condition, vital parameters through out the procedure. Any ECG changes to be documented carefully and inform them to Doctor who is

performing the procedure. Patient’s response to the whole procedure should also be documented. The amount, colour and appearance of fluid drained to be documented. Whether the sample send for investigations must also be documented. Any fluid left or how often the fluid was taped also need to be documented. Confirmation of guidewire withdrawn and time out be documented.

PELVIC FRACTURE STABILIZATION/ APPLICATION of PELVIC BINDER

A break of bony structure of the pelvis like hip bone is called pelvic fracture. It results from high velocity mechanisms. They cause massive blood loss and are one among the most severe injuries in musculoskeletal and has high incidence of mortality. Survival rates has improved over the year and most patient who died of pelvic fractures are due to concomitant injuries rather than pelvic fractures.

Purposes:

To bring back bony structures to correct position. To prevent blood lost, provide support, reduce pain and to minimize pelvic ring

injury. To control venous bleeding, reduce pelvic volume and prevent life threatening

pelvic hemorrhage. Reduction in intraperitoneal volume Control bleeding Splinting of fractures Pelvic stabilization and resuscitation

Indications:

Unstable or floppy pelvis by palpation Open book pelvic ring disruption (An open-book pelvic fracture is a term used to

describe any fracture that significantly disrupts the pelvic ring. These injuriescombine an anterior pelvic injury causing a widening (opening) of the pubicsymphysis, and a posterior pelvic fracture or ligamentous injury.

Hypotensive patient without other obvious reasons for hypotension (i.e. abdominal,chest, or extremity injuries).

Contraindications:

Skin problems like open wounds or burns. Pregnancy


Procedure/steps of Pelvic Binder Application:

Commercialize Pelvic Binder Application:

1. Position the patient in supine 2. How to prepare pelvic binder for application:

Undo the clips and remove the velcro straps to enable the long straps to be rolled small enough to pass under the patient

Line the Pelvic Binder up so that the middle strap will pass under the patient’s great trochanteric and pubic region

Log roll the patient and insert the Pelvic Binder by pushing the rolled straps through as far as possible.

Log roll the patient back and ensure that the flat square portion is under the patient’s buttocks and pull the straps through.

In the emergency department if a patient is expected who will require a Pelvic Binder, it can be put on the trolley ready for application rather than applying it via a log roll.

3. Reattach the velcro tabs and apply the straps: the most important strap is the middle strap or the one positioned between the symphysis pubis and the greater trochanteric region, the other straps are fastened above and below this area.

Strap 1: positioned between the anterior superior iliac spine and iliac crests (placed above strap.

Strap 2: positioned over the symphysis pubis and the greater trochanteric region.

Strap 3: positioned strap at the level of the symphysis pubis and ischial tuberosity (placed below strap 2).

Application by Sliding the Pelvic Binder Under the Patient’s Buttocks:

The Pelvic Binder can be applied in emergency situations (i.e. prehospital, patient who cannot log roll), by sliding it under the patient’s legs and then buttocks. In this case there will be no need to remove the buckles; the Pelvic Binder can be opened by pulling apart the Velcro.

Sheet Wrap Method:

The Sheet Wrap Method is used specially for stabilizing and reducing open book pelvic ring disruptions.

Here, the sheet is wrap at patient's pelvis using an ordinary folded bed sheet. Place and center the sheet under the patient, over the area of the femoral trochanters and the pubic symphysis (move the pelvis as little as possible). Wrap the sheet tightly around the patient’s pelvis and compress at this level.

Cross sheet ends and twist from opposing sides, by applying sufficient pressure. Use towel clamps to secure sheet ends. (See Figure 2.) Try avoiding folds and creases that may result in skin damage if the sheet is left in

place for long duration.


This Sheet Wrap Method helps in reduction of fracture by splinting it, which in turn control internal blood loss.

Figure 2.1 & 2.2: A Pelvic Sheet Wrap Patient

Advantages:

Sheeting helps in complete evaluation of perenium and lower extremities, as well as vascular access at the groin.

Sheet wrapping can be a great advantage when trans-arterial study and embolization of pelvic bleeding is available.

A sheet wrap prevents compression of muscle compartments that are prone to the development of compartment syndromes.

When correctly applied, a sheet wrap does not interfere with respirations and provides non-invasive external "fixation."

Sheet wrapping is also the most cost-effective treatment.

Disadvantages.

Sheeting is not a splinting procedure of lower extremity dislocations and fractures. The compression of the sheet may extend skin and wound areas that are already

injured. Exercise caution when placing a sheet over open skin areas due to burns or traumatic

injury. Complications:

Compression of sheet on the pelvis with already injured skin may cause further/extend injury to the patient.

Documentations:

Vitals parameters Time and duration of binders applied Patient’s response before and after pelvic application. Types of binder used

Reference: Comprehensive Advance life support, CALS.


Lesson 10

Hospital Preparedness for Emergencies and Disasters Role of the nurse in Hospital Emergency Response System

Objective:

On completion of the lesson the Emergency Nurse will be able to

1. Provide emergency care in Mass Casualty Event

2. Prepare and coordinate in Emergency response of Disaster within the hospital

3. Perform Incident Coordinator role in Disaster Scenario

This chapter prepares the Emergency nurse in handling disaster management both at Pre

Hospital as well as In Hospital as we receive victims. This requires clinical knowledge as

well as skill competencies which are highlighted.

Scenario: There is a massive train accident at nearby site involving more than 200 victims on the spot. What would be the response of the Hospital as a Health care team?

Pre Hospital

In Hospital (Emergency Department)

The emergency care in the above event will be preparedness of the Health care team to provide Pre Hospital and in Hospital care. In this context the role of nurse in emergency department will be as follows

1. Triage on the spot (Emergency Nurse representing the hospital or on the spot)

2. Extrication and Evacuation of the victims (Paramedics & Fire & Rescue Team)

3. Receive at Hospital (Emergency Room Preparedness)

4. Triage at Hospital (Emergency Nurse)

5. Management and Coordination within ER and within Hospital – Incident Commander

(Doctor)

6. Early Management of severe trauma (Doctor, Nurse and Paramedic Team)

7. Documentation

8. Medico Legal Aspects

10.1 On arrival of the victims to the Emergency Department or on receiving phone call from

the site the emergency nurse will apply the following method


1. Notification & Verification a. On receiving the call or receiving the first patient, the nurse will have to

confirm through the immediate supervisor in the department

2. Activation: The Emergency nurse along with the Emergency Medical Officer will activate the Incident

commander and the Mass Casualty Nurse Coordinator

3. Response: As the Medical Incident commander who is the overall in charge of the Disaster management

will ensure the overall management of the care

a. The MCM Nurse Coordinator will ensure

i. Availability of the needed emergency nurses

ii. Needed support service personnel

iii. Coordinate with other team members in ensuring the availability of

needed material resources such as medical equipments, Pharmacy

items etc

iv. Will keep track of the flow of patients.

v. The Emergency\Trauma nurses will team up with the Emergency

Medical Officer in providing optimal level of Trauma ca e to the

victims.

vi. Ensure maintenance of appropriate documents such as Medico Legal

Records

vii. MCM Nurse has to coordinate with other department such as Medical records, Pharmacy, Central Sterile Support Department, Security, Logistics, etc.

4. Deactivation:

On successful handling of the victims in transferring and admitting them at ICU\Ward etc,

the Incident Commander will deactivate the Emergency Response Activity to resume normal

activity of the Emergency department.

5. Critique & Debriefing: The Incident commander will organize a Debriefing meeting on the next day involving all the

Health care and support care team members. The team will be appreciated and encouraged to

share on the success aspects as well as the Pro’s and con’s of the Emergency Response.


Subsequently the existing plan will be relooked and modified as needed.

For better understanding of the terminology used in this lesson, the list and simple

explanations are given as follows.

Adopt an “ALL HAZARDS APPROACH” such as Fire, Earthquake, Terrorism, Biodisaster

etc. This particular approach is created on a principle of common emergency response protocol for any kind of disaster in the initial phase of management. After initiation of this

common emergency response protocol, different sub protocols for different types of disasters

are initiated depending on the type of disaster

Terms used in Hospital preparedness for Disaster

Disaster: A serious disruption of the functioning of a community or a society causing

widespread human, material, economic or environmental losses which exceed the

ability of the affected community or society to cope using its own resources.

Triage: Triage is the medical screening of patients according to their need for

treatment and the resources available. It applies to mass casualty situations, when

conventional standards of medical care cannot be delivered to all victims. The goal is

to optimize care for the maximum number of salvageable patients.

Hospital Incident Commander: The person responsible for all aspects of an

emergency response; in applying incident objectives, managing all incident

operations, application of resources as well as responsibility for the emergency care

involved.

Hospital Emergency response team (HERT): is a group of people who prepare for

and respond to any emergency incident, especially in hospital.

Emergency management: The organization and management of resources and

responsibilities for dealing with all aspects of emergencies, in particularly

preparedness, response

Hazard: A potentially damaging physical event, phenomenon or human activity that

may cause the loss of life or injury, property damage, social and economic disruption

or environmental degradation.

Hazard Identification and Risk analysis: Identification, and monitoring of any

hazard to determine its potential, origin, characteristics and behavior.

Multiple casualty incidents (MCIs): These disasters involve a number of casualties

who stretch the resources of a medical facility but do not overwhelm them.


o Local resources of the hospital/medical facility are put under stress and

patients are triaged (ref to Chapter NELS approach) with the aim of

identifying the patients with the most life threatening injuries who are treated

first.

Mass casualty events (MCEs):

o These are disasters where the numbers of casualties are so many that the

resources of the medical facility are overwhelmed and standard of care can in

no way be provided to all patients.

In a mass casualty event principle of providing care are different with the main

principle being that of “Doing most good for the maximum number of people

with the available resources” triaging being focused on identifying patients

with the greatest probability of survival.

10.2 The focus of this training will involve the following two classifications

Disaster Definition Examples

Internal

disaster

An event that occurs within the hospital,

where the Emergency Department has

to respond

Hazardous materials spill in hospital

laboratory, fire or explosion within

hospital, stampede injuries

External

disaster

An event that occurs external to the

hospital, where upon a large population

of victims are brought to the Emergency

Department

Transportation accident, industrial

accident, etc

10.3 The role of Nurse in Emergency Response to Disaster\Mass Casualty Management.

The core competencies of disaster management are vital both at Pre Hospital Care as well as

In Hospital Care.

These competencies can be at different level such as three levels of preparedness:

1. Staff\Emergency Nurse – Clinical Nursing Skills

2. Charge Nurse \ Middle Manager – Networking, Coordinating and Managerial Skill

3. Head of the Department\ Nursing Superintendent – Administrative skills.


Site of Mass Casualty Incidence

On site Triage (START) Performed by Paramedic\Emergency Nurse

Stable Unstable

First Aid Referred to Hospital

Referred to Hospital Resuscitation and Stabilization

Treated and Discharged Admit ICU\Ward Further Management

10.4 Role of Nurse in Hospital Emergency Operations Plan

Component Action

Activate emergency

operations plan

Notify and mobilize personnel and equipment

Establish decontamination,

triage, and treatment areas

Decontamination, triage, resuscitation, acute care,

and minor care areas; surgical triage and holding;

psychiatric area; morgue

Emergency Operations Center Coordinate with Emergency Operations Center

Assess hospital capacity Determine safety of hospital itself; determine

capabilities of hospital in all units

Create surge capacity Identify and mark specific locations for the patients

Establish communication

systems

Develop multiple contact systems, including cellular

phones.

Provide supplies and

equipment

Deliver available supplies to proper areas and plan

for resupplying or obtaining other needed materials


Establish support areas Volunteer, press, and family information centers

Terminate disaster response

and provide for remediation

Return personnel and supplies to normal activity;

provide emotional support for caregivers; improve

emergency operations plan for future incidents

10.5 Steps in Disaster Management

Hospital Disaster Plan: (HERP – Hospital Emergency Response Plan)

The hospital will have its own disaster plan with an “All Hazard Approach”, which

may require evacuation of the hospital,

Scaling up the capacity of hospital to manage sudden influx of sick and injured

persons into the hospital which may be more than capacity of the hospital to treat in

the emergency department/ indoor/ ICU.

a) Logistics:b) The Emergency Nurse Supervisor\Emergency Nurse should be aware of the hospital

disaster plan which has the provision to scale up capacity in terms of beds, drugs and

consumables, ambulance services and other needed resources

c) Operational:d) The Emergency Nurse Supervisor\Manager should be aware of the details of Health

Care team (doctors, nurses, paramedics and support staff) involved in the disaster

management

e) Each category of manpower (administrative, doctors, nursing, paramedical and

support staff) are regularly trained by conducting mock drills and are aware of their

roles and responsibilities during any emergency situation.

f) Incident Management System:g) In the event of any unforeseen emergency situation in the hospital, the doctor in

charge of emergency department should be able to coordinate and manage all

activities in the hospital to ensure that hospital services are scaled up to meet the

demand of the situation.


1. The Medical Superintendent will be the Incident commander of the hospital (Medical Superintendent/ Additional Medical Superintendent/ Deputy Medical

Superintendent) concerned and coordinate all activities in the hospital till comes to the

emergency department and takes over responsibilities of “Incident Manager”.

2. Triage: “Triage” is the process of categorizing a patient according to degree of

severity/ seriousness of his/ her medical condition in the event of large number of

patients/ casualties reporting to/ being brought to emergency department of a hospital.

Triage Protocol is to be followed by doctors, nurses and paramedics in emergency

department of hospital or at the site of any mass casualty/ disaster to prioritize

treatment of those patients who, if provided optimum medical care have the highest

probability of being saved.

The color codes followed to categorize patients/ victims of any mass casualty event/ disaster are:

Color Remarks Priority to be given the Patient

May survive if provided immediate lifesaving

medical interventions.

Highest (Category I)

Will survive if provided optimum medical

interventions within few hours.

Medium (Category II)

Walking wounded. Well oriented to time,

place and person. All vital signs stable.

Low (Category III)

Brought dead. Procedure to be followed for

death declaration and preserving the body for

autopsy.

Lowest (Category IV)


I. START TRIAGE (Pre- Hospital care) Simple Triage and Rapid Treatment

10.6 Principles for the Triage Nurse

Patients must be assessed and reassessed called re triaging at many places like

o at the site of disaster,

o for transportation,

o entry point of the emergency department,

o In the emergency department, for investigation (like X ray, CT, MRI), for

surgical intervention, in the operation room, and for intensive care admission.

Triage Nurse plays a significant role in Disaster Management with appropriate

emergency nursing and soft skills needed for the occasion

When there is prior information and time permits to call a trained senior person

designated as triage officer, it must be done.

o Designated triage officer should be trained to do triaging, has participated in

mock drills in disaster management of the hospital, who has knowledge about

existing hospital disaster plan, hospital resources and availability of manpower

and material at that moment.

When there is no prior information or time is limited to call the triage officer, senior

most nurse on duty should take the responsibility of triaging.


o In a small hospital, this person will have to do multiple roles. It will be easier

for her\him to manage the victims of disaster after triaging for treatment and

transfer.

Multiple casualty incidents: involve a number of victims who require extra resources

and the hospital is in a position to organize it.

o Local resources of the hospital/medical facility are put under stress and

patients are triaged with the aim of identifying the patients with the most life

threatening injuries who are treated first.

Mass casualty events (MCEs): Number of victims is so many that the requirements of

resources are more than the capacity of the hospital and hence proper care cannot be

provided to all victims.

o So in such a situation “Do most good for the maximum number of victims

with the available resources”. Triaging is focused on managing patients with

the greatest possibility of survival.

o A critically ill victim of disaster, who under normal circumstances would

receive maximum care using maximum resources of the hospital, would be

low on priority in receiving proper care in mass casualty situation so that

resources. For example: Red category victims who can be managed with

minimum utilization of resources including time, manpower and material, will

be treated first

10.7 Implementation of the above can be done by:

Activation of the hospital disaster plan

Activate Disaster Triage system

Establishment of an Incident Command Post

Ensure sufficient resources –deployment of adequate staff, facilities and

equipment, hospital telephone exchange plays a key role in informing heads of

key departments especially all acute care specialists (anesthesiologists,

emergency physicians, surgeons, burns specialists, intensivists, blood bank

officers, radiologists, laboratory staff, all doctors, nurses, paramedics,

ancillary staff, store keeper, security etc.

Early discharge of eligible patients from inpatients.


Elective surgeries as well as outpatient department are ceased for the time being

Identification of each departments’ surge capability, extra beds, monitors,

ventilators, oxygen therapy devices and staff that can man the extra beds.

Identification and mobilization of alternative medical care sites. Mobilize disaster teams of the hospital Preprinted Job description cards to be distributed to staff members as per their

roles Communication with all concerned authorities and agencies. Strengthen the security Traffic control system is very important for controlling flow of patients,

personnel, equipment, supplies and information/communication. Prepare for decontamination, triage and treatment areas for different category

patients.

Open Disaster ward & make available beds in ICU and free operation theatres.

Check supplies- fluids, drugs, blood, equipment especially resuscitation

equipment, food, water etc

Check power and public-address system

Co-ordination with local police, fire department, emergency medical services,

ambulance services, security agencies, public health & Government agencies

etc. Step up security

Establish a public information center responded by the Hospital Incident

commander

Must prepare for providing all levels of care for the red, yellow and green

patients

Prepare for transportation of casualties to other hospitals by prior agreement if

local facility is saturated.

Availability of Emergency Drugs in large volume controlled by the pharmacist

The Emergency nurse needs to be competent in the following skills towards disaster management Specific Skills

1. Cardio Pulmonary Resuscitation

2. Triage

3. Crisis Communication

4. Early Management of Trauma Care


5. Patient Transportation Skills

6. Pre Hospital Care

7. Ambulance care (Advanced Level)

General Create consistency in the care given;

Facilitate communication;

Build confidence;

Facilitate a more professional approach;

Promote shared aims;

Allow for a unified approach;

Enhance the ability of nurses to work effectively within the organizational structure;

and

Assist nurses to function successfully as members of the multidisciplinary team.

Networking

Team player

To control a large number of patients and manage the resulting problems in an organized manner,

By enhancing the capacities of admission and treatment.

By treating the patients based on the rules of individual management, despite there

being a greater number of patients.

By ensuring proper ongoing treatment for all patients who were already present in the

hospital.

By smooth handling of all additional tasks caused by such an incident.

To provide medications, medical consultation, infusions, dressing material and any

other necessary medical equipment.

The Emergency nurse should be aware of the components in the hospital emergency

plan

o Incident Command center

o Communications office/paging/hotline area/telephone exchange.

o Security office contact number

o Reception and triage area.

o Decontamination area in HAZMAT, Hazardous Material Scenario.

o Minor treatment areas.

o Acute care area (emergency department).


o Definitive care areas (OTs, wards).

o Intensive treatment area and activation of High Dependency Units (HDUs)

o Mortuary.

o Holding area for relatives/non-injured.

o Area for holding media briefings (separate media/PRO/spokesperson room).

o Area for holding patients in case a part of the hospital is evacuated.

o All these areas should be mapped on the outlay map of the hospital. The

normal capacities of the existing

Areas should be mentioned on these maps. Enhanced admission of patients requires

an enlargement of

Suitable spots, if necessary even by changing their function.

10.8 Disaster Nursing Job Description

1. Hospital Disaster Nursing Coordinator • Goal: Co-ordination of nursing functions in clinical areas as per the Incident

Commander instruction based on Hospital Emergency Response Plan

RESPONSIBILITIES

1 Perform the described Job Activity

2 Wear Disaster ID Vest

3 Report to Hospital Operations Centre

4 Ensure staffing of key ward areas

5 Appoint and liaise with Senior Nurse:

6 Pre-op; Post-op; Theatres; ICU; Admissions; Outpatients etc

7 Determine immediate requirements of key area supplies and linen

8 Overall control of nursing staffing

9 Maintain nursing services throughout hospital for 24hr cover

10 Liaise with Hospital Command Team

11 Deployment of staff and incident team

12 Debriefing of Nursing Staff

13 Liaise with Emergency Centre Nurse Commander

When you have finished your tasking, report to your immediate superior


2. Emergency Department Nursing Personnel • Goal: Coordinate Hospital Emergency Centre Nursing response

RESPONSIBILITIES

1 Perform described job activity

2 Wear Disaster ID Vest

3 Liaise with Emergency Centre Incident Commander

4 Activate the needed staff nurses

5 With Emergency Centre Incident Commander, ensure appropriate disposal of

Emergency Centre patients

6 Prepare patient reception areas

7 Appoint senior nurses for priority 1,2 and 3 areas

8 Contact Senior Porter and Security

9 Prepare Patient Reception Areas

10 Prepare clinical areas Nurses

11 Adequate Emergency Centre staffing

12 Control nursing in clinical areas

13 Ensure adequate stores

10.9 The role of nurse towards Preparedness

Preparing for disaster is most important and occurs at different levels. At the hospital level

we need to:

Identify risks of possible disasters that may occur in the area

Build capacity to handle the disasters- estimate need, keep separate equipment,

supplies, earmark space, flowchart of patients, supplies and personnel

Identify resources that may be required in the event of a disaster.

Develop a simple yet flexible hospital Disaster plan- JOB cards for personnel to be

made.

Training and drills/rehearsals to implement the hospital disaster plan

Recording of drills and debriefing.

Functions include

1. Activation of the emergency operations plan of the hospital


2. Establishment of an emergency operations center, located within the hospital

3. Assessment of hospital capacity,

4. Surge capacity planning, Alternate care site area, marked and kept ready

5. Communications, internal within the health care team

6. Supply and resupply, Logistics maintained

7. Triage and treatment of casualties,

8. Establishment of support areas, and

9. Termination of the disaster state to allow for recovery and the return to normal activities.

Phases of disaster management

PREPARATION MITIGATION RESPONSE RECOVERY

Mitigation phase:

This comprises of activities undertaken by the hospital for lessening the

impact and severity of a potential disaster.

The activities are:

Simple flexible disaster plan

*Identify risks

*Build capacity

*Identify resources

Job card

Training/Rehearsal

Activation of hospital disaster plan

Decontamination\

Triage

Surge capacity

Surge capability

Treatment of victims

Traffic control

Communications

Supplies

Resumption of operations after an emergency

Routine care/treatment

Psychosocial issues

Rehabilitation


o Formation of an Incident Command System (ICS) – It establishes clear

responsibilities, authority, and reporting and communication pathways

for all personnel who would be involved in management of potential

disasters.

o ICS involves both horizontal and vertical reporting for ensuring quick

decision making.

o ICS is at different levels with one Unified Incident Command for the

whole region and a Hospital Incident Command for managing all

modalities of disaster management at the hospital level.

o Communication between the two commands is very important for

sharing of relevant information.

Location of Incident command post must be predetermined in a hospital

situation. It should be in a safe, secure zone with easy access to area of patient

care (Warm zone in area of operations in the field)

Exercises and Drills for successful implementation, testing and refining of the

hospital disaster plan. This is one of the most important components of

disaster planning. Formation of Disaster Teams who are trained and drilled

under simulated realistic conditions. Drills should focus on type of potential

disasters as per the Hazard Vulnerability Analysis for that area.

Identification of Gaps in the hospital disaster plan by frequent drills.

Drill scenarios to include scenarios of special need population- elderly,

children, burns and the disabled.

10.10 Specific procedures that need to be done include:

1. Disaster plan should be frequently tested and re-evaluated

2. List of personnel to be informed in the event of a disaster both in and out of

hospital

3. Plan for clearing for area for access, triage, treatment(red, yellow, green)

4. Making functional disaster wards-where? Staff? Supplies?

5. Storage of equipment and supplies in a standardized format and easily

accessible area

6. Movement of inpatients, criteria for early discharge


7. Must provide for Communication –how? Where? With whom? Loss of

telephone landline circuits and cellular networks can occur.

8. Hazard Identification and Risk Analysis (HIRA) to be done and used to guide

for arranging any special resources

9. Have job cards ready for all staff members

o Identification tags for casualties to be prepared

o Training of all health care personnel in principles of disaster

management and emergency preparedness.

o Personal protective equipment.

10. Medical response teams to be prepared

Bibliography

The disaster risk reduction framework is composed of the following fields of action,

as described in UN/ISDR's publication "Living with Risk: a global review of disaster

reduction initiatives", (2004, page 15):

UN/ISDR (2008). Disaster Preparedness for Effective Response: Guidance and

Indicator Package for Implementing Priority Five of the Hyogo Framework, Geneva.

(Disaster Preparedness and Response (Tintinalli's Emergency Medicine: A

Comprehensive Study Guide,)

Disaster Nursing and Emergency Preparedness: for Chemical, Biological, and

Radiological Terrorism and Other Hazards, Third Edition (2012-08-24)


Lesson 11

Medical Emergencies: Nursing Acute Fever, Environmental Emergencies and Poisoning

OBJECTIVES Upon successful completion of this lesson the emergency nurse will be able to:

Describe the care of patient with Acute Febrile illness

Perform Emergency Nursing Care for patients with Acute Febrile

Illness

Describe Emergency management of patient with environmental

emergencies and poisoning

Perform Emergency Nursing care of patients with Poison & Drug

overdose

In Emergency Department patients always present with manifestations and not Diagnosis,

hence it is important for the nurse to be aware and alert to identify appropriate management

especially in life threatening conditions.

The presentations seen in the chapter are as follows

I. Acute Fever

II. Environmental Emergencies

a. Hyper and Hypothermia

b. Envenomation

III. Poison Management

A. Clinical Perspective

B. Nursing Perspective

C. Skills Involved


Scenario 1: General Approach to Fever

A 40 year old man presented with High Grade fever for a week with altered sensorium

11.1 FEVER

Aim:

1. Early identification and treatment of life threatening causes of febrile illness i.e.

meningococcal meningitis.

2. Early initiation of treatment / clinical care and symptom management within

benchmark time.

Always focus on life saving along with diagnosis and treatment.

Primary Survey:

• Airway: Patency

• Breathing: Respiration rate, accessory muscle use, air entry, SpO2

• Circulation: Perfusion, BP, heart rate, temperature

• Disability: GCS, pupils, limb strength

Associated sepsis syndrome manifestations

11.2 Assessment Criteria: On assessment the patient should have one or more of the

following signs / symptoms:

Fever >37.5°C Rigors / Chills Malaise

11.3 Escalation Criteria:

Immediate life-threatening presentations that require escalation and referral to a Senior

Medical Officer (SMO):

1. Sepsis

2. Pregnancy


3. Diagnosis

4. Acut Hypotension & tachycardia

5. Immunosuppressed \ steroids

6. e confusion\ Agitation

11.4 Life threats associated with Fever

Presenting Complaints Clinical examination

Nursing Interventions

1. Duration and severity of

fever,

2. Associated chills and

rigors

3. Headache, vomiting,

4. Photophobia

5. Neck stiffness, 6. Altered mentation

7. Seizures 8. Sore throat, ear discharge

or pain over nasal sinus

areas

9. Cough, expectoration, ,

10. Hemoptysis

11. Pleuritic chest pain

12. Jaundice

13. Skin rash

14. Abdominal pain

15. Fluid intake and urine out

16. Recent surgery

vital signs: Pulse,

BP, respiratory

rate, temperature,

oxygen saturation

Patient’s overall

appearance (toxic

or not).

Capillary refill

time.

Examine eyes, face

and oral cavity for

anemia, jaundice,

cyanosis,

tenderness over

nasal sinuses,

tonsillar congestion

or presence of pus

points

Examine chest for

features of

pneumonia

(bronchial

breathing,

crepitation)

Always secure Airway,

Breathing, Circulation

Hydration

Hypothermic

interventions

appropriate the

temperature

Standard

precautions

Assist in

identifying the

cause

Evaporative

cooling

Antipyretics as per

the Medication

order

Antibiotics at the

earliest as per order

Counseling the

patient and


In acute fever the Warning signs associated with organ in Emergency

Respiratory Dyspnea, cough, phlegm or sputum, pleuritic pain Gastrointestinal Nausea, vomiting, cramping, diarrhea, anal pain/itching, blood Skin/soft tissue Pain, rash, red streaks, induration, drainage Musculoskeletal Pain on movement or palpation, swelling, inability to bear weight Genitourinary Dysuria, discharge, dyspareunia, pelvic pain

Examine

cardiovascular

system for murmur

or pericardial rub.

Lower intercostal

tenderness (sign of

underlying liver

abscess).

Elicit renal angle

tenderness or any

area of tenderness

in abdomen.

Palpate for

hepatomegaly and

splenomegaly.

Look for signs of

meningitis or encephalitis

(altered mental status, neck

rigidity, Kerning’s sign,

focal neurologic deficits,

papilledema).

relatives

Health education in

emergency

Alert for

contagious illness

needing isolation

Documentation

Watch out for regional seasonal fever such as

Dengue Chikungunya,

Malaria, scrub typhus,

leptospirosis typhoid.


Head and neck Nasal drainage, tooth, throat or ear pain, CNS difficulty swallowing, confusion, neck stiffness, vomiting, headache,

back pain

11.5 Emergency Nursing Care

11.6 HYPOTHERMIA Frostbite is assessed like burns: in 1st, 2nd, 3rd, and 4th degree injuries, with more

prolonged exposure

1st degree partial skin freezing

Erythema, edema, hyperemia. No blisters or necrosis.

Occasionally may desquamate in 5-10 days.

2nd degree full thickness skin freezing

Erythema, substantial edema, vesicles with clear fluid.

Blisters desquamate and form black eschars.

Numbness

3rd degree full thickness skin and subcutaneous freezing

Violacious / hemorrhagic blisters. Skin necrosis. Blue-gray

discoloration

Initially no sensation. Tissue feels like “block of wood.” Later may

feel pain, burning, throbbing, and aching.

4th degree Full thickness skin, subcutaneous tissue, muscle, tendon, and bone freezing

Associated signs Concerns Airway compromise

Epiglottitis, pharyngeal abscess

Respiratory distress

Pneumonia, empyema

Circulatory collapse

Septic shock

Altered mental status

Meningitis, encephalitis, brain abscess

Peritonitis Perforated bowel, cholangitis, abscess, spontaneous bacterial peritonitis, appendicitis.


Little edema. Initially mottled, deep red, or cyanotic. Eventually dry, black,

mummified.

May have joint discomfort.

“Wind chill”. For example, skin exposed to +5 Fahrenheit in a 10-mph wind will

cause freezing within 1 minute (equivalent to -25 F). At -30 F in a 16-mph wind,

freezing may occur in 30 seconds (equivalent to -80 F)!

Hypothermia is defined as a core temperature less than 35 C. 11.7 HYPERTHERMIA

1 Minor Heat Illnesses

i. Heat edema is a self-limited condition presenting as mild swelling, usually confined

to the lower extremities. Shoes may be tight.

Treatment consists of reassurance, elevation of the legs, and support hose. CHF is obviously

in the differential diagnoses.

ii. Heat cramps usually occur in young physically fit, but acclimatized patients. They

occur after vigorous exercise, affecting the most used muscle groups. There is usually

a history of copious sweat production and hypotonic fluid consumption.

Treatment consists of rest, removing the victim from the hot environment, and oral

rehydration. Acclimatized individuals produce sweat with large amounts of electrolytes. Once

adapted, the sweat produced is nearly pure water.

iii. Heat syncope is a true syncope event precipitated by prolonged exposure to hot

environments, particularly with standing still in “parade” posture. It is accelerated in

dehydrated patients, but is self-limited.

Treatment consists of continued supine positioning, leg elevation and oral or IV hydration.

Prickly heat seen in infants and occasionally in inter trigenous areas is often referred to as

heat rash or simply “heat” is nothing more than milia rubra.

Treatment includes washing with soap and water and keeping the area dry.

2 Severe Heat Illnesses i. Heat exhaustion is the first step in the progression into severe heat injury.


a. Moderate water and salt depletion and a light rise in temperature are

underlying problems. Symptoms include vague malaise, fatigue, and

headache.

b. Mental status is normal and core temperature is less than 40 C (104 F).

c. Vital signs will demonstrate tachycardia and orthostatic hypotension.

d. Examples of prime candidates for this type of illness are road construction

workers and roofers.

Treatment consists of rest, a cool environment (even just getting under a tree), and IV and

oral hydration.

Needs evaporative cooling

e. Fans and moist sheets placed over the patient or spraying water on patient with

fans blowing will rapidly cool the patient’s temperature.

f. These methods are preferable to ice packs being applied which are not only

uncomfortable, but also induce vasoconstriction which actually slows heat loss

and often induces shivering which may actually increase the patient’s

temperature.

g. Most of these patients will be healthy otherwise and may be discharged after

treatment; however, elderly patients and patients with electrolyte

abnormalities should be admitted.

ii. Heat stroke is a medical emergency.a. It is an extension of a continuum form heat exhaustion.b. It is hallmarked by altered mental status, most notably coma seizures, and

delirium. It is often divided into classic and exertion (See Table 3.).c. The typical example of classic heat stroke is that of an elderly person found

unresponsive in bed in a house with no air-conditioning and perhaps a ceilingfan running during a heat wave.

d. Diagnosis: The diagnosis of classic (non-exertional) heat stroke is madeclinically based upon

An elevated core body temperature (generally >40ºC [104ºF]), CNS dysfunction (e.g., altered mental status) and Exposure to severe environmental heat

3 Investigations: CBC, LFT, electrolytes, creatinine, urea, PT, PTT, CPK, Blood c/s, ABG, ECG,

CXR, Urinalysis


4 Management: Secure airway and breathing and circulation, Fluid resuscitation: IV crystalloids to be rushed in Cooling measures:

o Move to a cool environment o Start internal cooling via cold NS, NG ice cold saline or water o Evaporative cooling: Undress the patient, spray tepid water and cool by

fans blowing parallel to the body to maximize evaporative heat loss. o Correction of electrolyte abnormalities o Diagnosis and treatment of complications (eg, CNS dysfunction,

rhabdomyolysis, AKI, acute liver failure, DIC) Drugs to be avoided:

Anti-cholinergics, Anti-pyretics (will not help), α adrenergics (increases

peripheral resistance), Salicylates (may worsen platelet dysfunction), and large

dose of Paracetamol (may worsen hepatic damage)

11.8 Nursing Care:

Goals and Outcomes

The following are the common goals and expected outcomes for Hyperthermia:

Patient maintains body temperature below 39° C (102.2° F).

Patient maintains BP and HR within normal limits.

Nursing Assessment

Assessment Nursing Actions & Rationale

Identify the triggering factors. Determination and management of the underlying cause are necessary to recovery.

Monitor the patient’s HR, BP, and especially the tympanic or rectal temperature.

HR and BP increase as hyperthermia progresses. Tympanic or rectal temperature gives a more accurate indication of core temperature.

Determine the patient’s age and weight.

Extremes of age or weight increase the risk for the inability to control body temperature.


Monitor fluid intake and urine output.

If the patient is unconscious, central venous pressure or pulmonary artery pressure should be measured to monitor fluid status.

Fluid resuscitation may be required to correct dehydration. The patient who is significantly dehydrated is no longer able to sweat, which is necessary for evaporative cooling.

Review serum electrolytes, especially serum sodium.

Sodium losses occur with profuse sweating and accidental hyperthermia.

Nursing Actions: The following are the therapeutic nursing interventions for Hyperthermia:

Interventions Rationales

Adjust and monitor environmental factors like room temperature and bed linens as indicated.

Room temperature may be accustomed to near normal body temperature and blankets and linens may be adjusted as indicated to regulate temperature of the patient.

Eliminate excess clothing and covers. Exposing skin to room air decreases warmth and increases evaporative cooling.

Administer antipyretic medications as prescribed.

Antipyretic medications lower body temperature by blocking the synthesis of prostaglandins that act in the hypothalamus.

Oxygen therapy for extreme cases. Hyperthermia increases the metabolic demand for oxygen.

Encourage ample fluid intake by mouth.

If the patient is dehydrated or diaphoretic, fluid loss contributes to fever.

Provide additional cooling mechanisms commensurate with the significance of temperature elevation and related manifestations:

Noninvasive: cooling mattress, cold packs applied to major blood vessels

These measures help promote cooling and lower core temperature.

Evaporative cooling: cool with a tepid bath; do not use alcohol

Alcohol cools the skin too rapidly, causing shivering.

Invasive: gastric Lavage, peritoneal Lavage, cardiopulmonary bypass in an emergency

These invasive procedures are used to quickly lower core temperature. These patients require cardiopulmonary monitoring.

Modify cooling measures based on the patient’s physical response.

Cooling too quickly may cause shivering, which increases the use of energy calories and increases the metabolic rate to produce heat.


Raise the side rails at all times. This is to ensure patient’s safety even without the presence of seizure activity.

Start intravenous normal saline solutions or as indicated.

Intravenous normal saline solution replenishes fluid losses during shivering chills.

Educate patient and family members about the signs and symptoms of hyperthermia and help in identifying factors related to occurrence of fever; discuss importance of increased fluid intake to avoid dehydration.

Providing health teachings to the patient and family aids in coping with disease condition and could help prevent further complications of hyperthermia.

11.9. Poisoning

I. Clinical Perspective

II. Nursing Perspective

III. Procedures in Poison Management

11.10 Core principles of management of Acute Poisoning

1. Resuscitation and stabilization

2. Reduce exposure

3. Diagnose type of poison involved by history and examination (toxidrome) and simple

laboratory tests

4. Reduce absorption of poison by various gut decontamination methods

5. Enhance excretion of already absorbed toxin

6. Use of antidotes

7. Supportive treatment

i. Approach to a patient with Acute PoisoningPrimary care of the patient with poisoning is resuscitation and stabilization using ABC

approach. Other steps are undertaken concurrently (and not sequentially) following initial

resuscitation.


ii. Resuscitation and Stabilization

• The initial resuscitation in a patient with acute poisoning is the ABC and is similar to

any other emergency.

• If there is an external exposure to a chemical agent, decontamination may be done

after opening the airway.

iii. Specific consideration in ABCs

Comprehensive Evaluation & Treatment

The primary focus of the emergency care in managing patients with poison is Immediate life

saving intervention along with assessment. Airway, Breathing, Circulation and Elimination of

the Poison

I. Airway.

The absence of airway-protective reflexes in poisoning leads to airway obstruction because

of he flaccid tongue, pulmonary aspiration of gastric contents, or respiratory arrest.

Be alert for potentially compromised airway in all poisoned patients

Patient who is able to talk has stable airway, continue to watch for detoriation.

The gag or cough reflex is an indirect indication of the patient’s ability to protect the

airway

Always be prepared for intubation

Pre Oxygenation, Pre sedation, Preparation, Placement of the Tube, Confirm the tube position

and fix it. Provide assisted ventilation

Do not perform neck manipulation if you suspect a cervical injury.

Intubation of the trachea provides the most reliable protection of the airway, preventing

aspiration and obstruction and allowing for mechanically assisted ventilation

Be prepared to assist for Naso-tracheal intubation as well.

Check breathing sounds to rule out accidental esophageal intubation or intubation of the right

main-stem bronchus.

Ventilate the patient manually with 100% oxygen while awaiting full paralysis


II. BREATHING

Airway and breathing difficulties play in an important role in the morbidity and death in

patients with poisoning or drug overdose. Patients may have following complications:

Ventilatory failure, hypoxia, or Bronchospasm.

I. Ventilatory failure. Immediately commence oxygenation for the patient as Hypoxia may result in brain

damage, cardiac arrhythmias, and cardiac arrest.

Obtain measurements of arterial blood gases.

Assist breathing manually with a bag-valve-mask device or bag-valve endotracheal tube

device and connect to mechanical ventilator.

Set the ventilator for tidal volume as per the Emergency Physician’s instruction.

Monitor the patient’s response to ventilator settings frequently by obtaining arterial

blood gas values.

II. Hypoxia. Hypoxia can be caused by the following conditions:

Disruption of oxygen absorption by the lung (eg, resulting from pneumonia or

pulmonary edema).

Pneumonia.

Pulmonary edema.

Cellular hypoxia.

Carbon monoxide poisoning

Nursing Action:

Correct hypoxia. Administer supplemental oxygen as indicated based on arterial pO2.

Intubation and assisted ventilation may be required.

Assist in correction of pulmonary edema.


Avoid excessive fluid administration.

Administer diuretics as per Physician Instruction

III. Bronchospasm

Pharmacologic effects of toxins, eg, organophosphate or carbamate insecticides or beta-

adrenergic blockers.

Hypersensitivity or allergic reactions.

Nursing Action:

Administer supplemental oxygen. Assist ventilation and perform endotracheal intubation

if needed.

Administer emergency drugs as per instruction based the type of poison consumed

III. CIRCULATION

Check blood pressure and pulse rate and rhythm. Perform advanced cardiac life support

(ACLS) for arrhythmias and shock.

Maintain continuous Hemo-dynamic monitoring of the patient. Watch for arrhythmias

and drug associated changes. Notify the Physician immediately.

Start IV line, Collect appropriate samples and administer drugs as per the Instruction. Be

ready for assisting to start central Administer IV fluids as per the findings and vital signs

Perform urinary Catheterization for the patient. Monitor the Intake output record.

Watch for the color of the urine

Watch for Bradycardia, Tachycardia and atrioventricular (AV) block, through periodic

ECG assessment

Watch for and treat electrolyte balance appropriately

Watch for Hypotension & Hypertension. Maintain vital sign records


IV. ALTERED MENTAL STATUS

I. Coma and stupor

The most serious complication of drug overdose is an alteration of the level of

consciousness

Nursing Action

Maintain the airway and assist ventilation if necessary

Administer supplemental oxygen.

II. Seizures

A. Common manifestation and complication in many Poison and drug overdose patients.

Nursing Action

Maintain an open airway and assist ventilation if necessary

Administer supplemental oxygen.

Administer appropriate anticonvulsants.

11.11 Assessment & History

I. History. Mostly unreliable or incomplete, the history of ingestion may be very useful if

carefully obtained.

A. Collect history about all drugs taken, including nonprescription drugs, herbal

medicines, and

vitamins

B. Ask family members, other significant information necessary.

II. Physical examination

Toxidromic approach to Diagnose Type of Poison

A toxidrome is the constellation of signs and symptoms produced by a group of poisons

to which the patient has been exposed. To identify the toxidrome, a detailed history and


physical examination including vital signs, pupillary size, skin whether dry or moist and

bladder whether empty or full is performed.

Cholinergic Toxidrome

The commonest toxidrome in Indian setting is cholinergic toxidrome, produced by

organophosphate and carbamate insecticides, and chemical warfare agents like sarin and

soman. These agents inhibit cholinesterases leading to accumulation of acetylcholine at

various receptor sites.

The features of cholinergic toxidrome are muscarinic, nicotinic and CNS.

Muscarinic features (DUMBELS) Nicotinic features CNS features

• D – Diarrhea

• U - Urination

• M – Miosis (common)

• B – Bronchorrhea, Bronchospasm, Bradycardia

• E - Emesis

• L – Low blood pressure, Lacrimation

• S – Salivation, Sweating

• Mydriasis

(Uncommon)

• Tachycardia

• Muscle weakness

• Hypertension

• Fasciculations

• Confusion

• Coma

• Convulsions

The three ‘Bs’ of mnemonic for muscarinic effects are known as killer ‘Bs’.


• This toxidrome is produced by agents such as Datura, tricyclic antidepressants,

phenothiazines, antihistamines, anti-parkinsonian drugs and atropine. These agents

block the action of acetylcholine at muscarinic receptor sites

• This toxidrome is opposite to the muscarinic effects of cholinergic toxidrome.

• The patient develops tachycardia and cardiac arrhythmias, hypertension,

hyperthermia, mydriasis, dry eyes, dry mouth, dry and flushed skin, reduced bowel

sounds and retention of urine. CNS features include confusion, delirium, and seizures.

Sympathomimetic Toxidrome

• Sympathomimetic toxidrome is produced by amphetamines, cocaine, phencyclidine,

etc. Features are similar to those of anticholinergic poisoning, except that the skin is

wet and sweaty, there is no retention of urine and intestinal motility is normal.

Opioid toxidrome

• Opioid toxidrome is produced by opium, codeine, morphine, heroin, pethidine,

diphenoxylate

• (LomotilTM), tramadol, pentazocin, propoxyphene, hydrocodone, etc.

• The features are respiratory depression, hypotension, pin-point pupils and coma.

• Miosis is not present in all cases. In addition, mydriasis may occur in severely

poisoned patients secondary to hypoxia.

Sedative-hypnotic toxidrome

• Produced by benzodiazepines, barbiturates, alcohol, anticonvulsants, antipsychotics.

• Features include decreased level of consciousness, hypoventilation, hypotension and

bradycardia.

• Barbiturates also produce hypothermia and miosis.

Investigations

Electrocardiogram

ECG should be obtained in all patients with acute poisoning, especially tricyclic

antidepressants, digoxin, aluminium phosphide, organophosphate and cocaine. It can

also reveal associated electrolyte abnormalities.

Anticholinergic Toxidrome


Other laboratory tests:

Urine may show oxalate crystals in ethylene glycol poisoning. These crystals appear

like envelopes.

In methemoglobinemia, blood is chocolate in colour.

Anion gap: It is the difference between measured anion gap and calculated anion gap.

Anion gap is calculated as: Sodium – (Chloride Bicarbonate)

MUDPILES:

• M – Methanol, Metformin, Massive ingestions

• U – Uremia

• D – Diabetic ketoacidosis

• P – Paraldehyde • I – Iron, Isoniazid • L – Lactic acidosis • E – Ethylene glycol • S – Salicylates

11.12 DECONTAMINATION

I. Surface decontamination

A. Skin. Using personal protective equipment’s, body surface is rapidly cleaned

(Decontaminated) of the toxins that can be readily absorbed through the skin, and

systemic absorption can be prevented only by rapid action.

Remove contaminated clothing and flush exposed areas with copious quantities of

tepid (lukewarm) water or saline.

Wash carefully behind ears, under nails, and in skin folds. Use soap and shampoo for

oily substances.

B. Eyes.

Flush exposed eyes with copious quantities of tepid tap water or saline.

If the substance is an acid or a base, check the pH of the victim’s tears after irrigation

and continue irrigation if the pH remains abnormal.


C. Inhalation: Inhalation is difficult to decontaminate as it rapidly absorbs into the alveoli

Administer supplemental humidified oxygen

Observe for evidence of upper respiratory tract edema, manifested by a hoarse voice

and stridor and may progress rapidly to complete airway obstruction.

Observe for late-onset non-cardiogenic pulmonary edema because of slower-acting

toxins, which may take several hours to appear. Early signs and symptoms include

dyspnea, hypoxemia, and tachypnea

Gut decontamination should not be considered unless the patient has ingested a potentially lethal amount of a toxic agent within 4 hours.

Gastric Lavage

• If patient has altered level of consciousness, then the airway should be protected

before performing gastric lavage.

• A large-bore orogastric tube should be passed into the stomach with the patient in left

lateral position.

• Contraindicated in ingestion of caustics, and hydrocarbons.

Activated Charcoal

• The dose is 1-2 g/kg or a ratio of 10 parts of activated charcoal to one part of toxin,

whichever is higher.

• Certain toxins are poorly adsorbed to activated charcoal and include lithium, iron,

cyanide andhydrocarbons.

• It is contraindicated in caustic ingestion and presence of ileus.

Antidotes

This table gives a list of commonly used antidotes. If specific antidote is available, it should be administered as per the physician order

Antidote Specific Poison

Amyl nitrite, sod. nitrite,sodium

thiosulphate

Cyanide


Antivenin Snake bites

Atropine Cholinesterase inhibitors

Calcium gluconate Beta-blockers, calcium channel blockers,

fluorides

Deferoxamine Iron

Dextrose Hypoglycemia

Ethanol Methanol, ethylene glycol

Flumazenil Benzodiazepines

Magnesium sulphate Toxins producing prolongation of QT interval

Methylene blue Methemoglobinemia

N-acetylcysteine Paracetamol

Naloxone Opioids

Oxygen Carbon monoxide, cyanide, hydrogen sulphide,

other hypoxia-producing agents

Physostigmine Anticholinergics (severe)

Pralidoxime Organophosphates

Pyridoxine Isoniazid, ethylene glycol

Sodium bicarbonate Toxins producing prolongation of QRS

complexes

Supportive Treatment

The most important treatment for patients with poisoning is the supportive treatment:

Central nervous system - control of seizures and care of comatose patient

Cardiovascular system - control of hypotension and cardiac arrhythmias


Respiratory system - adequate oxygenation / ventilation

Support of renal function

Correction of fluid, electrolyte, and acid-base disturbances.

Correction of hypothermia or hyperthermia

Dialysis and Hemoperfusion

Hemodialysis is effective in removing dialyzable toxins including salicylates, lithium,

methanol, isopropanol, ethylene glycol, theophylline, and phenobarbital.

In addition, hemodialysis may be required in patients who develop acute kidney

injury following

Poisoning or who develop severe electrolyte imbalance. An example is lactic acidosis

associated with metformin toxicity.

11.13 General Management of Poisoning- Role of the Emergency Nurse

ABC – AIRWAY, & BREATHING

Intubate when low GCS (8 OR < 8) signs of upper airway edema or hemodynamic

instability. Elective intubation in case of Hair Dye poisoning and Endosulphan

CIRCULATION

o Echo and IVC diameter guided Fluid Therapy and vasopressors

o Refractory Hypotension –GIK and IABP

Gather information

Decontamination

Prevention of re exposure

Antidotes

Standard ICU care which includes DVT prophylaxis, stress ulcer prophylaxis,

nutritional supplementation, infection control and other supportive care.


Key Points Investigations Disposition Decontamination

Gastric Lavage Skin, Eye, Hair &

Body wash

In Emergency Room (5 G’s)

1. ABG Systemic Acidosis

2. CBG 3. ECG 4. USG 5. Beta HCG for

women

Never discharge without Psychiatry Counseling

Treat the patient and Not just the poison.

Additional injuries \Co morbid need to be attended

Activated Charcoal

First Dose 1 gm.\Kg Body weight

Subsequent dose 0.5 gm.

As per respective hospital guidelines Enhanced Elimination

Urinary Alkanilization

Hemodialysis CRRT


11.14. Skill

GASTRIC LAVAGE

Gastric lavage is a method of gastrointestinal decontamination, performed in the setting of an

ingested overdose or acute poisoning, to decrease the absorption of substances in the

stomach. If timed and performed appropriately, this technique can significantly reduce the

amount of ingestant available for absorption and thus effectively decrease the total dose

absorbed. An absolute contraindication to gastric lavage is a deteriorating level of

consciousness with loss of protective reflexes or an unprotected airway. In this setting the

airway must first be secured by endotracheal intubation. Gastric lavage can then be

performed once the airway is protected.

Contraindications for gastric Lavage

o Abnormal or absent pharyngeal/upper gastrointestinal anatomy

o Active or substantial antecedent vomiting

o Caustic ingestion

o Coagulopathy

o Decreased mental status , Inactive or diminished airway reflexes

o Large pills and Large or sharp foreign body

o Nontoxic or minimally toxic ingestion

o Significant aspiration risk (e.g., hydrocarbon ingestion

Equipment

o Pulse Oximeter

o Cardiac monitor

o Noninvasive blood pressure monitor

o Protective clothing

o Bite blocker

o Oral airway

o Emesis basin

o Suction source with suction catheter

o Funnel or large (50 to 100 mL) syringe

o Tap water or saline

o Bulb suction device or large syringe


o Water-soluble lubricant

o Orogastric Lavage tube (Boas tube)

o Resuscitative equipment readily available.

o The method described below is a passive open system method which uses gravity to

instill and drain the Lavage fluid.

Procedure

Informed consent should be obtained

Arrange necessary equipment’s

Supine position while on insertion the tube

Measure the length of oro-gastric tube from the tragus of the ear to the angle of the

mouth & down to the xiphisternum

Make the spot up to which to be inserted

Apply adequate jelly over the tube

Insert the tube gently & ask the patient to swallow.

If patient is restless or the Airway is at risk, Intubate.

Confirm the tube position by auscultation.

Press the Siphon & listen for the sound in the epigastrium

Position the patient left laterally with head end down.

Positioning the patient on right lateral may increase gastric emptying & absorption of

the poison.

First siphon & hold the funnel down to evacuate any gastric content

Dilute activated charcoal in tap water to make it slurry. Dose 1gm/kg BWT.

Administer charcoal slurry through the funnel end.

Pour 150ml of tap water holding the funnel higher up.

Keep the funnel end down & see for effluent.

Note the smell of the effluent.

If no effluent siphon. Repeat the steps till clear & odorless effluent comes out.

Insert a Ryle’s tube & remove the Boer’s tube to facilitate administration of Multi-

Dose Activated Charcoal for the next 48 hours.


Complications

o Cardiac dysrhythmias

o Electrolyte abnormalities

o Esophageal tear or perforation

o Gastric perforation

o Hypothermia

o Laryngospasm

o Nasal, oral, or pharyngeal injury

o Pneumothorax

o Pulmonary aspiration

o Tracheal placement

o Tube impaction

11.15 GROSS DECONTAMINATION

Decontamination is generally achieved by washing them thoroughly with copious

amounts of water after undressing patients completely. The linen used to dry patients

and patient clothing, shoes, socks, watches, and jewelry should be handled as

hazardous waste. Gross decontamination should occur prior to the patient's entry into

the ED or other areas in the hospital. In mass casualty exposures, this will typically

occur at a staging area adjacent to the ED .Eyes Ocular exposures should be treated

immediately by copious irrigation (usually 2 L) with NS.

Gross Decontamination

a. Evacuate the patient(s) from the high-risk area. b. Remove the patient's clothing. c. Perform a one-minute quick head-to-toe rinse with water.

Secondary Decontamination

a. Perform a quick full-body rinse with water. b. Wash rapidly with cleaning solution from head to toe. c. Rinse with water from head to toe.

Definitive Decontamination

a. Perform thorough head-to-toe wash until “clean”. b. Rinse with water thoroughly. c. Towel off and put on clean clothes.


Bibliography

Institute of Medicine (US) Committee on R&D Needs for Improving Civilian Medical

Response to Chemical and Biological Terrorism Incidents. Chemical and Biological

Terrorism: Research and Development to Improve Civilian Medical Response.

Washington (DC): National Academies Press (US); 1999. 7, Patient Decontamination

and Mass Triage. Available from: https://www.ncbi.nlm.nih.gov/books/NBK230674/

A compendium for the Emergency Department of CMC, Vellore Dr.KPP Abhilash, I

Edition 2016

Oral Poisonings: Guidelines for Initial Evaluation and Treatment,

LARS C. LARSEN, M.D., and DOYLE M. CUMMINGS, PHARM.D., East Carolina

University School of Medicine, Greenville, North Carolina

Am Fam Physician. 1998 Jan 1;57(1):85-92.

Heat Stroke: A Comprehensive Review, AACN Advanced Critical Care April/June

2004, Volume :15 Number 2 , page 280 - 293


Lesson 12

Surgical Emergencies- Nursing

Acute Abdomen

Objectives:

On successful completion of this lesson the Emergency Nurse will be able to

1. Identify life threatening surgical emergency of abdominal manifestations

2. Perform appropriate assessment and intervention towards lifesaving of the patient with acute abdomen.

3. Identify and prevent complications associated with acute abdomen.

4. Document appropriate assessment and interventions associated with Acute Abdomen.

Core concepts. Always Lifesaving precedes all other action. Priority will be Airway, Breathing, and

Circulation

Unstable patients should be resuscitated immediately, and then diagnosed clinically

with emergent surgical consultation.

Be prepared for providing appropriate emergency care in the event of emergency

surgery

Pain management is mandatory subsequent to the assessment of the patient.

Administer the antibiotics at the earliest as per Medication order.

I. Common surgical emergencies

a. Acute abdomen

Acute appendicitis

Acute cholecystitis

Biliary colic

DU perforation

Intestinal obstruction

Ureteric colic


Testicular torsion

Aortic dissection

Diverticulitis

Mesenteric ischemia

Large bowel perforation

Nonspecific abdominal pain

Gynecological

Ectopic pregnancy

Pelvic inflammatory disease

Rupture/torsion of ovarian cyst

Endometriosis

Mittleschmertz

Medical

Acute pancreatitis

Inferior wall MI

Peptic ulcer disease

Acute hepatitis

Diabetic Keto Acidosis

Urinary Tract Infection

Gastroenteritis

Irritable bowel syndrome

CLINICAL FEATURES

Consider immediate life threats that might require emergency SURGICAL intervention.

1 Identify time of pain onset; character, severity, location of pain and its referral,

aggravating and alleviating factors; and similar prior episodes.

2 Cardio respiratory symptoms, such as chest pain, Dyspnea, and cough;

3 Genitourinary symptoms, such as urgency, Dysuria, and vaginal discharge; and

any history of trauma should be elicited.


4 In geriatric patients keep a watch on Myocardial infarction, dysrhythmias,

coagulopathies, and vasculopathy.

The History collection will involve

past medical and surgical history,

medications, particularly steroids,

Antibiotics or non-steroidal anti-inflammatory drugs.

A detailed gynecologic history is indicated in female patients.

RED FLAGS (Warning Sign)

The physical examination should include the patient’s general appearance.

Inspect the abdomen for contour, scars, peristalsis, masses, distention, and pulsation.

Patients with peritonitis tend to lie still.

Rebound tenderness is an indicator for peritonitis, the combination of rigidity,

referred tenderness, and, specially, cough pain usually provides sufficient diagnostic

confirmation.

Evaluate the skin for pallor, jaundice, or rash.

Accurate vital signs are mandatory to identify life threatening situation such as

Hypovolemic shock.

The presence of hyperactive or high pitched or tinkling bowel sounds increases the

likelihood of small bowel obstruction.

Palpation is the most important aspect of the physical examination.

The abdomen and genitals should be assessed for tenderness, guarding, masses,

organomegaly, and hernias.

Carnett sign is useful and in abdominal wall pain

After identification of the site of maximum abdominal tenderness, the patient is asked to fold

his or her arms across the chest and sit up halfway. The examiner maintains a finger on the

tender area, and if palpation in the semi sitting position produces the same or increased

tenderness, the test is said to be positive for an abdominal wall syndrome.


Perform a pelvic examination in all post pubertal females.

In the rectal examination, the lower pelvis should be assessed for tenderness, bleeding, and

masses.

Conditions, somewhat less frequent but proportionately higher in occurrence, among the elderly include sigmoid volvulus, diverticulitis, acute mesenteric ischemia, and abdominal aortic aneurysm. Mesenteric ischemia should be considered in any patient older than 50 years with abdominal pain out of proportion to physical findings. Diagnosis

Laboratory Test Clinical Suspicion Amylase

Lipase

Pancreatitis

β-Human chorionic gonadotrophin

Pregnancy

Ectopic or molar pregnancy

Coagulation studies (Prothrombin time/

Partial thromboplastin time)

GI bleeding

End-stage liver disease

Coagulopathy

Electrolytes

Dehydration

Endocrine or metabolic disorder

Glucose

Diabetic ketoacidosis

Pancreatitis

Hemoglobin GI bleeding

Liver function tests

Cholecystitis

Cholelithiasis

Hepatitis

Renal function tests

Dehydration

Renal insufficiency

Acute renal failure

Urinalysis

Urinary tract infection

Pyelonephritis

Nephrolithiasis

ECG Myocardial ischemia or

infarction


EMERGENCY NURSING CARE AND DISPOSITION

Always Lifesaving precedes all other action. Priority will be Airway, Breathing, and

Circulation

Unstable patients should be resuscitated immediately, and then diagnosed clinically with

emergent surgical consultation.

1 Life saving

2 Preparation for Surgical Intervention.

3 Pain Management

4 Prevent complications

5 Documentation

Life Saving

Follow the NELS-N guidelines in assessing and assisting for life saving procedures.

The emergency nurse will be able to identify life threatening manifestations at the earliest so

be alert.

The emergency findings are to be notified to the attending emergency physician\ surgeon at

the earliest and documented.

Ensure the availability of the life saving and drugs and equipments by checking and replacing

at the beginning of every shift.

Fluid resuscitation

1. The most common resuscitation need for acute abdomen patients is intravenous fluids

with normal saline or lactated Ringer’s solution.

2. During the initial evaluation, the patient should be Nil Per Oral 3. Pain management is MANADATORY after complete assessment of the patient.

4. Do not sedate without complete assessment, since sedation can mask the findings.

5. Where necessary anti emetics can play an important role in prevention of dehydration

and electrolyte imbalance.

6. Antibiotic treatment can prevent the complications.


7. Surgical “acute abdomen” has been identified by the presence of pain, guarding, and

rebound as indicating a likely need for emergent surgery.

8. Indications for admission include toxic appearance, unclear diagnosis in elderly or

immune-compromised patients, inability to reasonably exclude serious etiologies,

intractable pain or vomiting, altered mental status, and inability to follow discharge or

follow-up instructions.

9. Continued observation with serial examinations is an alternative.

10. Many patients with nonspecific abdominal pain can be discharged safely with 12 to

24 hours of follow-up and instructions to return immediately for increased pain,

vomiting, fever, or failure of symptoms to resolve.

Flowchart for Emergency Nursing

Assessment of Vital signs (Airway, Breathing, Circulation, and Disability)

If Normal

Assessment with History Collection & Physical Examination

Evaluate the need for surgery

1. History a. Acute pain, sudden onset and progressive exacerbation

2. Physical Examination a. Visceral or somatic pain b. Location

3. Need Surgery a. Bleeding b. Organ ischemia c. Pan peritonitis d. Acute inflammation of abdominal Viscus

4. History a. Chief complaint – Pain, fever, nausea, vomiting, diarrhea, melena, anuria b. Medical history – on any medication, previous surgery, coronary artery

disease, diabetes, hypertension, allergy c. Smoking, alcohol, others.

5. Physical Examination a. Signs of peritonitis b. Operative scar, hernia, pulsatile mass, palpitation of radial, femoral pulse


6. Laboratory test and imaging a. ABG b. PaCo2, ph, BE, HCo3, BS, Lactate c. ECG d. Blood\Urinalysis

i. CBC, Electrolyte, liver function, renal function, lipase, amylase, blood glucose level, CRP, Troponin, HBV, HCV, Blood Culture, Gestation test

7. Abdominal Ultrasonography, a. Enhanced CT OR Plain Xray

If ABNORMAL

1. Stabilization of physiologic state, emergency examination and if need be transfer to higher center

a. Secure ABC b. IV Cannulation (Rapid Transfusion) c. Portable chest x ray d. ECG and ongoing monitoring of the patient e. Abdominal Ultra Sound f. Abdominal CT (based on availability)

2. Diagnosis a. Urgent b. AMI c. Ruptured Abdominal Aortic Aneurysm (AAA) d. Pulmonary Embolism e. Aortic dissection f. Ectopic pregnancy g. Intestinal Ischemia h. Severe acute cholangitis i. Peritonitis with septic shock

3. Emergency Surgery


NURSING ACTIONS

Measure patient’s vital signs: Temperature, Pulse Respiration

Blood pressure- manual and machine

Neurological checks (orientation to time, place,

person; response to directions and painful stimuli, pupillary

reaction, extremity movement)

Weight

Administration of oxygen- set up, initiate and administer: Nasal Cannula

Face mask

Venturi mask

Non rebreathing mask

3. Blood products: Check, administer, and document blood product administration

Monitor patient during administration

Watch for transfusion reaction

Support and Maintain Nutritional Requirements

1.TPN, PPN, intra-lipids – administer and document

2. Tube feeding - check for placement, administer feedings, check and record residual

Nasogastric

Gastrostomy

Jejunostomy

3. Intravenous therapy (peripheral, intermittent infusion devices):

Verify order

Insert line/device and label dressing

Label bag and tubing

Calculate and regulate rate

Flush intermittent infusion device

Assess and document site condition.

4.Central line/Peripherally inserted central line

(PICC) catheter care:

Assess, change dressing, document site, condition


Maintain Infection Control (routine practices): 1. Hand washing 2. Isolation protocols 3. Universal precautions 4. Sterile dressing changes

5.Gowning, gloving, masking

Document Patient Care:

1. Admission nursing assessment. 2. Activity flow record

3. Nursing treatment

4. Fluid balance record

5. Medication administration record (MAR)

6. Integrated progress notes

7. Pre-op checklist

8. Pre-/postoperative teaching record 9. Informed consent

10. Transfer summary

11. Restraint flow sheet

12. Discharge nursing assessment

13. Patient discharge instructions


Bibliography https://teachmesurgery.com/general/presentations/acute-abdomen/

Nursing the Acute Abdomen Patient,

Paul Aldridge BVSc, Cert SAS, MRCVS Louise O'Dwyer MBA, BSc(Hons),

VTS(ECC),

Book Author(s): Paul Aldridge BVSc, Cert SAS, MRCVS Louise O'Dwyer MBA,

BSc(Hons), VTS(ECC),

Sheehy's Emergency Nursing, Principles and Practice, 7th Edition, Emergency Nurses

Association, 2019

Fast Facts for the ER Nurse, Third Edition: Buettner RN CEN, Jennifer,2017.


Chapter 13: Neonatal and Paediatric Emergencies

Topic Neonatal and Paediatric Emergencies Objectives: Upon completion of the lesson the trainee would be able to:

Triage all sick new born and children and prioritise according to the severity of the condition immediately

Provide initial nursing management Start resuscitation


Chapter 13: Neonatal and Paediatric Emergencies Introduction Triages helps us to identifying children with life-threatening conditions and help the medical personnel to take prompt action in a systematic way so as to improve the survival and outcome of these patients timely. NELS Approach to the sick children

1. The initial step in assessing children referred to a hospital should be triage – the process of rapid screening to decide to which of the following group(s) a sick child belongs (chart 1):

First assess every child for emergency signs and provide immediate emergency treatment if present.

If emergency signs are not present, look for priority signs. Those with priority signs is seriously ill and needs immediate assessment and treatment.

Children with no emergency or priority signs are treated as non-urgent cases 2. Once emergency signs are identified, prompt emergency treatment needs to be given

to stabilize the condition of the child. 3. After the child is stabilized, take a detailed history and perform examination relevant

to the presenting problems. 4. Perform relevant laboratory investigations.


Triage chart

In Children with Emergency Signs assess is done based on the following sequences and take actions as per priority: A: Appearance and Airway Assess airway and ensure patent protected airway B: Work of breathing. Assist breathing and maintain oxygenation C: Circulation. Assess and Manage shock, Level of consciousness. Assess and manage coma, and convulsions. D: Assess and manage severe dehydration in a child with diarrhoea. E: Events happened and environment control especially temperature of the baby

How to Triage

Keep in mind the ABCD steps: Airway, Breathing, Circulation, Coma, Convulsion, and Dehydration. Make sure that the child is warm at all times (chart 2). In view of the poor outcome in many small infants and severely malnourished children due to co-existent hypothermia and hypoglycaemia, the management this is important before ABCD. Efforts should be made to maintain blood sugar level and normothermia while managing ABCD. For assessment follow the steps to check the emergency signs

1. T-TEMPERATURE 2. A-AIRWAY 3. B-BREATHING 4. C-CIRCULATION, COMA, CONVULSION 5. D-DYARRHOEA




13.1 TEMPERATURE Initial step in managing sick new born and children are maintaining temperature. Normal temperature is 36.5ºC-37.5°C. Assessment of Temperature by Touch Baby's temperature can be assessed with by touching his/her abdomen, hands, and feet with the dorsum of hand. In case of cold stress feet are cold and abdomen is warm, on the other hand in case of hypothermia, both feet and abdomen are cold to touch. Take axillary temperature of a new born by placing the bulb of thermometer against the roof of dry axilla and keep baby's arm close to the body to hold thermometer in place for three minutes. Consequences of hypothermia In hypothermia baby uses a lot of energy to keep himself warm. A cold baby:

Is less active, poor feeding, weak cry, has respiratory distress, has risk of becoming hypoglycaemic.

As soon as a sick child is brought with severe hypothermia (temperature below 35.5ºc or who is cold to touch) start nursing intervention soon

Nursing management for maintain temperature

ASSESSMENT ACTION REMARKS /SKILL

General assessment for T-Temperature A-Air way B-Breathing C-Circulation, Coma & Convulsion D –diarrhoea Focused assessment for hypothermia and its symptoms

Environmental setups: Always keep the room ready to accept hypothermic and sick child with all lifesaving drugs and equipment and with normal room temperature.

Keep the infant dry and well wrapped. Remove wet clothes if any

Put Cap, gloves and stockings to reduce heat loss.

Use nesting and cling wrap to prevent heat loss Make sure that there is no heat source directed

straight at the new born except radiant warmer or open care system.

Keep the baby under a radiant warmer to bring the babies temperature to 36.5ºc.

In case of severe hypothermia, nurse under radiant warmer/open care system with manual mode to increase the body temperature up to 36 0C then turn into servo mode

While using manual mode, record baby’s temperature half hourly to prevent over heating

Keep the baby in draught free area

Set room temperature between 24-29 0C (depends upon climate) Attach skin probe over the right hypochondrium area in the supine position and to the flank in the prone position (Ref annexure-3)


Once the baby became normothermic check temperature 2 hourly

Provide psychological support to the parents and relatives

Maintain record and reports

Hyperthermia Remove extra clothes and allow the body expose to room temperature if the temperature is ˃ 1000F give antipyretics, calculate the dose according to body weight (10-15mg/kg/dose) Tepid sponging can be done if needed to prevent febrile convulsion Nursing management for Hyperthermia ASSESSMENT ACTION REMARKS /

SKILL General assessment for T A B C D Focused assessment for hyperthermia

Manage the condition based on assessment Remove extra clothes Give antipyretics if body temperature

is ˃ 100 0F Give tepid sponging to keep body

temperature within normal range to prevent febrile convulsion

Assist for investigation to rule out underlying cause

Administer medications as per order Reassure the child and relatives

using soft skills Provide psychological support Maintain record and reports

Follow standard Protocol for the administration of antipyretics eg: - Paracetamol oral dose 10-15 mg/kg/dose can be repeated every4-6 hours

13.2 CHECK AND TREAT HYPOGLYCAEMIA Check for blood glucose in all sick children and infants:

If hypoglycemia detected (hypoglycaemic if blood sugar is < 45mg/dl for young infants and <54mg/dl in older sick children beyond 2 months), give I/V bolus dose of 10% dextrose, in the dose of 2ml/kg for young infants, and 5ml/kg for older children.

If you cannot measure blood glucose, give bolus dose as above.


Nursing management for Hypoglycaemia

ASSESSMENT ACTION REMARKS / SKILL

General assessment of T A B C D Focused assessment for sign of hypoglycaemia

Not active poor

sucking weak cry

Initial Manage same for all case Keep the child warm Remove wet clothes if any

Take a sample using heel prick to check blood sugar and carryout the intervention based on the blood sugar level and order

Insert IV cannula (collect blood sample for investigation) if needed

Administer I/V bolus of 10% dextrose (2ml/kg for young infants, and 5ml/kg for older children).

Assist for further management Start maintenance fluid as ordered Maintain blood sugar chart Maintain records and reports Reassure the relatives

Check blood glucose for all children presenting with emergency sign. Heel prick method is used for quick assessment of hypoglycaemia hypoglycaemia defined as < 45mg/dl for young infants and < 54mg/dl in older sick children beyond 2 months)

13.3 AIRWAY & BREATHING Managing Airway and Breathing The letters A and B in “ABCD” represent “airway and breathing”. If there is no problem with the airway or breathing, you should look for signs in the areas represented by C. To assess if the child has an airway or breathing problem you need to ask yourself: • Is the child breathing? • Is the child blue (centrally cyanosed)? • Does the child have severe respiratory distress?

Infants <2 months

The process of resuscitating gasping or apnoeic baby below 2 months is same as that at birth. Most babies breathe spontaneously but one in twenty babies might require help with breathing at birth. Up to half of them (who require resuscitation) have no identifiable risk factors before birth. Hence, resuscitation must be anticipated at each birth. At least one personnel who is skilled in new born resuscitation should be present in delivery area/emergency area. An increased risk of breathing problems may occur in babies who are:


Preterm Born after long traumatic labour Born to mothers who received sedation during the late stages of labour

Any baby can have breathing difficulty at birth. It is important to anticipate and be prepared for managing such deliveries, which include environment preparation -having warm corner to do the resuscitation, keep all equipment and supplies ready.

Chart-3 Silverman Score Chart

FEATURE SCORE-0 SCORE-1 SCORE-2

Chest movement Equal Respiratory Lag Seesaw Respiration

Intercostal Retraction None Minimal Marked Xiphoid Retraction None Minimal Marked Nasal Flaring None Minimal Marked Expiratory Grunt None Audible with Stethoscope Audible


Chart-4: Airway and breathing

PREPARING FOR RESUSCITATION Preparation includes environmental and articles as follows: - 1. A draught free, warm room with temperature 26-28 0C 2. A clean, dry and warm delivery surface 3. A radiant warmer/open care system 4. Two clean, warm towels/clothes, with cord clamps or threads/tie 5. A folded piece of cloth (Shoulder roll) (1/2 to 1-inch thickness) to position the baby 6. Neonatal resuscitation bag (250-500 ml) with oxygen reservoir 7. Face masks, term (1) and pre-term (0) sizes 8. Suction devices with pressure set at 80 to 100 mm Hg & catheters, No. 12FG, 14 FG

(oral suction), or a mucous extractor (Single use) 9. A Feeding tube with the 10-20ml syringe in case prolonged ventilation is needed 10. Oxygen with flow meter and tubing (if available) 11. Oxygen air blender (if available) 12. Pulse oximeter (if available) 13. A clock with second hand 14. Stethoscope for evaluation 15. Crash cart with all equipment and Medications (Epinephrine, normal saline) for

resuscitation 16. Identification band 17. If baby is not breathing/crying at birth, start resuscitation as per NRP guidelines.

(flow diagram given below)

ASSESS AIRWAY AND BREATHING

Not breathing at all/gasping/obstructed breathing/central cyanosis

Severe respiratory distress

IF NOT BREATHING/GASPING

Rule out neck trauma Manage airway Provide basic life

support IF FOREIGN BODY ASPIRATION

Manage airway in choking child

IF NO FOREIGN BODY ASPIRATION

Manage airway Gove oxygen Make sure child is warm


Chart -5: Neonatal Resuscitation


Infant and Child BLS

The principles of BLS in infants and children remain the same as in adults, with only a few differences that are outlined below.

1. To check for responsiveness, tap on the heel of the infant’s foot or the child’s shoulder and shout for help.

2. If the victim is breathing normally and has a pulse, he/she should be monitored till medical help arrives.

3. For pulse check, feel the brachial artery in infants and the carotid or femoral artery in children. Check pulse for at least 5 seconds.

4. In case the victim is not breathing but has carotid pulse, then rescue breaths should be provided every 3 seconds (about 20 breaths/minute). Check for pulse every 2 minutes.

5. If the victim is not breathing or is gasping and there is no pulse or the pulse rate ≤60/min with signs of poor peripheral perfusion, then start CPR. Follow the CAB sequence: Compression- Airway- Breathing. In case of a single rescuer, give cycles of 30 compressions and 2 breaths. If there are two or more rescuers, use compression to ventilation ratio of 15:2. Switch roles after every 5 cycles (In case of a single rescuer, in case of two rescuer switch after every 10 cycles)

6. Use the AED as soon as it is available. Continue CPR until help arrives or the victim starts to breathe or move.

*Signs of poor peripheral perfusion

Look: a) Skin appears pale, mottled or cyanosed. b) Altered consciousness. Feel: a) Cold hands and feet. b) Weak pulses. Follow the steps for new born resuscitation*

If baby is not breathing, clamp and cut the cord immediately and Call for help Shift the baby under radiant warmer/open care system Position the baby in slight neck extension (sniffing position) using a shoulder roll If there is thick meconium and the baby is unresponsive(non-vigorous), suction

should be carried out before drying the baby Dry the bay Reposition Assess the breath and heart rate for 6 seconds Apply approximately sized mask (term (1) and pre-term (0) sizes) correctly

covering the mouth and nose up to chin Start providing positive pressure ventilation (PPV) or bagging. Start with 5

prolonged inflation breaths (lasting 2-3 seconds) If chest rise is see it indicates correct technique


If chest does no rise, check for correct position, look for leak from the face mask /seal and give 5 inflation breath again

Assess breathing and heart rate (using two finger techniques to check code pulse) for 6 seconds. Apply pulse oximeter and connect to the machine (if available)

If the baby is not breathing well and /of HR˂100/mt continue PPV (baging) for 30 seconds at a rate of 40-60 breaths/mt (call out 1,2, squeeze)

Provide O2 if available. Extra precaution for new born, always try to keep O2 saturation between 90-95%(too much oxygen to a new born especially pre term, can cause serious retinal damage and blindness)

If baby breathing well and HR˃100 refer for observational care, asking for help for detail resuscitation

If no improvement, continue bag and mask ventilation and prepare for referral to appropriate centre. Continue bagging.

Basic Life Support (Children older than 2 months) Basic Life Support for a young infant is different from that of an older child because of differences in anatomy and physiology. The following sections refer to children older than 2 months. To assess the child is breathing or not follow the steps, • Look: If active, talking, or crying, the child is breathing or not and see whether the chest is moving. • Listen: Listen for any breath sounds. • Feel: Feel the breath at the nose or mouth of the child If the child is not breathing, manage the airway and support breathing artificially by ventilating the child with a bag and mask and continue further steps. Management of airway in a child with gasping or who has just stopped breathing

Always ask and check for head or neck trauma before treating to avoid further injury during assessment or treatment.

It is also important to know the child’s age because you will position an infant (under 2 months of age) differently from an older child. Positioning to improve the Airway when no neck trauma suspected


If the child conscious If the child unconscious Inspect mouth and remove foreign

body, if present. Clear secretions from throat using

suction catheter. Let child assume position of

maximal comfort. Give Oxygen. Continue with further assessment.

Open the airway by Head tilt and Chin lift method.

Inspect mouth and remove foreign body, if present

Clear secretions from throat Check the airway by looking for

chest movements, listening for breath sounds and feeling for breath

Head tilt-chin lift manoeuvre (Fig 1) The neck is slightly extended and the head is tilted by placing one hand on to the child’s forehead. Lift the mandible up and outward by placing the fingertips of other hand under the chin. Infant Older Children

Fig-1 Position for opening airway Positioning to improve the Airway when neck trauma suspected To limit the risk of aggravating a potential cervical spine injury, open the airway with a jaw thrust while you immobilize the cervical spine. It is safe to use in cases of trauma for children of all ages. If Neck trauma suspected (possible cervical spine injury)

1. Stabilize the neck(figure14) 2. Inspect mouth and remove foreign body, if present 3. Do suction to clear secretions from throat 4. Check the airway by looking for chest movements, listening for breath sounds, and

feeling for breath


Jaw thrust manoeuvre (Fig 2) The jaw thrust is achieved by placing two or three fingers under the angle of the jaw on both sides, and lifting the jaw upwards and outward. The jaw thrust manoeuvre is also used to open the airway when bag-mask ventilation is performed. If after any of these manoeuvres the child starts breathing, an oropharyngeal / naso pharyngeal airway should be put and start oxygen.

Fig 2: Using Jaw thrust without head tilt Ventilate with Bag and mask If the child is not breathing even after the above manoeuvres or if spontaneous ventilation is inadequate (as judged by insufficient chest movements and inadequate breath sounds), ventilate with a self-inflating bag and mask. During bag and mask ventilation a “sniffing” position without hyper-extension of the neck is usually appropriate for infants and toddlers. For older children ( more than 2 years) give padding under the occiput to obtain optimal airway position. Infants need padding under the shoulder to prevent excessive flexion of the neck that occurs when their prominent occiput rests on the surface on which the child lies. In correct sniffing position, the opening of the external ear canal should be in line with or in front of (anterior to) the anterior aspect of the shoulder. Extreme hyperextension of the infant neck can produce airway obstruction (Fig 3). Bags and masks should be available in different sizes for the entire paediatric range (mask size 0, 1 and 2 and bag size 125cc-750cc).


Fig 3: Bag and mask ventilation, correct size face mask

It is important for the mask to be the correct size for the child; it must completely cover the mouth and nose without covering the eyes or overlapping the chin. The correct size and position are shown in the figure 4 Self-inflating bags of minimum volume 250-500ml should be used. Use force and tidal volume just enough to cause the chest to rise visibly. Reservoir and oxygen (5-6 L/min) should be connected to the self inflating bag during resuscitation. Call for help in any child who needs Bag and mask since some of these children may additionally need chest compression. If ventilation is ineffective follow the steps:(remember the mnemonic-MRSOPE)

M-Reapply mask R-Reposition the head S-Suction the throat O- keep mouth slightly open P-Increase the pressure E-Do endotracheal intubation if skilled


Chest compressions The technique for chest compression is different for a child under 1 year and those between 1-8 years:

Chest compression in the infant (less than 1 year of age) There are two techniques for performing chest compression. These techniques are:

a) 2-finger technique(figure -5), where the tips of the middle finger and either the index finger or ring finger of one hand are used to compress the sternum, while the other hand is used to support the baby’s back (unless the baby is on a very firm surface).

b) Thumb technique, (fig-6)in this method 2 thumbs are used to depress the sternum, while the hands encircle the torso and the fingers support the spine.

Fig 4: Two finger technique of chest compression

Important point to remember

Compress the lower half of the sternum but do not compress over the xiphoid. After each compression allow the chest to recoil fully because complete chest re-expansion improves blood flow into the heart.

“Push hard”: push with sufficient force to depress the chest approximately one third to one half the anterior- posterior diameter of the chest.

“Push fast”: push at a rate of approximately 120 compressions per minute. Minimize interruptions in chest compressions.

Fig 5: Thumb technique


• Avoid giving compression and ventilation simultaneously, because one will decrease the efficacy of the other. Therefore, one ventilation interposed after every third compression, for a total of 30 breaths and 90 compressions per minute Chest compressions for the child (1 to 8 years of age) (Fig 7)

Place the heel of one hand over the lower half of the sternum. Lift your fingers to avoid pressing on the ribs.

Depress the sternum 1/3 to 1/2 of the depth of the chest. This corresponds to a 1 to 1-½ inches.

Compress at the rate of approximately 100 times per minute.

Fig 6: chest compression for the child

Use of AED in infants and children (Figure 8)

1. Ideally child pads should be used for infants and children< 8 years of age. 2. Anterolateral pad placement is used in children while in infants, the pads are placed

anteroposteriorly (see figure 8). 3. As lower energy dose is often needed in infants, a manual defribrillator should be

used in infants. If not available, an AED with a pediatric dose attenuator can be used. If neither is available, one can use an AED without a pediatric dose attenuator.

Figure 7: Anteroposterior pad placement in an infant.


Important points to remember in infant and child BLS 1. In case of an unwitnessed collapse, give 2 minutes of CPR and then leave the victim to activate the emergency response system and get the AED. 2. In case the victim is not breathing but has a pulse, then rescue breaths are given at the rate of about 20 breaths/minute (one breath every 3 seconds). 3. CPR is given even when the pulse rate ≤60/min with signs of poor peripheral perfusion. 4. In case of a single rescuer, the compression to ventilation ratio is 30:2, while in 2 or more rescuers, it is 15:2. Setting up of IV access and Use of drugs Set up an intravenous access preferably using a large peripheral vein, in case the patient does not have an intravenous line in place. Some children may require intraosseous access in case IV access is not possible. Adrenaline 0.1ml /kg (1: 10,000) intravenous can be used in a child who does not respond to initial ventilation and chest compressions and his pulses are absent. Two such doses can be used 3-5 minutes apart. The outcome of babies who do not respond to 2 doses of adrenaline is generally poor but the continuation of therapy may be done in situations where expertise is available or condition is potentially reversible like poisoning, hypothermia, pneumothorax, etc. The decision to terminate resuscitation rests with the treating physician which is usually based on assessment of etiology, time from arrest to CPR and co-morbid disorders. If the condition of the child improves, (s) given oxygen and start fluids according to the assessment and physicians order. An unconscious patient should be placed in recovery position. An airway may be placed if the child is unable to maintain airway. Bag and mask ventilation is a very effective way of ventilation if done correctly. If the nurse has the necessary skills and equipment, airway can be secured by endotracheal intubation. You should call for help or more trained hands by this time. Setup an intravenous or an intraosseous line for use of any drugs, where needed


For Airway, Nursing Management Breathing and Circulation ASSESSMENT ACTION REMARKS General assessment of T A B C Focused assessment for Airway, Breathing and Circulation look: whether the chest is moving. • Listen: Listen for any breath sounds. • Feel: Feel the breath at the nose or mouth of the child

Focused assessment Look: If active, talking, or crying, the child is obviously breathing. If none of these, look again to see whether the chest is moving. • Listen: Listen for any breath sounds. • Feel: Feel the breath at the nose or mouth of the child

Initial management same as of 13-1(a) Environmental preparation

Normothermic, draught free area for resuscitation

Equipment Suction and oxygen supply

Call for help Initiate resuscitation and team management be with the team Get ready with resuscitation trolley (crash cart) Pre assign the role of each team member Follow the steps of neonatal resuscitation Cut the cord place the baby under warmer care Dry the baby Do suction if secretion present with pressure 80-100mmof Hg /manual suction If no response repositions the baby using shoulder roll Initiate bag and mask ventilation with adequate amount of O2 (adjust flow rate according to SpO2 ) Check cord pulse if ˃60/mt Initiate chest compression using two finger/thumb technique Assist for inserting IV cannula/ umbilical catheterisation / intraosseous Give injection adrenaline 0.1ml/kg (1:10000) Communicate with the team members during each step of the procedures Carry out the order to treat underlying cause More vigilant while preparing and administering medications Assist for ento- tracheal intubation if needed use AED if needed (pads are placed anteroposteriorly in infants) Time to time information about the condition to the relatives Recording and reporting Timely referral and prompt action

Ref annexure-1 for new born resuscitation algorithm Refer Annexure -5 for crash cart Counting squeeze------ two ----------three Depress the sternum 1/3 rd of the anterior- posterior diameter of the chest (about 4cm). Use size and age appropriate articles for the child Make sure that there is extra battery and AED Machine is in working condition Use Head tilt-chin lift maneuver –if no neck injury and chin lift maneuver for suspected neck injury


Brief history of Fall or other trauma

Children aged 1-8years Open air way using pad under occipital region Do suction if secretion present with pressure 80-100mmof Hg Check for any visible foreign body inside the mouth if resent remove using magil forces Initiate bag and mask ventilation Follow the steps of resuscitation Use AED if needed (Anterolateral pad placement is used in children) Assist for intubation and fixing up of the ET tube –if needed Time to time information about the condition to the relatives Recording and reporting Timely referral and prompt action After care of instrument

Severe Respiratory distress It can be seen as respiratory difficulty in breathing while talking, feeding or breastfeeding. Child can be seen breathing very fast, with severe lower wall In-drawing, or using the accessory muscles for breathing which cause the head to nod or bob with every inspiration. Certain noises like stridor and grunting can also be heard. A harsh noise while breathing in is called stridor, a short noise when breathing out in young infants is called grunting. Stridor in a calm child and grunting are signs of severe respiratory distress.

Signs of severe respiratory distress Respiratory rate ≥ 70/min - Severe lower chest in-drawing - Head nodding - Grunting - Apnoeic spells - Unable to feed - Stridor in a calm child - Central Cyanosis at room air

Management of a child with severe respiratory distress Assessment 1. Look: - Count respiratory rate in one minute. . Look for chest indrawing. 2. Listen: For stridor when the child is calm. 3. Feel: For the movement of air through nose, mouth.


Management 1. Maintain airway and start oxygen. 2. Provide assistance for ventilator support if already in respiratory failure. 3. Treat underlying cause. Common causes of respiratory distress in children are:

Respiratory: Pneumonia, bronchiolitis, laryngotracheobronchitis, bronchial asthma.

Cardiac: Congestive cardiac failure due myocarditis, congenital heart diseases like VSD, PDA and severe anemia.

Foreign body aspiration.

Giving Oxygen to a child with respiratory distress

A child with cyanosis or severe respiratory distress is put in a comfortable position of his choice and given oxygen. In these children, oxygenation is given with a hood (8-10 L/min) or a face mask (5-6 L/min). When the child improves, catheter/prongs can be used for oxygen delivery.

In neonates, initiate minimum oxygen flow as per need to maintain SpO2 between 90 to 94%.

Monitor the baby for signs of improvement (respiratory distress i.e. respiratory rate, intercostal recession, grunt, colour) with DVM/silverman scoring (scoring for respiratory distress in newborn)

In preterm babies with Respiratory distress usually start CPAP at birth. Sources of oxygen to treat hypoxemia are: Oxygen concentrators and Oxygen-filled cylinders.


Oxygen Delivery

Give oxygen to a child in a non-threatening manner as anxiety increases oxygen consumption and possibly respiratory distress. If a child is upset by one method of oxygen support, attempt should be made to deliver the oxygen by an alternative technique. It is important to have the proper equipment to control oxygen flow rates. Oxygen can be administered through different methods like nasal prongs, nasal catheters, masks, oxygen hoods etc

Nasal Prongs These are short tubes inserted into the nostrils . Prongs come in different sizes for adults and children In newborns, appropriate size prongs, fitting well should be used as large size can cause

blanching of the alanasi and injure the nose If only adult-size prongs are available, and the outlet tubes are too far apart to fit into the

child’s nostrils, cut the outlet tubes off and direct the jet of the oxygen into the nostrils. A flow rate of 0.5-1 litres/min in infants and 1-2 litres/min in an older child to achieve

target saturations is used. Nasal prongs are preferred over nasal catheter for delivering oxygen to young infants

and children with severe croup or pertussis as catheters can provoke paroxysms of coughing.

Place them just inside the nostrils and secure with a piece of tape on the cheeks near the nose.

Take care that the nostrils are kept clear of mucus, which could block the flow of oxygen.

Fig 8: Giving oxygen by nasal prongs.

Oxygen hood and face mask Face Mask (need flow rates 5-6 litres/min) or Oxygen hood (need flow rates 8-10 lit/min) are good devices to achieve oxygenation in severely distressed and in emergency situations. • Place a hood over the baby’s head. Ensure that the baby’s head stays within the hood, even when the baby moves. However, the hood is a rather wasteful manner of oxygen delivery and should not be used routinely used for permanent oxygen delivery. • An alternative method in emergency settings is the use of a face mask. • Using hood with low flow of oxygen can lead to rebreathing of the expired air and is dangerous.


Fig 9: Oxygen hood

NASAL CATHETER

Use a 8 French size catheter. • Determine the distance the rube should be measuring the distance from the nostril to the inner margin of the eyebrow. • Gently insert the catheter into the nostril. • Ensure that the catheter is correctly positioned. • A flow rate of 0.-1 litres/min in infants and 1-2 litres/min in an older child shall deliver 30-35% oxygen concentration in the inspired air. • Adjust flow of oxygen to achieve the desired concentration. • Change the nasal catheter twice daily.

Fig 10: oxygen nasal catheter


If the baby’s breathing difficulty worsens or the baby has central cyanosis: • Give oxygen at a high flow rate (5-10 litres/ min) • If breathing difficulty is so severe that the baby has central cyanosis even with high flow oxygen, organize transfer and urgently refer the baby to a hospital or specialized centre capable of assisted ventilation, if possible. Duration of oxygen therapy Continue giving oxygen continuously until the child is able to maintain a SpO 2 >92% in room air. When the child is stable and improving, take the child off oxygen for a few minutes. If the SpO 2 remains above 92%, discontinue oxygen, but check again 1/2 hour later, and 3 hourlies thereafter on the first day off oxygen to ensure the child is stable. Where pulse oximetry is not available, the duration of oxygen therapy is guided by clinical signs, which are less reliable. Any child who has been successfully resuscitated or any unconscious child who is breathing and keeping the airway open should be placed in the recovery position. This position helps to reduce the risk of vomit entering the child’s lungs. It should only be used in children who have not been subjected to trauma. A child with cyanosis or severe respiratory distress should be allowed to take a comfortable position of his choice.

Fig 11: Recovery position


Nursing Management for respiratory distress

ASSESSMENT ACTION REMARKS / SKILL

General assessment of TABC Focused assessment for cyanosis and heart rate Check the level of consciousness by following AVPU Auscultate for lug sound-stridor ,wheeze and chest expansion

Start O2 and regulate flow rate to maintain SpO2 (90-95%) Do suction if secretion is present •Positioning according to the condition and intervention (upright or semi sitting) Start nebulisation (if ordered) •Insert IV cannula for further management (collect blood sample for routine investigation) •Carry out treatment orders Reassure the child and family •Observe for the effect of the treatment •Recording and reporting •If no improvement call specialist for further management

Connect to SpO2 monitor Use face mask, nasal prongs or O2 hood according to the age and condition of the child Up right or semi sitting in case of severe respiratory distress Ref annexure -2 for Silverman score adequate room temperature 26-28 0C,make sure that all articles are ready and working condition for procedures including crash cart


Diphtheria Diphtheria is a bacterial infection caused by Corynebacterium diphtheriae, a gram-positive bacillus. The organisms easily invade the tissue lining the throat, and during that invasion, they produce exotoxins that destroy the tissue and lead to the development of a pseudomembrane. Signs and symptoms Signs of diphtheria often appear within two to five days after infection. The most visible and common symptom of diphtheria is Fever, sore throat, cervical lymphadenopathy and a thick, grey membrane on larynx or trachea(cause stridor and obstruction). Diphtheria toxin causes muscular paralysis and myocarditis, which is associated with increased mortality. Diagnosis Carefully examine the child’s nose and throat and look for a grey, adherent membrane, which cannot be wiped off with a swab. A child with pharyngeal diphtheria may have an obviously swollen neck, termed a ‘bull neck’. Treatment Any child with suspected diphtheria give antibiotics as advised. Give 40 000 units of diphtheria antitoxin (IM or IV) immediately, because delay can lead to increased mortality. Oxygen Administer if there is incipient airway obstruction. Signs of severe in drawing of the lower chest wall and restlessness are more likely to indicate the need for tracheostomy (or intubation). Prepare for an emergency tracheostomy. Oro tracheal intubation is an alternative (may dislodge the membrane and fail to relieve the obstruction). Supportive care ● If the child has fever (≥39 °C or ≥102.2 °F), give paracetamol. ● Encourage the child to eat and drink. If there is difficulty in swallowing, nasogastric feeding is required. ● Avoid frequent examinations or disturbing the child unnecessarily. Monitoring vital signs, especially respiratory status, and refer for further management.


Complications Myocarditis and paralysis may occur 2–7 weeks after the onset of illness. Assess the signs of myocarditis include a weak, irregular pulse and evidence of heart failure. Nurse the child in a separate room using respiratory precautions Give all immunized household contacts a diphtheria toxoid booster. Nursing Management for Diphtheria ASSESSMENT ACTION REMARKS / SKILL General assessment of TABC Focused assessment for cyanosis and heart rate Check the level of consciousness by following AVPU Auscultate for lug sound-stridor ,wheeze and chest expansion

Initial Management same as that of respiratory distress Call for specialist Assist for tracheostomy Secure the tracheostomy tube properly Administer antibiotics and anti-toxin as per order Do not disturb pseudo membrane Soft suction –superficial suction if needed Follow doctors order to Meet nutritional needs through parenteral or nasogastric route Follow respiratory isolation Maintain records and reports Reassure child and family members

Ref annexure-5 crash cart Arrange articles for tracheostomy Tracheostomy set, suction, tracheostomy tube etc

Air way management for choking /foreign body aspiration Infants

Place the infant on your thigh or arm in a head down position Apply blows to the infants back with the heal of your hand- 5 times If obstruction still persists, turn infant over and give chest thrust with two fingers (one

finger breadth below nipple level in the middle) If obstruction remains, check infants mouth for any foreign body which can be

removed If necessary, repeat the procedure with back slaps again

Fig 12: Choking first aid for infants


Children

Provide 5 blows to the child’s back with the heel of your hand –child can be placed in sitting, kneeling or lying position

If symptom persists, place the child in standing position and stand behind the child, pass your arm around the child’s body; forma first with one hand immediately below the child’s sternum; place next over the first and pull upwards into the abdomen (Heimlich manoeuvre); repeat this procedure for 5 times

If obstruction remains, check the child’s mouth for any foreign body which can be removed

If necessary, repeat the procedure with back blows again. How to manage the airway in a child with obstructed breathing (or who has just stopped breathing). No neck trauma suspected If the Child conscious: -

Inspect mouth and remove foreign body, if visible Clear secretions from throat Let child assume position of maximal comfort

If the Child unconscious: - Tilt the head towards the side Inspect mouth and remove foreign body, if present Clear secretions from throat Check the airway by looking for chest movements, listening for breath sounds and

feeling for breath


Neck trauma suspected (possible cervical spine injury)

Stabilize the neck, as shown (can be used Iv fluid bottle or sand bags)

Fig 13: Stabilizing neck

Inspect mouth and remove foreign body, if visible Clear secretions from throat Check the airway by looking for chest movements, listening for breath sounds, and

feeling for breath If the child is still not breathing after carrying out the above, ventilate with bag and

mask Look, listen and feel for breathing

Nursing Management for chocking /foreign body aspiration

ASSESSMENT ACTION REMARK Assess ABC and level of consciousness (AVPU)

Check oral cavity for foreign body Do suction if there is secretion Call for help Tilt the head towards one side If foreign body is visible try to remove Start air way management Reassess the child If the child is unresponsive and not able to breathe start CPR foreign body is still in tact Refer to specialist for further management

Back blow and chest trust for infants and Heimlich manoeuvre for children If suspected neck injury ,stabilise neck( ref text )


13.4. CIRCULATION, COMA, CONVULSION

Shock It is defined as weak and fast pulses, cold extremities, capillary refill time > 3 seconds with or without pallor or lethargy or unconsciousness. •To assess the circulation, child’s hand and feet are touched, if it feels warm, the child has no circulation problem and no need to assess capillary refill or pulse. If the child’s hands and feet feel cold, need to further assess the capillary refill. •Capillary refill time (CRT) is a simple test that assesses how quickly blood returns to the skin after pressure is applied. It is carried out by applying pressure to the pink part of the nail bed of the thumb or big toe in a child and over the sternum or forehead in a young infant for 3 seconds. The capillary refill time is the time from release of pressure to complete return of the pink color. It should be less than 3 seconds. If it is more than 3 seconds, the child may be in shock. Lift the limb slightly above heart level to assess arteriolar capillary refill and not venous stasis. This sign is reliable except when the room temperature is low, as cold environment can cause a delayed capillary refill. In such a situation check the pulses and decide about shock. •Evaluation of pulses is critical to the assessment of systemic perfusion. The radial pulse should be felt. If it is strong and not obviously fast, the pulse is adequate; no further assessment is needed. In an infant (less than one year of age) the brachial pulse may be palpated in the middle of upper arm. In a child with weak peripheral pulses, if central pulses (femoral or carotid) are also weak it is an ominous sign. If the child has cold extremities, a capillary refill time more than 3 seconds, and a fast weak pulse -Then he or she is in shock Note :- blood pressure is not an indicator for identifying shock because: Low blood pressure is a late sign in children and may not help identify treatable cases, and the correct size BP cuff necessary for children of different age groups required to get correct reading.

Fig14: Cheking capillary refill time


Checking capillary refill

Applying pressure to the nail bed for 3 seconds Check the time to the return of the pink colour after releasing the pressure

The most common cause of shock in children is due to loss of fluid from circulation, either through loss from the body as in severe diarrhoea or when the child is bleeding, or through capillary leak in a disease such as severe Dengue fever. In all cases, it is important to replace this fluid quickly. An intravenous line must be inserted and fluids given rapidly in shocked children without severe malnutrition. Treatment of Shock Treatment of shock requires teamwork. The following actions need to be started simultaneously:

If the child has any bleeding, apply pressure to stop the bleeding. Do not use a tourniquet

Give oxygen Make sure the child is warm Select an appropriate site for administration of fluids Establish IV or intraosseous access Take blood samples for emergency laboratory tests Begin giving fluids for shock. Assessment of shock in severe acute malnutrition (SAM) is difficult and the fluid

therapy is also different Treatment of shock in Dengue (DHF/DSS

Fluid Management of Shock Fluid resuscitation Infuse fluid bolus of 20ml/kg of normal saline over 20-30 minutes. E.g. In a baby weighing 3kg, 60ml of normal saline should be infused over 20-30 minutes. If no or partial improvement (i.e tachycardia and CRT still prolonged), repeat a bolus of 20ml/kg of normal saline. •If the signs of poor perfusion persist despite 2 fluid boluses, start vasopressor support as per doctor’s order •The most commonly used vasopressor in practice is dopamine. Usual starting dose is 5 -10μg/kg/min and if no improvement occurs, the dose can be increased by increments of 5 μg/kg/min every 20 - 30 minutes to a maximum of 20 μg/kg/min.


Dopamine calculation For giving 1 mcg/kg/minute of dopamine Amount of dopamine(mg) to be added = Weight in kg x6 To convert this dose into amount to ml of dopamine divide by 40 (1ml of dopamine = 40mg of dopamine) Add this amount of dopamine (ml) to make 100ml of total fluid 1ml/hour of this fluid gives 1 mcg/kg/minute To give 10 mcg/kg/minute give 10ml/hour or 10 microdrops/minute (as 60 microdrops = 1ml) Example Giving 10 mcg/kg/minute for a 10kg child Amount of dopamine(mg) to be added = 10 x 6 =60mg To convert this dose into amount to ml of dopamine: 60/40 =1.5ml Add 1.5ml of dopamine to 98.5ml to make 100ml of total fluid 10ml/hour of this fluid gives 10 mcg/kg/minute or 10 microdrops/minute Formula for making IV infusion of life Saving drugs ml /hr= weight in kg X 3/40 Once following amount in mg of drugs added in 50 of Normal saline in 50 ml syring, ml/hr calculated as per above formula will be equivalent to:

200mg of Dopamine or Dobutamine = 5ug/kg/min 20mg of Nitroglycerine = 0.5ug/kg/min 2mg of noradrenaline or adrenaline = 0.05ug/kg/min

To increase or decrease the amount of fluid to be infused in children, amount of drug can be proportionately changed or vise versa


Chart -6: Management of shock in a child with severe acute malnutrition


Nursing management for shock

ASSESSMENT ACTION REMARKS/SKILL Focused assessment TABC Assess for the sign of dehydration & CRT Assess A-Alertness V-Response to Voice P-Response to Painful stimuli U-Unresponsive to voice

Keep the child warm Apply pressure to stop the bleeding (if present) Give oxygen Select an appropriate site to establish IV or intraosseous access and assist for the procedure collect blood samples for emergency laboratory tests Follow fluid resuscitation regime and start fluid as early as possible Keep the child in side lying position or recovery position Carry out doctor’s order Use syringe pump to start lifesaving drugs (if ordered) Maintain intake and output chart Re assess for the improvement and IV cannula site for extravasation and swelling Initiate Team management Reassure the child and family

Do not use tourniquet If shock in severe acute malnutrition (SAM) carry out the order properly Ref page no- Ref annexure-4 for drug calculation & preparation

Coma and convulsion The following signs indicate impaired neurological status: coma, lethargy, and convulsions. An awake child is conscious. If the child is asleep, ask the mother. In case of any doubt, assess the level of consciousness. Try to wake the child by talking to him/her e.g. Call his/her name loudly. A child who does not respond to this should be gently shaken. A little shake to the arm or leg should be enough to wake a sleeping child. Do not move the child’s neck. If this is unsuccessful, apply a firm squeeze to the nail bed, enough to cause some pain. A child who does not wake to voice or being shaken or to pain is unconscious. To assess the conscious level of a child is, a simple scale (AVPU) is used: A -Is the child Alert? If not, V -Is the child responding to Voice? If not, P -Is the child responding to Pain? U -The child who is Unresponsive to voice (or being shaken) and to pain is Unconscious. A child who is not alert, but responds to voice, is lethargic. An unconscious child may or may not respond to pain. A child with a coma scale of “P” or “U” will receive emergency treatment for coma as described below.


Nursing management for coma

ASSESSMENT ACTION REMARKS /SKILL Assess for TABC Alertness Response to Voice Response to Painful stimuli Unresponsive to voice Evaluate motor function –posturer, muscle tone, muscle power and reflexes Assess for the sign of meningeal irritation (photophobia, neck pain and stiffnes) Opisthotonos position

Manage the airway, breathing • Position the child in side lying or head turned to one side Insert IV cannula and collect blood samples for routine investigation • Check the blood sugar Do suction if needed Administer O 2 with age appropriate equipment Administer drugs according to the order Activate team management Assist for intubation and stabilising the child Change position frequently Elevate head end at 45 0 if not contraindicated Document blood glucose level Insert oral/nasal airway if needed Provide adequate ventilation Maintain records and reports Documentation: - include following points,

level of consciousness incontinence of urine and stool Injury or pressure sore

Check patency of the IV line before giving any medication to prevent tissue damage Nurse must be aware about the stability and compatibility of drugs Fig -16

A convulsion is characterized by the sudden loss of consciousness associated with uncontrolled jerky movements of the limbs and/or the face. There is stiffening of the child’s arms and legs and uncontrolled movements of the limbs. The child may lose control of the bladder and is unconscious during and after the convulsion. Sometimes, in infants, the jerky movements may be absent, but there may be twitching (abnormal facial movements) and abnormal movements of the eyes, hands or feet which are known as subtle seizures. Treatment of coma and convulsions are similar and will be described together

Coma Convulsion • Manage the airway • Position the child (if there is a history of trauma, stabilize the neck first) • Check the blood sugar • Give IV glucose

• Manage the airway • Position the child • Check the blood sugar • Give IV glucose • Give IV calcium in young infants


a. Manage the Airway Managing the airway is done in the same way as treating any child with an airway or breathing problem. This has been discussed in earlier. To manage the airway of a convulsing child, gentle suction of oropharyngeal secretions should be done & child put in recovery position and oxygen started. Do not try to insert anything in the mouth to keep it open. b. Insertion of an oropharyngeal (Guedel) airway (Fig 14) The oropharyngeal or Guedel airway can be used in an unconscious patient to improve airway opening. It may not be tolerated in a patient who is awake and may induce choking or vomiting. Guedel airways come in different sizes (Guedel size 000 to 4). An appropriate sized airway goes from the centre of the teeth (incisors) to the angle of the jaw when laid on the face with the convex side up.

Fig 15: inserting an oropharyngeal airway in an infant

Select an appropriate sized airway. Position the child to open the airway as described above, taking care not to move the

neck if trauma suspected. Using a tongue depressor, insert the oropharyngeal airway the convex side up. Re-check airway opening. Use a different sized airway or reposition if necessary. Give oxygen


Nursing management for convulsion

ASSESSMENT ACTION REMARKS Assess for TABC Alertness Response to Voice Response to Painful stimuli Unresponsive to voice Evaluate motor function –posturer , muscle tone, muscle power and reflexes Assess for the sign of meningeal irritation (photophobia, neck pain and stiffnes) Opisthotonos position

Nurse the baby in thermoneutral environment Manage the airway, breathing • Position the child in side lying or head turned to one side Insert IV cannula and collect blood samle for routine investigation • Check the blood sugar Do suction if needed Administer O 2 with age appropriate equipment Administer drugs according to the order Activate team management Assist for intubation and stabilising the child Change position frequently Elevate head end at 45 0 if not contraindicated Keep side rails up and padded Keep Bed in lowest level Decrease stimulants like noise and bright light Provide privacy, remove patient's eyeglasses and loosen any constricting clothing Observe seizure precautions Keep bed and bedding free of dust, moisture and debris Document blood glucose level Do not try to push anything into the mouth Provide adequate ventilation Stay with the child if there is convulsion Administer drugs to control convulsion Environmental preparation like dim light, noise control Maintain records and reports Documentation: - include following points, type and stages of convulsion Duration of convulsion, level of consciousness during convulsion, was there incontinence of urine and stool, is there is any weakness or paralysis after seizure ,is there is any injury and the child slept after seizure if so how long.

Check patency of the IV line before giving anticonvulsants to prevent tissue damage Nurse must be aware about the stability and compatibility of drugs


If seizures persist even after correction of hypoglycemia /hypocalcemia, give anti convulsant drugs (ACD) as per order: Following are the drug of choice and the recommended dose a) Injection Phenobarbitone 20mg/kg IV over 20 minutes. If the baby has no further seizures do not start maintenance. If seizures persist after completion of this loading dose, give additional doses of phenobarbitone at 10 mg/kg every 20-30 minutes until total dose of 40 mg/kg has been given. b) If seizures persist after maximal dose of phenobarbitone (40 mg/kg), Phenytoin is given at a dose of 20 mg/kg IV. A repeat dose of 10 mg/kg is given in refractory seizures. Phenytoin should be diluted in normal saline as it is incompatible with dextrose solution. c) If seizures are controlled, a maintenance dose of Phenobarbitone and Phenytoin is started at 3-5mg/kg/day in 2 divided doses,12 hours after the loading dose. Both these drugs are administered at a rate not more than 1mg/kg/min. d) If seizures still persist, benzodiazepines are indicated. The commonly used benzodiazepines are lorazepam and midazolam. Lorazepam has a longer duration of action than Midazolam, the latter being faster acting and can also be administered as an infusion. The infant must be closely monitored for respiratory depression and bradycardia with anti convulsant infusion. For doses of these drugs refer drug chart (A-4): If the child is convulsing in front of you, give Injection Diazepam IV or per rectal. Rectal Diazepam acts within 2 to 4 minutes. In an emergency, it is easier and quicker to give it rectally than intravenously, unless an intravenous line is already running. The dose is 0.5mg/kg (0.1ml/kg) rectally or 0.25mg/kg (0.05ml/kg) intravenously. An estimated dose of rectal diazepam is shown below. Give 0.5mg/kg diazepam injection solution per rectum by a tuberculin syringe or a catheter. Hold the buttocks together for few minutes. If you already have intravenous access, give the correct volume of drug directly, but slowly, in at least one full minute. Reassess the child after 10 minutes. If still convulsing, give a second dose of diazepam. (Diazepam is generally avoided in neonates because of its short duration of antiepileptic effect but very prolonged sedative effect, narrow therapeutic index and the presence of sodium benzoate as a preservative) If convulsions do not stop after 10 minutes of second dose of diazepam, Inj Phenytoin is given intravenously at 20mg/kg. Phenytoin is diluted in about 20ml of saline and given slowly (not more than 1mg/kg/minute). If seizures persist, give Phenobarbitone as infusion in a dose of 20mg/ kg IV (in 20ml saline). If seizures are controlled, give maintenance dose of Phenytoin/ Phenobarbitone. The total fluid used for administration of Anti convulsant drugs should be deducted from daily fluid requirement.


Dose of Phenobarbitone for young infant

Inj. Phenobarbitone intravenous dose (200mg/ml) Weight of Infant Initial dose Repeat dose 2kg or less 0.2ml 0.1ml 2 to 4kg 0.3ml 0.15ml

Table 2: Dosage of diazepam

Diazepam given rectally 10mg / 2ml solution Age / weight Dose 0.1ml/kg 2 weeks to 2 months (<4kg) 0.3ml 2 - <4 months (4 - <6kg) 0.5ml 4 - <12 months (6 - <10kg) 1.0ml 1 - <3 years (10 - <14kg) 1.25ml 3 - <5 years (14 – 19kg) 1.5ml

If there is high fever: •Sponge the child with room-temperature water to reduce the fever. •Do not give oral medication until the convulsion has been controlled (danger of aspiration)


TETANUS

Tetanus, also known as lockjaw, is a serious but preventable disease that affects the body's muscles and nerves. It typically arises from a skin wound that becomes contaminated by a bacterium called Clostridium Tetani, which is often found in soil. Signs and symptoms Signs of tetanus are a headache and muscular stiffness in the jaw, followed by stiffness of the neck, difficulty in swallowing, rigidity of abdominal muscles, spasms, sweating and fever. As the toxin produced by the bacteria circulates more widely, the toxin interferes with the normal activity of nerves throughout the body, leading to generalized muscle spasms. Symptoms usually begin 8 days after the infection, but may range in onset from 3 days to 3 weeks. Without treatment, tetanus can be fatal. Vaccination is the best way to protect against tetanus. Neonatal tetanus is a form of generalized tetanus in newborn infants that do not have protective passive immunity because the mother is not immune. It usually occurs through infection of the unhealed umbilical stump, particularly when the stump is cut with an unsterile instrument. Clinical evaluation Tetanus should be considered when patients have sudden, unexplained muscle stiffness or spasms, particularly if they have a history of a recent wound or risk factors for tetanus. Tetanus can be confused with meningo encephalitis of bacterial or viral origin, but the following combination suggests tetanus: Medical management

Supportive care, particularly respiratory support Wound debridement Tetanus antitoxin (TIG: - Dose can range from 250-500 units IM, depending on

wound severity) indifferent two sites Tetanus vaccine IM: 0.5 ml per dose (If no immunisation or unknown immunisation

status: administer at least 2 doses at an interval of 4 weeks. If incomplete immunisation: administer one dose)

Benzodiazepines for muscle spasms (refer convulsion for drug management) Metronidazole or penicillin


Nursing Management for Tetanus

ASSESSMENT ACTION REMARKS Focused assessment TABC Neurological assessment AVPU Evaluate motor function –posturer, muscle tone, muscle power and reflexes Assess for the sign of meningeal irritation (photophobia, neck pain and stiffnes) Opisthotonos position

Initial management same as in case of convulsion Ensure intensive nursing care. Nurse the patient in a dark, quiet room. Blindfold neonates with a cloth bandage. Handle the patient carefully, plan cluster care for minimal handling Change position every 3 to 4 hours to avoid bedsores. Establish IV access for hydration, IV injections at least two IV lines. (Continuous IV infusion of diazepam in a dedicated vein. When the frequency and severity of the spasms have decreased, start weaning the diazepam based on physician’s order). Gentle suction of secretions (mouth, oropharynx) if needed. Insert a nasogastric tube for hydration, feeding and administration of oral medications. Constant and close monitoring of the patient ‘s respiratory rate (RR) and oxygen saturation (SpO2) is essential, with immediate availability of equipment for manual ventilation (Ambu bag, face mask) and intubation, suction (electric if possible) and Ringer lactate. Psychological support to the family member and the client Maintain record and report

Place signage to control environmental stimuli Prevent injury and comfortable environment and to reduce stimulation Make sure that crash cart is ready Keep ready Equipment for central line assess


13.5 DEHYDRATION The letter D in the ABCD formula stands for Dehydration. In this section we will look at the assessment of severe dehydration in the child with diarrhea or vomiting. If the child is severely malnourished these signs are not as reliable.

Chart-7: Assess for severe dehydration

To assess for severe dehydration, look for the following signs. Presence of any two signs Indicates severe dehydration:

o Lethargy o Sunken eyes o Skin pinch takes longer than 2 seconds to go back

World Health Organization (WHO-2012) scale for dehydration It is important to determine the degree of dehydration in order to select the appropriate plan to treat or prevent dehydration. Clinical assessment for degree of dehydration associated with diarrhoea is as follows

A B C General appearance well, alert restless, irritable lethargic or unconscious Eyes Normal sunken Sunken Thirst drinks normally, not

thirsty thirsty, drinks eagerly drinks poorly, or not able

to drink Skin turgor goes back quickly goes back slowly goes back very slowly

If two or more of the signs in column “C’’ are present - the patient has "severe dehydration"


If two or more signs from column B (and C) are present - the patient has "some dehydration".

patients who fall under column A - "no signs of dehydration" Estimation of fluid deficit (and the requirement) in children with some dehydration or severe dehydration should be carried out by weighing them without clothing. (if weighing is not possible, a child's age may be used to estimate the weight) (1).

Estimated fluid deficit

assessment

fluid deficit as % of body weight

fluid deficit in ml/kg body weight

Treatment

no signs of dehydration <5% <50 ml/kg use treatment plan A some dehydration 5-10% 50-100 ml/kg use treatment plan B severe dehydration >10% >100 ml/kg use treatment plan C

How to give IV fluids rapidly for shock (child not severely malnourished) Make sure that the child is not severely malnourished Insert an intravenous cannula (and draw blood for emergency laboratory investigations). Connect Ringer’s lactate or normal saline—make sure the infusion is running well, transfuse 20 ml/kg as rapidly as possible.

Age/weight Volume of Ringer’s lactate or normal saline solution (20 ml/kg)

2 months (<4 kg) 75 ml 2–<4 months (4–<6 kg) 100 ml 4–<12 months (6–<10 kg) 150 ml 1–<3 years (10–<14 kg) 250 ml 3–<5 years (14–19 kg) 350 ml

Reassess after first infusion:-If no improvement, repeat 20 ml/kg as rapidly as possible. Reassess after second infusion:-If no improvement, repeat 20 ml/kg as rapidly as possible. Reassess after third infusion: - If no improvement, give blood 20 ml/kg over 30 minutes.



Plan C chart

How to treat severe dehydration in an emergency setting Follow chart when the child’s pulse becomes slower or the capillary refill is faster. Give 70 ml/kg of Ringer’s lactate solution (or, if not available, normal saline) over 5 hours in infants (aged <12 months) and over 2 1/2 hours in children (aged 12 months to 5 years). Total volume IV fluid (volume per hour) Weight Age <12 months

Give over 5 hours Age 12 months to 5 years Give over 2 1/2 hours

<4 kg 200 ml (40 ml/h) — 4–<6 kg 350 ml (70 ml/h) — 6–<10 kg 550 ml (110 ml/h) 550 ml (220 ml/h) 10–<14 kg 850 ml (170 ml/h) 850 ml (340 ml/h) 14–<19 kg 1200 ml (240 ml/h) 1200 ml (480 ml/h) Reassess the child every 1–2 hours. If the hydration status is not improving, give the IV drip more rapidly. Also give ORS solution (about 5 ml/kg/hour) as soon as the child can drink; this is usually after 3–4 hours (in infants) or 1–2 hours (in children). Reassess after 6 hours (infants) and after 3 hours (children). Classify dehydration. Then choose the appropriate diarrhoea treatment plan to continue treatment. If possible, observe the child for at least 6 hours after rehydration to be sure that the mother can maintain hydration by giving the child ORS solution by mouth.

Weight Volume of IV fluid Give over 1 hour (15 ml/kg)

Weight Volume of IV fluid Give over 1 hour (15 ml/kg)

4 kg 60 ml 12 kg 180 ml 6 kg 90 ml 14 kg 210 ml 8 kg 120 ml 16 kg 240 ml 10 kg 150 ml 18 kg 270 ml


MANAGEMENT OF THE CHILD WITH A SERIOUS INFECTION OR SEVERE MALNUTRITION Give this treatment only if the child has signs of shock and is lethargic or has lost consciousness: Insert an IV cannula (draw blood for emergency laboratory investigations) Weigh the child (or estimate the weight) to calculate the volume of fluid to be given Administer IV fluid 15 ml/kg over 1 hour. Use one of the following solutions (in order of preference):

1. Ringer’s lactate with 5% glucose (dextrose); or 2. half-normal saline with 5% glucose (dextrose);

Measure the pulse and breathing rate initially and every 5–10 minutes. Fluid management for children with serious infection or severe malnutrition If there are signs of improvement (pulse and breathing rates fall): repeat IV 15 ml/kg over 1 hour; then switch to oral or nasogastric rehydration with ORS, 10 ml/kg/h up to 10 hours; Volume of ORS for serious infection or severely malnourished children

weight Volume of ORS solution per hour <4kg 15ml 4- <6kg

25ml

6- <10kg 40ml 10 - <14kg 60ml 14 – 19kg 85ml

If IV treatment not possible, give ORS 20ml/kg/hour for 6 hours (120ml/kg) by NG tube •Reassess an infant after 6 hours and a child after 3 hours. Classify dehydration. Then choose the appropriate plan (A, B, or C) to continue treatment as •Give oral antibiotic when indicated, eg, for dysentery, cholera. — initiate refeeding with starter F-75. If the child fails to improve after the first 15 ml/kg IV, assume the child has septic shock: — give maintenance IV fluid (4 ml/kg/h) while waiting for blood; — when blood is available, transfuse fresh whole blood at 10 ml/kg slowly over 3 hours (use packed cells if in cardiac failure); then refer for further management including — initiate refeeding with starter F-75. If the child deteriorates during the IV rehydration (breathing increases by 5 breaths/min or pulse by 25 beats/min), stop the infusion because IV fluid can worsen the child’s condition.


Nursing management for dehydration

ASSESSMENT INTERVENTION REMARKS General assessment for TABC Focused assessment for dehydration and malnutrition

Fluid volume deficit

Altered

tissue perfusion

Impaired

gas exchange

Initial management based on initial assessment ( same in all cases ) Nurse the child under warmer care Check O2 saturation using SpO 2 monitor and start O 2 using age/condition appropriate equipment insert IV cannula and collect blood sample for routine investigation Carry out the order and start IV fluid. Regulate fluid rate (use syringe/infusion pump) Maintain Sterile technique Care of the IV site and fluid management Check vital signs half hourly Reassess the child for the sign of dehydration and fluid over load Check stool for consistency, colour and order ,collect sample for investigation and rule out the cause Send stool sample in a cold pack immediately for hanging drop to rule out cholera Maintain intake and output chart strictly Maintain records and reports Reassure parents and relatives using soft skills

Ref page no- Preferably two separate IV cannula Child with SAM needs extra care ( right fluid/duration and fluid rate)

Nurses responsibilities in emergency ward

The most important responsibility for an emergency nurse is the ability to prioritize the cases based on the immediate need and carryout initial assessment as quickly as possible because time management is crucial. Along with triage, emergency nurse must quickly ascertain the following information from the clients:

Obtain baseline vital signs quickly Check for any allergies and current medications Priorities based assessment and assist the team for intervention Perform IV cannulation,( collect articles appropriate for the age and size of the child )

collect blood samples, administer medications, starts IVs, performs catheterizations and CPR to stabilise patients

Plans individualized patient care based on assessment and implements plan to meet immediate needs in collaboration with the interdisciplinary team.

Evaluates patient's response to interventions and adjust the plan of care accordingly


An emergency room nurse's overall duties are to stabilize patients in trauma, discover medical conditions rapidly, control pain, and give direction for injury prevention.

Respect the cultural beliefs and practice Follow the protocol and policies Maintain the records and report Follow the standard safety measures Observe the legal and ethical values Make sure that all equipment are in working condition ,adequate staff on duty for

each shift and availability of consumable goods

Conclusion Triage is the sorting of patients into priority groups according to their need. All children should undergo triage. The main steps in triage are: • Look for emergency signs. • Check for head/neck trauma. • Treat any emergency signs you find. • Call for Help • Draw blood for emergency samples. • Look for any priority signs. Scenarios 13-1: Mayank, three weeks old, is brought to you with complaints of 4 days of diarrhea and vomiting. His temperature is 36.2ºc and he is lethargic, breathing normally, his hands are cold and capillary refill is < 3 sec. The eyes are normal, skin pinch takes more than 3 sec, and he has a weak and fast pulse. On the basis of the triage chart, categorize the child. List the signs on the basis of which you assigned the category. 13-2: An 8-day-old baby fed on top milk is brought to a health facility with complaints of diarrhoea. The eyes and skin pinch are normal and baby is alert. On the basis of the triage chart, categorize the child. List the signs on the basis of which you assigned the category. 13-3: Monu, one year old, had a seizure outside the hospital. He became unconscious. His breathing sounds very wet and noisy and there is drooling from his mouth. He has central cyanosis. On the basis of the triage chart, categorize the child. List thesigns on the basis of which you assigned the category. 13-4:Sunita four-month old baby is brought to hospital with fever, respiratory rate of 60/min. She has had 2 episodes of vomiting and watery diarrhoea. Weight 5kg. Her hands are cold. The capillary refill is more than 3 seconds. The femoral pulse is palpable but fast and weak. There is no chest indrawing and there are no abnormal respiratory noises. List the emergency signs. Write the initial steps of management.


13-5:Vijay 12 months old is brought to you with loose stools and vomiting. He weighs 5.0kg and has visible severe wasting. The child is very lethargic and extremities are cold with capillary refill of more than 3 seconds. The pulses are weak and fast and have mild respiratory distress. List the emergency signs. Write the initial steps of management.

13-6:A 7 days old baby weighing 2kg is admitted with refusal to feeds, fast and weak pulse with mottling of skin, cold extremities and a CRT of 5 seconds. What are the steps of initial management? After giving 2 fluid challenges, CRT is still 4 seconds with HR of 190 bpm. How will you proceed?

13-7:Sunil two-year old boy is carried in by his grandmother. He weighs 12kg. He is febrile and having a seizure. The child is breathing normally and the CRT is < 3seconds. How would you manage the child?

13-8:Anil is an 18 month old boy who has fever for two days. His mother has noticed that he has fast breathing. The respiratory rate is 72 /min and temperature is 38º C. He weighs 11kg. His airway is clear, and he has no chest indrawing. His extremities are warm and there is no history of diarrhoea. However, the boy started to convulse while being examined. List the emergency signs. What are the most appropriate measures?

13-9:12 days old infant weighing 3kg is brought to the facility with generalized tonic seizures with refusal to feed. The child is breathing normally and has warm extremities. Baby’s blood sugar is 60mg/dl. How will you manage this case?

13-13:Paediatric emergency department received a new-born (delivered on the way to hospital with intact placenta and wrapped in a wet, dirty cloth. On arrival central cyanosis and poor respiratory effort Nursing management •Cut the cord •Change the wet clothes and wrap in warm clothes and shift under radiant warmer •Arrange articles for resuscitation and follow the steps according NRP guidelines and do the resuscitation

13-14:Emergency department received on new born delivered half an hour before. On arrival baby was with central cyanosis and has severe respiratory distress On examination, Lethargic, Cyanosed and No external nasal opening


Nursing management • Receive under warmer care • Change wet and cold clothes • Do suction if oral secretion present • Insert IV line, collect sample for routine investigation and check blood sugar • Get oral airway (Guedel) &articles for intubation • Refer the case for further management • Maintain reports and records 13-15: 7 year old male child weighing 22kg brought to the emergency department by his mother with the history of cold like symptoms, fever and breathing difficulty for one week. On examination the child is with acute respiratory distress, chest wall in drawing, respiratory rate of 28/min shallow, O 2 saturation 72%, irritable with saliva drooling from the mouth and greyish membrane resent in the Oral cavity. Nursing intervention

Start O2

Do soft suction to the mouth to remove secretion Call specialist, insert IV cannula ,collect blood sample for routine care Start maintenance fluid and administer antibiotic according to the order Arrange articles for tracheostomy Reassure the child and family Maintain records and reports

13-16:5 year old male child weighing 18 kg brought to the emergency department by his parents with the history of ear discharge since one week and showing symptoms of seizure for last 12 hours, history of fever one week before.

On examination pulse-100/mt, respiration 28/mt and temperature 1000F Purulent discharge in the right ear, child is oriented but irritable and sensitive to noise and light Nursing intervention

Check vital signs Seizure precaution Insert IV cannula and collect blood samples Start IV fluid and anticonvulsants as ordered If there is any difficulty in inserting IV line control seizure with PR drugs like

diazepam Nurse in quite dark room Administer TIG & TT



13. ANNEXURE-1 Radiant Warmer Introduction Maintaining normal body temperature is essential for optimal growth and development, which in turn control caloric expenditure and oxygen consumption. Lack of attention to thermoregulation continues to be one of the causes of deaths in neonates. Radiant warmer (also called open care system) was developed as an open incubator to provide a warm microenvironment surrounding the baby and reduce the conductive loss of heat energy. The overhead quartz heating element produces heat which reflected by the parabolic reflector on to the baby on the bassinet. The quantity of heat produced is displayed in the heater output display panel. Select desired skin temperature using selection knob. This information is processed by the microprocessor inside the control panel and matched against the actual temperature of the baby. If the temperature of the baby is lower than the set temperature, the microprocessor will send feedback to the quartz rod heater to increase the heat output till the baby’s temperature reaches the set temperature. At this point, the heater output will be reduced. This system in which the heater output is determined automatically based on skin temperature is called servo system. Servo system is the preferred method of running the open care system. The heat out can be increased or decreased manually by using heater output control knobs .This is called the manual mode of operation. Whenever the baby’s temperature rises by more than 0.5o C above the set temperature, a visual/audible alarm is activated in the servo mode. Caregiver can pay attention to sort out the fault. Often this occurs when the skin probe comes off the baby. Parts of open care system

Bassinet- For placing the neonate Quartz rod - Provides radiant heat Skin probe -When attached to the baby’s skin, displays skin temperature Control panel -Has a collection of display and control features/knobs Heater output display- Indicates how much is the heater output Heater output control knobs - For increasing or decreasing the heater output manually Temperature selection panel -Select either set temperature or skin temperature Temperature selection knobs - Select a desired set temperature Temperature display - Display temperature as selected, either of the baby’s skin (via

skin probe) or the set temperature Mode selector - Selects manual or servo mode

Heater assembly The heating element (silicon quartz/infrared/ceramic/quartz crystal), the control panels (electronic/electrical/microprocessor based) and alarms (air over temperature/skin over


temperature/air sensor fail/power failure etc.) forms the basic unit of all the warming devices. Power consumption is around 750 watts. In good equipment, temperature stability is usually with an accuracy of ±0.5ºC. Steps for operating radiant warmer

1. Connect the unit to the mains. Switch it on. 2. Select manual mode. 3. Select heater output to 100% for some time to allow quick pre-warming of the

bassinet covered with linen. 4. Select servo mode. 5. Select the desired set temperature of baby as 36.5 0C. 6. Place baby on the bassinet.

Connect skin probe to the baby’s right hypochondrium with sticking tape (in supine position).

If you want the manual mode to be used in the baby, select the desired heater output.

In manual mode, record baby’s axillary temperature at 30 minutes and then 2 hourly.

Respond to alarm immediately. Identify the fault and rectify it.

Do’s &Don’ts to apply skin probe Do’s

1. Prepare the skin using an alcohol/spirit swab to ensure good adhesion to the skin. 2. Apply probe over the right hypochondrium area in the supine position. 3. Apply probe to the flank in the prone position. 4. Check sensor probe regularly so as to ensure that it is in place. Ensure that skin probe

is free of contact with bed. 5. Cover probe with a reflective cover pad, if available (foil covered foam adhesive pad). 6. Ensure that the area where probe is applied is dry.

Don’t

1. Do not apply to bruised skin. 2. Do not apply clear plastic dressings over probe. 3. Do not use fingernails to remove skin surface probes. 4. Do not reuse disposable probes.


Use of cling wraps to decrease insensible water losses Use of cling wrap (transparent polythene used for covering fruits or vegetable for storage) over the baby, tied across with the panels of warmer has been shown to reduce insensible water losses and result in better thermal control for VLBW(<1.5 kg) babies. Potential pitfalls of servo-controlled warmer In the event of displaced probe from baby’s abdominal skin, overheating of the baby will occur because the skin probe depicts air temperature and heater output keeps on increasing till probe temperature matches control temperature. In servo mode repeated activation of alarm will occur when baby develops fever. In this situation, one should shift to manual mode with least heater output. Useful tips for use of radiant warmers

Don’t use the warmer in a cold room. It works best when the environmental temperature is above 20ºC.

Ensure that the baby’s head is covered with cap and feet secured in socks and the baby is clothed or covered unless it is necessary for the baby to be naked or partially undressed for observation or for a procedure

Keeping the warmer where there is lot of air currents reduces its efficiency. The warmer must be pre-warmed around 20 minutes before the arrival of the baby or

till the set temperature is reached with less than 50% of total heater output. While using the manual mode in a warmer without a temperature display, record the

baby’s temperature regularly, preferably 2 hourly. Train junior doctors and nurses about the proper use of servo and manual modes. The manual mode is used for initial preparation of bed for the baby; or when rapid

warming of a severely hypothermic baby has to be done. However, this may be hazardous as babies may become overheated. Except in the continuous presence of a nurse who is watching the skin temperature, it is preferable to use the skin probe with the warmer on servo-mode.

Precautions for manual mode Use maximum (100% output) for rapid warming of bassinet in labor room 10 minutes before delivery. Reduce output to 25-75% after 10 minutes depending on ambient temperature. If left on with heater output >80% alarm is activated within 15 or 20 minutes later and there after the heater output goes to 40%; if alarm is silenced the heater will kept on for another 15 to 20 minutes as per manufacturers recommendation.

Read temperature on display. Adjust heater output to:

a) High : If baby temperature is below 36ºC- b) Medium : If baby temperature is between 36-36.5ºC and to c) Low : If baby temperature is between 36.5-37.5ºC-

sssmode. Never use full (100%) heater output unsupervised and always record baby

temperature every 2-4 hourly.


Disinfection

When the equipment is in use, all approachable external surfaces should be cleaned daily with an antiseptic solution like 2% bacillocid or gluteraldehyde. Spirit or other organic solvents must not be used to clean the glass side panels or display panel. For disinfection of reusable probe, isopropyl alcohol swab should be used.

Every seventh day, after shifting the baby to another cot, the used equipment should be cleaned thoroughly, first by light detergent solution and then by antiseptic solution. All detachable assemblies are to be treated similarly.

Maintenance Ongoing maintenance is the key to increase the mean time between failures. The hospital biomedical engineer must regularly check equipment but the authorized company engineer must be called for preventive checks and major breakdowns. The control and power units should be calibrated every 4-6 months and thorough servicing should be done annually. Temperature calibration should ensure sensitivity to ±0.5ºof the set value.

RADIANT WARMER


ALARMS ON THE SERVO RADIANT WARMER (No alarms in manual mode)

Alarm Problem Response

1. “Power alarm” This alarms if the mains power fails

Find alternative means for heating if power cannot be fixed e.g. (KMC). Check the fuse

2. “System alarm” This alarms if there is an error in the electrical/ electronic circuit

Change WARMER, as it needs repair

3. “Skin Probe failure alarm”

1This alarm sounds if the temperature probe sensor is not connected properly or if it is not functioning properly

Try to re-connect the sensor correctly. If this does not work, change it

4. “Skin temperature alarm High or Low”

This alarm operates in servo mode only. It sounds when the patient temperature differs from the SET temperature by >0.5oC

Change to manual mode with maximum output if baby is having low temperature and adjust the temperature to try and normalize the baby’s temperature. If baby is having fever, shift to manual mode and set appropriate heater output. Check for signs of infection.

5. Heater failure Indicates heater is not working

Change warmer, needs repair.

13. ANNEXURE -2

CRASH CART - EMERGENCY WARD

Crash Cart Top Side Defibrillator with leads 02 tank Disposable gloves (sterile & unsterile) Back board Sharps container suction catheters ( size 5-14) 1 package of defibrillator pads

Medication Drawer –first drawer Amiodorone Atropine 1 mg Vasopressin Calcium gluconate


Dextrose 50% 5ml Dexamethasone Epinephrine 1 mg Lidocaine 100mg Sodium Bacarbonate Dopamine Lasix Oxytocin Misoprost Dobutamine Diazepam Paraldehyde Verapamil Magnesium sulfate Midazolam Phenobarbitone

Airway Management Drawer-second drawer Airways( oral, nasal different sizes) Laryngoscopes with blades (0-1) Xylocaine jelly Syringes Stylet Tape Batteries ET tubes – sizes 2.5- 7.5 02 mask with tubing Nasal cannula Naso Gastric tube (5-14)

Venipuncture equipment-third drawer Syringes –different size IV cannulas-different size Tourniquet Vacutainers - different color 3 way stopcock Needles- different size Band aids Betadine swabs Alcohol swabs Lidocaine topical solution Umbilical and Radial artery catheterization set


Tape

Drawer 4

Electrodes B/P cuff (different size)with stethoscope Sterile Gloves Packages of defibrillator pads NG tube 5F-12F Oxygen key and wrench

Drawer 5

IV solutions: DNS, 5% DEX , RL,4.5%DNS,Isolyte –P,NS, 3% NaCl, Distilled Water etc & colloids

Tubing- Micro & macro set , extension tubing

Drawer 6 (Bottom) Electrodes Ambu Bags, Adult & Peds Suction Set Up (Portable Cart) Spinal Needles Bone Marrow Needles Of Various Sizes Umbilical Catheters Cut Down Tray Tracheostomy Tray Nasopharyngeal and Oropharyngeal airways Sutures of various sizes and materials Lumbar puncture kit Articles for vaginal exam

Nurses responsibilities for maintaining crash cart

Always make sure that crash cart has been checked and refilled with the required equipment on daily basis.

Make sure that all health care providers are aware about the crash cart and its contents.

It is extremely essential that carts are well-stocked with all the necessary drugs and equipment to ensure that the doctors /nurses are able to confidently handle emergencies.

A licensed official is designated for the purpose of checking the defibrillator, oxygen cylinder levels, and the other contents of the crash cart including expiry date of drugs.

He/She is also responsible for rechecking and restocking the cart following its use and Drawers of the crash cart need to be clearly labeled.


He/She is also responsible for documenting compliance on crash cart checklist. In fact, code drills are often conducted to check the response of the staff during such situations.

Broselow Paediatric Emergency Cart / Trolley

The Broselow Tape, also called the Broselow pediatric emergency tape, is a color-coded length-based tape measure that is used throughout the world for pediatric emergencies



Color Estimated Weight (in kilograms)

Estimated Weight (in pounds)

Grey 3–5 kg 6-11 lbs Pink 6–7 kg 13-15 lbs Red 8–9 kg 17-20 lbs Purple 10–11 kg 22-24 lbs Yellow 12–14 kg 26-30 lbs White 15–18 kg 33-40 lbs Blue 19–23 kg 42-50 lbs Orange 24–29 kg 53-64 lbs Green

30–36 kg

66-80 lbs


Drugs

Drug Presentation Action indication Dose Preparation Mode of administration

Adverse effect

Nursing Responsibility

1. Dopamine

200 mg/5 ml

Vaso pressor,

BP support Brady cardia Septic shock Cardiogenic shock Severe CHF

2-20 mcg/kg/mt

200 mg=200,000 micro gram/ 5ml 2.5ml+47.5 ml D5 100,000/50=2000 mcg/ml. 20 kgx 5mcg =100 mcg/mtx60 mts=6,000mcg/hr = 3ml/hr

IV Infusion via syringe pump

Headaches, dyspnoea, arrhythmias, palpitation, nausea, Vomiting.

Monitor for tachycardia Check vital signs and Bp Administer through central line Setting of syringe pump and adjust the flow rate Check sign of extravasation to avoid tissue damage Always Double check the dose

2. Dobutamine

250mg/5ml Vaso pressor,

Impaired cardiac contractility

5 to 25 μg/kg/min.

250mg/5ml= 250,000mcg/5ml =5000mcg/ml 10kgx5mcg=50mcg/mtx60 =3000mcg/hr=0.6ml/hr

IV Infusion via syringe pump

CNS – Headache. GI – Nausea. CV – increase in systolic BP, tachycardia, premature Ventricular contraction, anginal pain, palpitation, shortness of breath.

Monitor for tachycardia Check vital signs and Bp Administer through central line Setting of syringe pump and adjust the flow rate Check sign of extravasation to avoid tissue damage Always Double check the dose

3. Adrenaline (Epinephrine)

1 mg/ml Vasopressor Cardiac arrest or profound bradycardia, asystole, ventricular fibrillation, or pulseless electrical activity Anaphylaxis Status asthmaticus, bronchos pasm

1mg stat IV Every 3-4 mts used in CPR

1ml + 9ml =10ml (1:10000)=1ml flushed by 2-5 ml saline and elevate the hand

IV INFUSION I/M, S/C

Arrhythmias Sweating Head ache Dizziness Anxiety Palpitation Pallor

Maintain dilution and always flush with saline after administration Check vital signs and Bp Reassure the client Supportive treatment for symptoms like head ache, vomiting

4. Nor adrenaline

2mg/2ml Potent Vaso constrictor

Severe hypotension Sepsis

0.05-0.1/mcg/kg/mt 1-1.5 mcg/minute

1amp= 2 mg/2ml (2000 mics+48 ml) 2000/50=40 mics/ml . 20x0.05=1mics/mt(3x 60 mts=6 mics/hr=1.5ml/hr)

IV INFUSION via syringe pump

Hypertension which may associated with bradycardia Extravasion

Monitor BP Setting of syringe pump and adjust the flow rate Do not cease infusion abruptly Discard dilated solution after 24 hrs.


5. Atropine

.6mg / 1ml Anti cholenergic

Brady cardia AV Block OP Poisoning

0.01-0.02mg/kg/dose Maxi mum dose 1 mg 2-4 mgorhigher

Direct push IV /IM/SC Blurred vision Constipation Dizziness Head ache Dry mouth flushing

Monitor vitals Encourage fluid intake Allow slow change of position

6. Lignocaine

2% without vasoconstriction(lignocaine plain) -2% with Epinephrine (1: 50,000) -2% with epinephrine1,00,000

Anti Arrhythmic

Regional nerve block Arrythimia Status epilepticus Neuropathic pain

1.0mg /kg for child not to exceed 5mg/ kg of lingo caine with out a vaso constriction

Direct push IV INFUSION Dermal patch, Nasal instillation /spray /Tropical gel

Drowsiness Confusion Tremors Altered taste

Make sure that the iv line is Patent Make sure that correct dose is given Close monitoring of heart rate And effect of treatment

7. Adenosine

6mg/2ml

Anti Arrhythmic

Supraventricular tachycardia

0.05 -0.1mg/kg as rapidly as possi ble

1ml+9ml saline =0.3mg/ml 20 kg child 0.1mg/kg=2mg 6.6ml Direct push Followed by saline Flush

IN INJECTION

Facial flushing,head Ache, sweating, chest pain, hypotension , light headedness, dizziness

8. Sodium Bicarbonate

7.5% 10 ml amule 0.9mEq/ml

Systemic Alkalinizing agent

Metabolic acidosis 2) Tricyclic antidepressant overdose

1-2mEq/kg/ dose

9kg child 9mEq stat=10mldiluted with distilled water or 5%dx ,slow push

IV INJECTION

Head ache, nausea, vomiting, muscle pain and twitching

9. Calcium Gluconate

10%w/v 10ml ampule

Ionized hypocal cemia Hyperka lemia Hypermag nesemia Calcium channel blocker toxicity

1-2mg/ kg/ dose or 6ml/kg (10%)

10 kg child 6ml to be diluted with 5%dx or distilled water

IV INJECTION

Nausea, Vomiting, Constipation, Dry Mouth, Tingling Sensation Decreased Appetite

10. Activated Charcoal

250mg /tab 50gm suspension

Binding agent (drug & chemical)

Acute ingestion of selected toxic substances

1 to 2 g/kg /dose Reeat 4-6hourly

For 10kg child 10gm charcoal

(Tablet/ powder) oral/ naso gastric

Chance of aspiration vomiting Gi obstruction

Observe for complication Maintain position to prevent aspiration of vomitus


11. Dexametha sone

4mg/ml Hormone elevated intracranial pressure Croup

0.5mg/kg/day

10kg child 5mg IV slow

Tablets/injection

Dizziness, menstrual change, head ache, weight gain Stomach upset

Strict to the regime Taer off the dose

12. Diazepam

10mg/2ml Anticonvulsants

status epilepticus,muscle sasm due to tetunus, seizures

0.3-0.75 mg/kg/dose IV q 15-30 minu tes

1ml=5mg 10kg child,0.5 mg/kg=5mg,1ml dilute with distilled water and slow push

IV INJECTION, Per RECTAL ,oral

Drowsiness, fatigue, Head ache, ataxia, Dizziness, low BP

Check patency of IV line Make sure that correct dose and route is selected Check vitals specially BP Change position slowly Reassure the client

13. Phenytoin

100mg/ 2ml

Anticonvulsants

Status epilepticus

15-20mg/kg (load ing dose) 5-8mg/ kg (maintanence)

10kg child maintenance dose is 5mg/kg, 1ml diluted with NS (no other fluid) slow injection

Oral/ Iv Brady cardia, confusion, ataxia, vertigo, CNS depression, lethargy, dizziness. GI.- Nausea, vomiting, constipation, diarrhea. Phenytoin use can cause gingival hyperplasia. Diplopia, nystagmus.

Vital monitoring, Check patency Assess for allergy to drug. Administer IV slowly to prevent hypotension. Give oral drug with food to enhance absorption and to reduce GI upset. Monitor hepatic function periodically. Taper dose gradually after long term therapy.

14. Furosemide

20mg/2ml Diuretics Fluid overload Congestive heart failure

2-4mg/kg/day oral dose 1-2mg/ kg/day , IV

10kg child 10 mg of drug ie 1ml drug diluted with distilled water

Tablet/injection

Ototoxicity along with raid administration Confusion ,drowsiness, confusion muscle crams,

Slow administration Maintain intake and output chart Monitor the signs of electrolyte imbalance and inform about this

15. Insulin, Regular

40iu/ml Hormone Diabetic ketoacidosis Hyperka lemia

SC: 0.25 to 0.5 unit/kg per dose IV infu sion dose: 0.1 unit/kg/h

10kg 1unit/hr 1ml+39ml NS @1ml/hr (total 40ml in 50 ml syringe)

Injection Hyoglycemia and hyokalemia

Close monitoring of blood sugar Diluted medicine should not be kept for reuse proper labelling of dose and dilution


13. ANNEXURE - 3

Equipment required for neonatal intubation

Laryngoscope Handle Blades: 00, 0 (Premature), 1 (Neonatal) Self-Inflating Bags (125,250&500cc) Magills forceps for use during naso-tracheal intubation endotracheal tubes: sizes 2.5, 3.0 and 3.5 mm or as appropriate for gestation and size,

suction catheters and nasogastric tube (different size) connectors to fit between ET tubes and ventilation bag and circuit, T-piece or

mechanical ventilator (none should be required with most circuits) tapes for securing ET tubes - skin prep swabs, Leukoplast or Elastoplast

16. Kayexalate (Sodium Polystyrene Sulfonate)

15gm /ouch A cation Hyperka lemia

PO: 1.0 g/kg every 6 hours Rectal: 1.0 g/kg/ dose every 2hrly

10kg child give 10gm ie 1/3 rd ouch diluted in distilled water

Common in powder and tablet

Hypokalemia Dysrythmia Lung paralysis Muscle spasm Constipation

Observe for hypokalaemia proper calculation of the dose check vital frequently check for muscle weakness urine out put monitoring

17. Phenobar bital

200mg/ml Anticonvulsants

Seizures, epilepsy

15-20mg/kg (loading) 5-8 mg/kg(main tenan ce)

10kg child (5mg/kg)=50mg stat 1ml+9ml ns or distilled water =20mg/ml administer 2.5ml slowly

Injection Dizziness, drowsiness, irritability, Loss of balance and coordination Confusion

Check patency of IV line Make sure that correct dose and route is selected Check vitals Change position slowly Reassure the client Provide comfortable environment

18. Hydrocor tisone sodium Succinate

100mg vial Hormone Status asthmaticus

25-50mg/kg/ dose

10kg child 25x10=250mg stat Dilute with 2ml distilled water each vial then administer 5ml as slow Push

Injection /tab

Weakens the immune system, nausea, weight loss, muscle pain, head ache

Taper of the dose Take extra caution to prevent Cross infection due to immune supression


Equipment for intubation of a neonate

Endotracheal tube (ET) size

A rough guide for ET tube size by weight/gestation: < 1,250 g (<32 weeks) 2.5 mm ET tube 1,250-3,000 g (32-38 weeks) a 3.0 ET tube > 3,000 g (>38weeks) a 3.5 ET tube.

Table 1 is a guide to ET tube size and depth of insertion, measured to the lip and to the ala of the nostril, depending on whether intubating orally or nasally respectively.

Baby weight (kg)

Tube size (mm) Oral tube length at lip (cm)

Nasal tube length at nose (cm)

Suction tube size (Fr)

<1.0 2.5 5.5 7.0 6 1.0 2.5-3.0 6.0 7.5 6 2.0 3.0 7.0 9.0 6 3.0 3.0 8.5 10.5 6 3.5 3.0-3.5 9.0 11.0 8 4.0 3.5 9.0 11.0 8

ET tube size and length by weight

An alternative is to assess ET tube length by the rule of six.

Oral tube length(cm) = 6 + wt (kg)

Nasal tube length(cm) = 6 + (1.5 x wt)

The formulas are general guides only and appropriate position must always be confirmed clinically and radiologically. The oral tube formula may produce a low lying tube while the nasal tube formula may result in a high tube.

Procedure

1. Observe standard precautions.

2. Maintain sterility of equipment until use. Use a new ET tube for each intubationattempt.


3. Aspirate stomach contents prior to procedure if the infant has been fed recently.

4. Place infant’s head in the slightly extended ‘sniffing’ position avoid over-extension of the upper airway.

5. Pass laryngoscope blade gently along the side of the mouth and gently pull tongue andepiglottis forward by lifting the blade. If the vocal cords and epiglottis do not comeinto view, pull the laryngscope back gradually until the cords are visualised. This isimportant in avoiding intubation of the oesophagus. Application of cricoid pressuremay be helpful to bring the larynx into view.

6. If the infant remains bradycardic for more than 30 seconds during the procedure andintubation is not near complete, remove the ET tube and ventilate the infant by maskventilation until the heart rate, colour and oxygen saturation are within normal limits/atbaseline for the infant, before attempting intubation again. Remember that intubationof the oesophagus or the right main bronchus are the main reasons for the infant’scondition not improving after intubation. If this is suspected, remove the tube andstabilise the infant by mask ventilation before another attempt.

7. Following insertion of the ET tube, confirm that the tube is in the correct position. Thetip of the ET tube should lie approximately midway between the vocal cords and thecarina. In a term baby this corresponds to 2.5 to 3.0 cm beyond the vocal cords. Theperson in charge of the airway should hold the tube in position at all times, taking carethat the tube does not dislodge, until secured.

8. Confirmation of tube position

Tube position can be confirmed by:

o visualising the black strip on the ET tube pass through the cords

o use of an End Tidal CO2 detector

o observing symmetrical chest-wall motion

o hearing equal air entry on both sides of chest and not over the stomach (maybe an unreliable sign in tiny infants)

o seeing vapour in the ET tube during exhalation

o improvement of clinical condition

o chest x-ray (ET tube tip is seen at the level of T2-T3).


Chapter 14

GYNECOLOGICAL AND OBSTETRIC EMERGENCIES

14.1 Core Concepts

14.1.1 Anatomical & Physiological changes: ● First trimester (upto 12 weeks): Uterus is a pelvic organ & not palpable ● Second trimester (12-28 weeks): Uterus becomes an abdominal organ ● At 28 weeks the uterus is halfway between umbilicus and xiphisternum ● Third trimester (28-36 weeks): Uterus reaches up to the xiphisternum ● After 20 weeks of pregnancy, the pressure of the gravid uterus on the inferior vena

cava can cause a significant decrease in cardiac output, which can be improved by applying a 15 degree left uterine tilt.

● Plasma volume increases by 40-50%: On account of this increased blood volume, a pregnant patient can tolerate blood loss up to 1-1.5 L approximately without showing signs and symptoms of hypovolaemia. However, maternal hypovolaemia may cause signs of fetal distress which is reflected as abnormalities in fetal heart rate.

● The cardiac output increases by 40% and it reaches a peak at 32 weeks. This may cause cardiac decompensation in a patient with pre-existing cardiac disease.

● Dilutional anaemia occurs due to a greater increase in plasma volume as compared to


RBC volume. This causes a decrease in the oxygen carrying capacity of blood. Oxygen demand is also increased. Functional residual capacity is reduced by 20%, so hypoxia sets in faster.

● Tidal volume & minute volume increases by 40%. Due to increased minuteventilation the normal PaCO2 , the value is around 30mmHg. Thus a PaCO2 value of35-40mm Hg may suggest impending respiratory failure.

14.1.2 Nursing responsibilities The Nurse is the first person to start with the life saving intervention , the rest of the team joins the nurse identifying the prioritized problem and immediate action is very crucial in obstetric emergencies. The team has to save two lives, the mother and the baby born or the foetus in the uterus. Till the arrival of the specialist, immediate intervention has to be started, before the arrival of the specialist from the concerned department in an emergency set up. This is a life saving measure .The Nurse must understand the physiology behind the problem and the consequences , each minute has to be utilized by the team effectively for saving the patient.

Common emergency presentations in a female patient:

Table 1: Common emergency presentations in a female patient

Fig 1: Approach for assessment, investigation and disposition


● Use the NELS approach of Assessment and Action ● Take a Focused history especially Last Menstrual Period (LMP) ● Examination – Abdominal, Per Speculum(PS) and Per Vaginum (PV) ● Investigation-Urine for pregnancy test(UPT)/ serum β HCG and Ultrasound(USG)

pelvis. ● Stabilization of ABC of mother (which ensures fetal resuscitation) followed by

specific obstetric management. ● Disposition for definitive management

14. 2 Steps to manage the emergency Start with the needed action and call for help , immediate intervention to be done by not losing time. The four minute principle is to be adopted - The mother with the viable fetus should be resuscitated within 4 minutes, emergency should have the facility to have the perimortem cesarean to save the fetus within 4 minutes. Along with all other emergency facilities. Experienced team with the specialization in obstetric and newborn nursing is to be available at the emergency department . Applying the knowledge of physiological changes is essential for appropriate intervention.

Immediate action is needed by ruling out the causes, and the intervention is to be done without losing time.

Diagramatic representation of the management:

Fig 2: Diagramatic representation of management

14.2.1 Steps ● Initiate the managemen, rather than waiting ● Assist for the management wherever required ● Assist in laboratory diagnosis ● Consent to be taken, wherever required ● Monitor the ongoing care:

ABC

Focused history

Resuscitate the mother and the new born Save new born

All action in NELS

approach


Ethical consideration- pregnancy and related management (eg.disposal of a dead fetus etc.) must comply with ethical guidelines

● High quality resuscitation and intubation ● Effective communication among the team

14.3 Common Obstetric Emergencies

Common emergencies related to obstetrics:

Fig 3: Common emergencies related to obstetrics

14.3.1 Abdominal pain

● Abdominal pain can be related to pregnancy ● Ectopic pregnancy ● Related with abortion ● Premature labour pain /labour pain ● Any gynecological reasons as torsion of ovary ● Surgical reasons such as appendicitis etc. ● Postpartum causes

Bleeding

Trauma &

Assault

Shock Eclampsia

Abdominal pain


Diagramatic representation of cause of pain in abdomen:

Fig 4:Diagramatic representation of cause of pain in abdomen

14.3.11 Scenario 1: A 28 year old married female with 14 weeks of amenorrhea presents with history of acute onset, of pain at right lower abdominal pain since last night and has been persisting since about 4 hours

Steps: 1. Must be assessed for the ABC and try to rule out for the causes through focused

history and carry the needful intervention2. On examination, BP 90/50 mmHg pulse rate 110 /min3. Multiple reasons may the cause, management can be done through the following

nursing care plan and action4. Assess for any bleeding5. Assess the nature of pain6. Keep in mind that the reason may be – Obstetric / Non obstetric7. Obstetric reasons include abortion, ectopic pregnancy, torsion and twisted ovary with

pregnancy,ovarian cyst

8. Surgical reasons may include causes such as appendicitis and other causes like abuse,domestic violence etc.

9. After the initial ABC assist for diagnosis and management


Algorithm for patient with suspected ectopic pregnancy:

Table 2: Algorithm for patient with suspected ectopic pregnancy

Management of woman with acute abdominal pain with 12 weeks amenorrhea for the last four hours. On examination BP is 90/50 mmHg , pulse rate 110/ min


14.3.12 Nursing management of acute abdominal pain

Assessment Action Remarks Assess for -ABC asses for the signs of shock Assess the vital signs Asses for pregnancy Pulse, BP and skin temperature and respiration Assist for diagnosing through history Assess for any vaginal bleeding

Check the BP, pulse, skin temperature by touching Provide with blanket, check the room temperature Ask the history BP is 90/50mmHg, respiration is 28/min, pulse is 110/min Call for help as vital sign monitoring and fluid administration should go Start the oxygen by mask provide the blanket Check the room temperature Open two IV line with large bore 16 or 18 number needle and start the IV with RL and administer within 15 to 20 minutes Draw the blood too while opening the IV line Continue, pulse, skin temperature by touching Ask the history Ask and find out through focused history Observe for any vaginal bleeding by maintain the privacy Continue checking the IV fluid flow

Checking for ABC to for right intervention Can go to circulatory collapse so fluid replacement is essential maintaining temperature is important adjust the IV fluid drops and observe for patency and complication and regulation of fluids in case of cold weather it is important to maintain the room temperature Blood sampling article, specimen bottles to be ready, syringe, needle pair of gloves. Checking vital signs is needed for assessing the basic status of the patient ,temperature checking will take time, effective initial time utility is mandatory for saving the patient Correct history will assist for right diagnosis stabiles the patient first TPR tray and ,BP instrument- in


Assess the cardiac function

Observe for the general status of the patient check the anxiety level through the facial expression and through the behavior

Assist for diagnosing

Asses the abdominal pain, type and the location, colicky, spasmodic, radiating to the back, Assess for the abdominal tenderness

with NS/RL 500ml and finish within 15 to 20 minutes

Assist in placing patient in monitoring observe the respiration

In case of breathing difficulty

Start the oxygen by mask continue Monitoring the pulse, BP

Observe /ask for any bleeding per vagina

Communicate with the patient

Check the temperature of the extremities by touch

Explained

Talk and make the patient calm as the patient has found apprehensive place the patient in cardiac monitor if there is no improvement in the vital signs, communicate with the patient

Be with the patient be with the patient if the examination has been done by a male medical person

Assist in taking the detail history and for examination

Repeat in checking the BP pulse and skin temperature

good working condition to be available

Ensure privacy has been maintained

Pregnancy test kit in working condition to be availed

Time management is needed and certain intervention to be done together

History will help for diagnosis

Care of the IV line is needed

Perform the abdominal examination

If the vital signs are low, place the patient in the cardiac monitor to know the status of the patient easily

Communication will ease the apprehension of the patient and the relatives assist to take the quick history,

to assess the cardiac function as the Bp is low and an automatic reading will ease the management for intervention and for diagnosis

Bring the PV examination tray and explain to the patient

Stabilizing the patient is needed


Nausea, vomiting , Fever rebound tenderness Abdominal distention bowel sound present or not Confirm for pregnancy Assess the cervix for any changes, presence of tinge of blood Asses for laboratory diagnosis Continue to assessing for ABC help in assessing further for diagnosis by taking a detailed

Document all the findings and treatment in a quick manner Continue the observation Perform pregnancy test Document all the action done and file all the reports Continue the observation Collect the urine sample and perform he pregnancy test through the kit Perform the pregnancy test Assist /do the pv examination gently After a gentle vaginal speculum examination to make sure about the cervical condition, and for any signs of pregnancy in the absence of an ultrasound report Assist in pv examination by arranging the article for ie , a tray with vaginal speculum gloves betadine cotton swab so .lubricant, ,kidney basin and good source of light , privacy to be maintained Draw the blood sample for complete blood analysis and for any other sample ordered

for further diagnosis and management Tension can further deteriorate the condition Ethical aspect to be observed For confirmation of diagnosis ultrasound is needed Must be ready with the requisition and patient to be prepared for the detailed investigation for correct diagnosis if the vitals signs are stable For ethical reasons female nurse has to be with the patient For immediate interventions ultrasound report is mandatory Documentation is a part of nursing procedure which is essential for reference and treatment and for record Identifying any other surgical problem is mandatory Severe pain can be due to any critical condition which may lead to shock Tray should include Sims speculum / cuscus speculum long gloves, lubricants water soluble kidney tray, mackintosh / disposable protective sheets Changes in cx s denotes the


obstetrical history Assess further for diagnosis through ultrasound Assist for confirming the diagnosis Assess the lab report to assist for the diagnosis Assist in confirming the diagnosis and management ABC monitoring Assess for any vaginal bleeding

Ask for any fainting ,bleeding and reveals that she had fainting and bleeding few days back and there is no history of any fever Assist in diagnosis, by preparing and explaining for ultrasound as ordered Prepare for ultrasound Collect the report and assist interpreting the report Check the vital signs, and talk to the patient. If bleeding is present, observe the amount and type of bleeding Observe the bleeding per vagina continue monitoring the vital signs Assist for diagnosis by collecting the report

pregnancy and any other changes to be monitored Tinge of blood has found in the finger To confirm the pregnancy Blood sampling article, specimen bottles to b ready, syringe, needle pair of gloves Needle and syringe disposable puncture proof container and colour coded disposable bags to be available Should no miss any low lying placenta and other condition which may hinder the treatment and management/cause damage Pv examination assists for diagnosis Collect the urine sample for the pregnancy , kit ready for the test Bleeding can be of concealed type so presence of blood in the gloved finger denotes bleeding Annexure for pregnancy test Assist for arranging blood and lab Diagnosis helps in diagnosing and for management incase of pregnancy


Assist in confirming the diagnosis through the investigation

Reassess the vital signs and any sign of deterioration

Continue assessing ABC

Assist in assessing the report of the ultrasound

Identify the order for surgery

Assess the sign for circulatory collapse By monitoring the vital signs

Asses the severity of pain and check for the order for

Reassure and interact with the relatives /follow the protocol of the hospital

Assist in collecting the report, interpreting the report

Reassure the patient

Continue monitoring the vital signs monitoring

Prevent from circulatory collapse, continue with the IV crystalloids as fast iv flow /ordered assist in arranging the blood Assist in measuring the SI

Prepare for surgery

Take the consent

Arrange for blood

Continue monitoring the vital signs

In case of ectopic pregnancy twisted ovarian twist prepare for surgery immediately in a very fast manner

Complete the documents, make sure that lab reports have been attached with the file and file have been completed

Give the analgesic

DIC can aggregate the condition

Team work will facilitate for better management

Assessment and examination suggests for ectopic pregnancy -Refer the annexure

All protocol for preparing for the laparotomy

Severe pain can lead to shock too

HCG level with ultrasound reports confirm s the diagnosis of ectopic pregnancy

If any surgical cause as acute appendicitis etc refer for surgical emergency and prepare for surgery

Nurse should have the basic knowledge

To assist in planning an immediate intervention

Helps in identifying the status of the woman ,talking will help to assist understand about the deteriorations

Work as a team in a fast manner fluid collection may be a sign of


analgesic Assist diagnosis Assist in assessing the laboratory diagnosis If planned for any surgery according to the diagnosis Assist for the surgical intervention planned by the doctor

Prepare for surgery soon once it has decided. Inform the OT arrange for blood according to the order Follow all the protocol Reassure and communicate with the patient Complete the document follow all the protocol for sending a patient to OT and shift the patient to the OT Follow the order prepare for surgery according to the order Complete all the documents Inform to the concerned department that the patient will be shifted after surgery In case of abortion has been the diagnosis Restrict the movement of the patient, Perform the p v examination and make sure for dilatation of the OS if so and presence bleeding of Ensure privacy make sure that the patient is relaxed ,and applied sanitary pad after the procedure Continue observe the patient Check for pulse, and feel for the skin temperature, check BP Assess in performing the ultrasound and identify uterine sac completeness

ruptured tube and intervention to be in a delayed response can lead to shock nurse should have the basic knowledge to work along with Follow the protocol of collecting the report HCG level along with the ultrasound to confirm the diagnosis prepare for ultrasound Needed for correct diagnosis Any incoherent speech is one of the sign of deterioration internal bleeding may not be able to detect easily follow the protocol of surgery If physically challenged guardian can give the consent Collect the report and assist in identifying and interpreting the report if any doctor may be busy in small center


Asses for the ABC Ensure the diagnosis Assess for abdominal tenderness Nausea, vomiting, Fever rebound tenderness Abdominal distention bowel sound present or absent continue assessing the ABC Continue assessing the ABC Observe for circulatory collapse ABC Assess for vaginal bleeding or spotting Assess the ultrasound sound report to confirm for any surgical

Assist for abdominal palpation If os is fully dilated prepare for D&E If not and the observe for bleeding and counsel the patient and relatives about the need for strict bed rest and if the bleeding has controlled ,can send home and treat as OPD patient If the OS is open and the bleeding has been continued has been turned into inevitable abortion treat according to the order ie Prepare for D&E Prepare for surgery follow the protocol of the surgery Complete the document Reassure the patient Continue assessing the vital signs If surgical causes are detected follow the order for laparotomy by assisting and following the surgical protocol ,make sure that reference of the case has been done and the case has been handed over to the surgeon by sending the reference in the midst of preparation ,give analgesic if ordered for Complete the documents Follow the protocol for surgery

Circulatory collapse can occur , intervention to bed one in a swift manner identify the SI to detect the condition and hypovolemia than the pulse SI ie pulse rate divide by the systolic pressure and if it is within .6 to.7 is normal and if it is above .9 it indicate hypovolemia in case of internal bleeding patient can go to hypovolemia In a hurry no error to be committed by the nursing personnel or by the team Team work to save the life Prepare for the P.V tray , There is chance for bleeding and vaginal discharge after p v examination, making the patient comfortable is the one of the nursing action Profuse bleeding, and blood loss can lead to shock Confirming the diagnosis is needed for the treatment and general examination is the part of the diagnosis Follow the OT protocol Observe for the effect of the analgesics


intervention

Assess for preparation for surgical intervention

Consent , part preparation etc

communicate with the woman and with the relatives

and brief about the management /surgery

assess the vital sign continuously and monitor follow the OT protocol

ensure the completeness of the documents

Follow the NELS protocol

Follow the protocol ,call the team for assistance to prepare for surgery

Communication ,makes the woman and the relatives ,accompanied personnel at ease

Internal bleeding can make the patient deteriorate

Assist in caring the patient belonging and valuable according to the protocol

Accompany the patient

Team work on a fast track is needed to save the patient and for better management Follow abortion follow as NELS direction

14.4 Ovarian cyst

(Condition 1: Abdominal pain due to ovarian cyst) For the woman who has come with abdominal pain in the collapse stage diagnosed as ovarian cyst.

14.4.1 Nursing management of ovarian cyst Assessment Action Remarks

Assess ABC

Assess the vital signs continuously

Continue all the protocol as in case of pain abdomen above with case NO1 above and prepare for surgery if ordered for

During pregnancy ovarian cyst may undergo torsion and rupture

Initial steps are same as above prepare for surgery if needed as ordered


If the patient has been settled treat as OPD patient

Complete the documents

Maintain the documents

Communicate therapeutically

Provide all care based on holistic approach

Communication and holistic approach and documentation is part of nursing activity

14.5 Dysmenorrhea

(In case of negative pregnancy test) with the clinical manifestation mentioned above. 14.5.1 Nursing management

Assessment Action Remarks

Assess for ABC

the pulse and respiration

Assess the location of pain and confirm

Assess the menstrual history

Assess in ruling out the cause for pain

Perform the initial assessment as in scenario 1

Check the vital sign pulse is 90 respiration is 30 /min

Administer oxygen

Assist in physical examination of the abdomen and remain with the patient

Administer the analgesic ordered

Communicate with the patient s and with the attentender maintain privacy throughout the investigation an during the assessment make sure that a female nurse /attentender is with the patient

Assist in the diagnostic procedures

Dysmenorrhea can cause dyspnea in rare case due to VVSS

Correct diagnosis is essential

For ethical reason patient should not be left out

History reveals that she has a history of severe dysmenorrhea and has not taken any pain killer

Injectable analgesic will act faster

Ethical reason female as t


as ultrasound

when the pain has subsided patient can be advised for the detailed ultrasound

discharge advice should be given

and as an OPD patient can be treated

Advise to take the prescribed analgesics as a routine for each menstrual period and to have the follow up in the OPD If the pain is not controlled rule out for other cause as ordered by the doctor

Keep for observation minimum for an hour Reassure and communicate to the relatives

Assist in referring the case according to the case if required

Complete all the documents

be with the patient if examined by any male

Dysmenorrhea also can cause

Severe pain and management is required

Other causes of abdominal pain may be associated with the bleeding per vagina either perfuse or mild so accordingly the protocol to be followed


14.6 Bleeding Per Vagina

Fig 5: PV Bleeding

Bleeding per vagina can occur during and after the delivery, and due to other causes and is one of the major cause of woman’s death related to pregnancy and after delivery ,if related to pregnancy it may be of

⮚ An implantation bleeding which is less in amount and is of spotting in nature ⮚ Laceration in the genital tract ⮚ Cervical erosion ⮚ Hydatidiform mole ⮚ Abortion ⮚ APH

After the delivery: The causes may be of

⮚ PPH ⮚ Laceration of genital tract

Understanding the physiology is crucial for the prompt management, low lying placenta can lead to hemorrhage in case of APH

Haemodilution occurs during pregnancy and 50% of the woman during pregnancy is anemic ,massive changes occurs to the uterine blood flow during pregnancy , placental perfusion is about 700 to 900ml per minute 20% of the total circulation goes to the uterus, uterine blood vessels and capillaries have no capacity to constrict by its own uterine muscle’s contraction is crucial to control bleeding after the delivery..Atonic uterus is the main causes of bleeding after delivery


Women's physiological changes are such that bleeding up to 1000 ml can be tolerated without showing any symptoms during the last trimester and after the delivery.Internal collection of blood clots can occur in the genital tract

Any retained products in the uterus during delivery will lead to atonics uterus and there by bleeding results Uterine massage and compression reduces the bleeding by stimulating the uterine contraction Blood coagulopathic changes during pregnancy is another factor that trigger bleeding related to pregnancy and postpartum

Surgical intervention of compressed suture known as lynch suture, and ligation to the major arteries reduces the bleeding after the delivery and saves the woman so reference to the experts ,/to the tertiary hospital is mandatory after the initial protocol

Attending the woman with immediate effect for a woman with bleeding is very important as massive blood flow to the uterus during pregnancy and the changes in the circulation to the uterus leads to bleeds larger volume of blood than of other patient, so action to be in a very swift manner

Bleeding related to abortion to be identified and the, psychological impacts of losing a fetus to be understood based on the type the management varies and strict bed rest is mandatory for a threatened abortion and shift to the woman to the Gynecology department, ethics behind the abortion and MTP acts to be complied with to the team working with these woman

So focus on the history of the woman and the methods of conception ,as whether it is it a precious pregnancy or not to be considered and break the news accordingly

Ethical aspects and hospital protocol to be followed to discard a fetus. After the human structure has formed handle the dead fetus according to the protocol by filling the forms with the handing of the fetus Periodical review and government protocol to be considered in the management as the methodology and the directions are changing frequently on evidenced based practice e and the policy of the nation

Separate chart to be made ready for compacting with obstetric bleeding , as quick action is needed However the objective is to prevent further bleeding, restore the blood and fluid loss, preserve pregnancy as far as possible and prevent any further damage


14.6.1 Causes Diagrammatic representation of the causes of bleeding:

Fig 5: Diagrammatic representation of the causes of bleeding

14.7 Type of abortion:

1. Spontaneous 2. Induced abortion 3. Septic abortion 4. Threatened abortion 5. Complete abortion 6. Incomplete abortion 7. Missed abortion 8. Habitual abortion

● In threatened abortion the fetal sac is intact OS is not open ● Inevitable abortion- vaginal bleeding and OS is dilated ● Complete abortion - all the fetal parts have been expelled out ● Missed abortion- is the repeated pregnancy loss due to incompetence OS ● Missed abortion- the fetus dies or not well formed and fetal part may be expelled but

placenta and the pregnancy products retain in the uterus ● Any abortion with the clinical manifestation of infection can be termed as septic

abortion


Table 3: Terminology for misscarriage

Terminology for spontaneous miscarriage

Terminology Definition

Threatened miscarriage

Pregnancy-related bloody vaginal discharge or frank bleeding during the first half of pregnancy without cervical dilatation

Inevitable Miscarriae

Vaginal bleeding and dilatation of the cervix

Incomplete miscarriage

Passage of only parts of the products of conception

More likely to occur between 6–14 week of pregnancy

Complete abortion Passage of all fetal tissue, including trophoblast and all products of conception before 20 week of conception

Missed abortion Foetal death at <20 week without passage of any fetal tissue for 4 week after foetal death

Septic abortion Evidence of infection during any stage of abortion


Algorithm for management of spontaneous abortion:

14.8 Immediate observation and line of management

Fig 6: Immediate observation and line of management

Non threatened abortion can be Evitable and Inevitable

Abortion

ABC

Assess for the amount of bleeding

and fetal parts or conception sacs /part

presents inthe expelled part

Assess the chances for continuing the

pregnancy


14.8.1 Clinical manifestation The woman will be presenting with the history of missed period ,with bleeding with lower abdominal pain spasmodic in nature with or without the history of expulsion of fetal parts/conception sac blood clots can be collected in the lower genital tract so ABC Monitoring and management is very crucial . Take consent, explain to the patients and the relatives as number of time an abortion is unacceptable to the couple .News to be broken to the patient based on the history of the conception PV examination will reveal whether the OS is closed or not ,if the OS is open and no chance for continuation of pregnancy prepare for uterine evacuation with immediate effect to prevent from hypovolemia and shock due to blood loss . Arrange for blood, nursing action to be very swift to save the woman as the bleeding may be of massive till the arrival of the specialist all arrangement for evacuation to be ready ie inform the OT ( operation Theater ) , OT protocol to be completed with as consent , drawing of sample for lab diagnosis, ultrasound preparation , to be completed with to save time and basic protocol for these intervention to be available at the emergency.

If the conception sac is intact and diagnosed with threatened abortion woman should be advised for strict bed rest ABC, monitoring and management to be continued and stabilize the patient.Once stabilized refer the patient to the ob gyne ward, assist for the lab diagnosis

Expulsion of the fetal parts to be observed carefully. Plan of management has been done according to the type of abortion but the aim is to stabilize the patient and prevent from shock due to the blood loss

Fig7: Diagram showing the management of threatened abortion

Threatened abortion

Observation of bleeding for any fetal parts

ABC monitoring

Fluid and blood replacemnets


14.8.2 Nurses Flag

Fig 8: Nurses flag

Objective After the management will be able to --Preserve the pregnancy and prevent from shock

-If the abortion has been neglected or and gets infected called septic abortion

14.8.3 Septic abortion When and induced abortion gets infected is called septic abortion patient will present with septic shock if has not treated on it:


14.8.31 Clinical manifestation of septic abortion

Fig 9: Septic abortion

Management:

Management should include ,prevent from further infection and from septic shock ABC management High antibiotic as ordered assist for all general care and well being reassure the patient and relative is important and refer the patient to the gyne department for further care once the patients vital signs are stabilized Symptomatic management and referral if related infection as peritonitis etc have been ruled out upon the delay for the approach for medical aid Counsel the relatives too

14.9 Ectopic pregnancy ● Bleeding with abdominal pain can lead to shock and tubal rupture if pregnancy is

within the tube● Patient can go to shock so immediate management is important● All protocol as per the logarithm consent and try to prevent from tubal rupture prevent

from shock surgical intervention to be done patient can go to shock as internalhemorrhage takes places and

● incase of tubal pregnancy tubal rupture can occur an emergency ultrasound reveals thediagnosis

Ectopic pregnancy can be misunderstood by the patient and the relatives ,if any delay in admitting and taking the intervention can go to shock and even tubal rupture


14.10 Placenta praevia ● Placenta is located in the lower pole of the uterus and can be classified as:

a) Central b) Lateral c) Marginal

● The centrally lying placenta can be called as degree four as the placenta is located centrally ie the placenta lies s over the center of the placenta

● Lateral –placenta lies over the os when the os is closed and is up to 4cm dilation is can be also termed as degree three

● In marginal placenta the edge of the placenta is at the margin of the os in degree two and edge of the placenta is in the lower segment and can be categorized as degree one

● An ultrasound will show the placental position and the likely interference with the labour in case of massive bleeding placental blood vessel rupture must have occurred and the only remedy is to perform the LSCS and deliver the baby restore the blood arrange for the blood ,inform the neonatal team , and OT for the LSCS less movement to be done throughout the management as the movement may initiate more bleeding ,no vigorous abdominal palpation as a part of assessment to be done review the hemodynamic status till the arrangement RL / blood substitute to be given understand the circulation and the chances for massive bleeding and care .

● If the bleeding has subsided shift the woman to the gyne ward complete the document maintain the privacy and respectful care

● Any woman with the history of frank bleeding without any pain after 20 weeks to be suspected of placenta previa

Figure 10: Placenta praevia

● Placenta is highly vascular, and is in elastic in nature so massive bleeding can occur. ● No, attempt to do the P.V examination

Degree 1 Degree 2 Degree 3 Degree4

Diagram showing the placenta praevia


● Nature of bleeding will be of frank and fresh ultra sound will reveal the lower lyingplacenta if not done it should be done

● Placenta praevia diagnosis is confirmed through ultrasound. If the woman comeswith labour pain immediate preparation to be done for LSCS, blood to be arranged soteam management to be done in a fast manner

● Fetal heart sound to be monitored and make sure about the fetal wellbeing anydelivery attempt will be done in the OT only

● Key point to remember is that the placenta is in elastic and while the os getsstretches the blood vessel tear off and bleeding occurs so no attempt to be done forvigorous or repeated palpation or for pv examination

● Fetal well being to be monitored though CTG /Doppler● Prepare for ultrasound to identify the placental location and separation● Call for the neonatologist, for the resuscitation for LSCS● In case of marginal Placenta praevia attempt of delivering a baby to be done

only in the OT● Make sure about the consent, right communication, about the condition, need for

LSCS, need for the arrangement of blood● Complete the documents● Patient to be ready for LSCS /when the specialist reaches and protocol to be available

for emergency midwife /nurse posted in the emergency for the all above interventionthan waiting for the doctor

● in case of mild bleeding with a stable ABC, allow the pregnancy to continue till 37weeks, strict bed rest under the monitoring of Obg team

14.11 Nurses flag

Figure 11: Nurses Flag


14.12 Placenta abruption Bleeding is from the normally located placenta is associated with trauma ,PET ,and is accompanied with the abdominal pain bleeding will be of dark blood in color ,and there can be micro bleeding to the uterine fibers, internal bleeding will occur and patient will be showing the symptom of shock It is important to understand about the nature of bleeding and the related symptoms .if the patient is not able to manage uterine damage can occur and the uterus undergoes a condition called uterine apoplexy/ couvelaire uterus ,patient will go in shock

For the initial plan and to save the mother and the fetus it is important to know the difference in the clinical manifestation of placenta praevia and placenta abruptio and all initial steps to done till the arrival of the specialist inclusive of the information to the OT to save the life of mother ,fetus and the uterus presence of DIC to be monitored patient with abruption placenta can go to shock due to concealed hemorrhage

Key clinical manifestations of placenta praevia and placenta abruption

Placenta abruption Placenta praevia

Bleeding is concealed ,may not be visible Bleeding is revealed

Associated with abdominal pain Not associated with abdominal pain

Ultrasound reveals a normally located placenta Ultrasound revels the lower line placenta at the os or near to the os

There is microcirculation to the uterine muscles and uterine apoplexy develops

Not present

Associated with trauma or PET and a chance of shock is there

Not present

Chances of DIC is present Not usually present

A 26 year female with 12 weeks of pregnancy complaining of spotting since three hours and abdominal pain since morning


Scenario

Objective

After the skilled nursing interventions, the nurse will be able to ● Prevent from shock ● Preserve the pregnancy ● Reassure and support

14.12.1 Nursing management of client with spotting with the history of pregnancy

Assessment Action Remarks

Assess the ABC

Asses for any vaginal bleeding and assist in diagnosing

Assessment to confirm the pregnancy through ultrasound in case of negative pregnancy test

Check the Bp is 100/60,spo2 98% pulse 90/min responding to verbal questions

Call for help and call the team

Start the IV line with two large bore needle and start the RL/NS

Inspect for any vaginal bleeding / and examination of abdomen for any rigidity ,tenderness ,and location of pain and type of pain take the focused history

Perform the pregnancy test for identifying the pregnancy prepare for ultrasound monitoring

Ultrasound monitoring is needed

Collect the Blood sample along with the iv line opening

Direct the patient to have bed rest provide the sanitary Pad and observe the amount and type of bleeding

Assist in performing the pv examination /perform the pv examination

Prevent from any shock is needed

Spotting have been found

Confirmation of pregnancy is needed for diagnosing

To identify the fetal sac and confirm the pregnancy in case of negative pregnancy test

No need for another action and time can be saved

Pv tray containing surgical gloves ,lubricant water soluble ,speculum cuscus or Sims

Assemble the article syringe ,pair of gloves ,sample bottles ,label ,and request ion form if


Hemodynamic Assessment

Assess the status of cervical os and sign of inevitable abortion

Assess for the for lab diagnosis and the status Hb%&,Gh and other hemodynamic status &HCG Level

Ensure all the blood sample have been collected and send for CBC,Gr RH ,blood for cross matching

Advice for strict bed rest under close monitoring

Collect the blood report

If no bleeding follow as in above case as opd patient

Provide psychological support reassure the patient

Withdraw the blood samples and send for investigations

If the pain subsides plan for discharge under strict direction

Very strict bed rest

With the direction of

Observe for any blood clot ,abdominal pain ,or passage of fetal products And strict antenatal diet& with the direction to -

Come to the hospital /facility with immediate effect for any of the problem

Incase of perfuse bleeding /the

not done

Os is closed and blood spotting has been found in the gloves

Woman is very sensitive during pregnancy ,abortion gives mounting pressure to have psycho logic tension

Protocol for right sample in right bottle and rule of infection control and right disposable of syringe needle and used item to be done

Threatened abortion can become an inevitable one if bleeding is excessive and disturbs the fetal sac

Proper intervention will facilitate for the management in case of timely report


bleeding have been increased prepare for the intervention mentioned under abortion if diagnosed as abortion

And follow the OT protocol


Holistic approach nursing management ,efective communication and ensure privacy and consent according to the protocol

Ensure a good team management for total care


14.12.3 Nursing management of placenta praevia Action Remarks

ABC Assessment

Assess for the week of gestation and the amount and type of bleeding, as whether it is frank fresh or brownish color bleeding

Assess the status of circulation tachycardia, pallor, confusion

Assess the FHS

Finds deterioration of the patient and BP is 90/60 mm hg and above

Assess the fetal well being

Monitor the pulse ,BP and skin temperature

call for help

talk to the patient and brief the patient what intervention are going to do along with the action in a fast manner

Open two IV line with wide bore needle and crystalloid within 15to 20 minutes and

Collect the blood sample while starting the IV

Continue observing the vital signs and for any deter orations of patient as disorientation massive bleeding cold as above and cold clammy skin along with the management and intervention

Arrange for fresh blood /frozen plasma and administer the blood and the plasma

Monitor the FHS /CTG /Doppler

Feel for the skin temperature saves time

No pv examination will be done

Patient apprehensions will increase the chance for non co operation for treatment and management patient has to know about the treatment plan the right

Close monitoring and vital sign monitoring is important while having massive bleeding with low lying placenta

Placenta provides


Asses for the type of placenta praevia marginal lying , central if marginal lying with the symptom of labour pain send the woman to the OT and prepare for

Assess for all laboratory diagnosis

Assess the condition and the bleeding amount

Assess the ABC

Continue assessing the woman’s ABC check for SI

Till shifting the woman to the OT

Check the fetal heart sound

Ask for an ultrasound report if the patient is carrying the report if not immediately prepare for an ultrasound

Check for BT,CT ,,fibrinogen level report arrange for the blood by collecting the report

In case of perfuse bleeding

Prepare for LSCS on a very fast manner arrange for more blood according to the order

Inform the OT and inform the neonatologist as the baby is premature and may be born with asphyxia and related problem

Accompany the patient to OT and assist for delivery in case of marginal placenta in the OT as the bleeding can occur and attempt for delivery in the OT under ’obstetrician’s ,management and manage under strict observation as

Check the pulse and BP

oxygen and nutrition and any disturbance in the placental circulation affects fetal condition

Identification of the type of placenta praevia is important to ha an effective management of location of

For centrally lying placenta with severe bleeding the management is only LSCS without any trial labour

Bleeding related to placenta previa is very heavy direct bleeding comes from the blood vessel of low lying placenta and mechanism of clotting and the process of controlling the bleeding from the lower uterine


Continue with the assessment of ABC

Continue the assessment and general condition

Check the hemodynamic status ie find out the fibrinogen level, platelet count and it is above 250 and 100000/respectively

Check the pulse an BP and talk to the patient

DIC is common complication in pregnant woman with massive bleeding so observe for bleeding

Maintain the bed rest and restrict the movement

Close monitoring of vital signs and excessive bleeding for pph to be done after the birth of the baby

Check the vital signs

Keep the woman under observation under close monitoring of amount of bleeding and in every half an hour checking of the pulse

Communicate with the woman and with the relatives continue monitoring the vital signs and the bleeding

Continue the care in post partum ward

Observe for bleeding and monitor

segment even after birth is very is poor as compared to the upper segment located placenta

Chances of normal delivery is there in case of marginal placenta praevia but there is a risk for bleeding so be done

Vulnerable to have pph after the LSCS and the delivery of the baby

Movement will cause the bleeding from the low lying placenta in the


Assess for ABC

Incase of mild bleeding

and the vital signs are stable with marginally lying placenta

Assessment shows

If no bleeding observe for 24 hours under close

the amount of bleeding for 24 hours make sure that woman is on 24 hours strict bed rest convince the woman and the relatives about the need for bed rest and the consequences

Make sure that patient has been shifted to the obg/gyne ward for further observation and care

Continue checking the type of bleeding keep all the pads saved to assess the amount of bleeding

Check the fibrinogen and the platelet level prior to the shifting

Start the IV with two large bore needles of 16&18 size with RL/NS

Observe fetal hear sound

Vital sign monitoring

Check for FHS

Assist in taking the focus

general ward close observation may not be possible

Allow the pregnancy to continue till 37 weeks of gestation and can plan for delivery in a higher /tertiary center

Incase of abruptio placenta internal bleeding is more


monitoring

Assess for the amount and the type of blood usually red in colour and fresh bleeding on examination

Assess the haemo dynamic level

If Assessment shows the sign of abruption placenta

history(focus ) for – the following -

history of fall –

hypertension during pregnancy

call the patient to check the alertness

assist for abdominal examination

draw the blood sample

Draw the blood sample

Assist for ultrasound after stabilizing the vital sign

Prepare for delivery ,notify the doctor

assist for pv examination for any labour signs

Arrange for blood

separation very marginal keep the woman under observation for 24 hours and shift to the gyne department

check for any uterine contraction

Fetal heart sound

Check the vital signs continuously

SIt is needed to assess the placental location for pv examination

Arrange article for Pv examination

Internal bleeding may worsen the condition and internal bleeding is common with the


abdominal pain -usually will have the abdominal pain

Fundal height /size of

the uterus is more than of the gestational age

Uterine tetany

Uterine tenderness and rigid

Asses

FHS –

Perform the pv examination

Start with the induction in case

if the vital sign of the woman is stable

with a viable fetus

Observe for labour signs

Continue the observation

Alertness –confusion tachycardia ,low Bp

Abdominal pain,

Uterine tenderness

Continue assessing the ABC

For blood coagulopathic -fibrinogen studies

Assist to Assess the degree of placental separation through ultrasound

Assessment shows Placenta in the funds

If the placental separation is severe

For any labour sign to ascertain

Any critical patient urine out put to know the function of the kidney

Continuing the assessment and care is mandatory


ABRUPTIO PLACENTA

Nursing management of abruption placenta

Assessment

Assess the woman for ABC

Asses the uterus

Asses for the fetal conditions

Assist in assessing the status of woman and the fetus

Action

Check the vital signs, BP pulse, respiration and temperature by touch

Start the iv line with large bore needle of 16 or 18no if (associated with eclampsia make sure with the clinical feature and restrict the fluid )

Assess for ABC and signs of shock

Ensure and remind for the blood coagulopathy related investigation has been done ie BT,CT fibrinogen ,

And LFT &KFT as ordered

Check the abdominal girth ,tenderness

Do the fetal assessment ,can assess through CTG etc

Continue monitoring the ABC ,blood pressure ,and signs of shock

Ask and find out the level of orientation by calling out the name and the response

Remark

The patient can go to shock

Abrutio placenta is associated with eclampsia ,and hyper tension and trauma

Ultrasound can reveal the damage of uterus due the abruptio placenta and the of can intervene

internal bleeding to the uterus will be massive and complete damage may occur

DIC and blood coagulation disorder is commonly associated with

Team work will facilitate the work

Fetal condition can be monitored clearly through CTG and Doppler

Internal bleeding will be of concealed type and can go to shock

And will be of severe in nature

Annexure –

PET is associated with

Abrupt placenta for management right diagnosis is essential

Knowing the history is essential to plan the intervention like


Observe for fetal distress if the fetus is viable

Document the fetal, condition with the time

signs for PET as edema protein urea ,hypertension ,blurred vision ,headache to be monitored

Continue assisting the status and for PET

Assess for the urine out put

Complete all the documents

Continue assessing the uterus for any enlargement or sign of apoplexy

hysterectomy as a management patient and relative preparedness is essential

Saving the fetus is also important but priority to be given to the maternal life

After the emergency management from the OT continue the care in critical care ICU and the neonatal care will be followed under the care of neonatologist

Placenta abruptio can be associated with PET ,DIC ,which can affect all the major organ observing kidney function is important

Timely intervention will save the woman and can preserve the uterus

Timely checking the haemo dynamic

Will assist to arrange the blood if required as an emergency

Right intervention is needed to save the mother and the baby


Continue the ABC monitoring

If the condition is for surgery by assessing the status

Prepare for surgery by following all the protocol

Talk to the patient to know about any disorientation

Continue monitoring the vital signs

Monitor the vital signs and FHS

Assist with the intervention planned ie prepare for LSCS if the uterine damage has not happened to preserve the uterus

Collect the blood sample for platelet count, fibrinogen level ,BT,CT,PT

Continue the care stabillise the patient and send to ob gyne department /OB gyne ICU

If planed for surgery follow the protocol maintain the communication


Saving the woman ,her uterus ,and the fetus to be prioritized


14.13 POST PARTUM HAEMORRHAGE It is the excessive bleeding after the delivery, within 42 days up to 1000 ml of bleeding, above 500ml to be considered as under observation, or any amount of bleeding after the delivery that deteriorate the physical condition of the patient

14.13.1 Classification Primary pph –which occurs within 24 hours of giving birth Secondry pph –occurs after 24 hours to 42 days of delivery

14.13.2 Causes Trauma Tissue Tone Thrombin After the delivery the uterus contract and constricts the blood vessels to stop the blood flow as was having during pregnancy the blood vessels are large in number with collateral circulation and uterine muscular contraction is important to constrict the blood vessels uterine massage stimulate for the uterine contraction which helps to constrict the blood vessel Any placental part or fragments retains in the uterus, the uterus will not completely contract and sub involution occurs and this will lead to pph removal of any placental fragments is crucial to control the bleeding Empty the bladder full bladder causes pph Coagulopathic -- Though there is not much evidences about this it has been found there is marked change that occurs in the blood coagulation and introduction of Tanexamic acid for pph has found that marked reduction of pph have been observed The four T should be observed, as mentioned above The main reason for the pph is atonic uterus

14.13.3 Physiology During pregnancy massive changes occurs to the uterus with maximum blood circulation to the uterus and collateral circulation increases blood vessels will not have the capacity to constrict by its own, along with the uterine contraction the blood vessels are constricted and there by bleeding have been controlled

1. Tissue Any tissue remains in the uterus will not be allowed as it will not cause effective uterine contraction to constrict the blood vessels to cause the involution; it can be of any placental fragments, tissue remaining of the placenta 2.Trauma Any trauma Any injury occurs to the genital tract can cause bleeding


3.Tone Uterus should have a good tone ad tone can be lost due to various reason as retained placenta and due to unknown reason (many of the causes are not sure about) 4.Thrombin Coagulation changes occur to some extent and shown that altered coagulopathic during pregnancy also leads to pph

14.13.4 Initial assessment and Action Woman will not show any clinical manifestation till she loses the blood up to 1000 ml after LSCS and 500ml after normal delivery and any bleeding that deteriorated the vital signs referred to as PPH Immediate intervention to be of the following to be done without wasting any time to save the woman Start iv line ,oxytocin ,uterine massage Empty the bladder Do the PVexamination and remove the retained products Focus history to be taken ,and briefing about the labour and delivery is important planning the management Draw the blood sample for BTCT and ,cross match if not controlling surgical intervention to be done

14.13.5 Definitive Management:

● Oxytocin infusion 20units in 500ml of NS/RL at 60 drops per minute ● Misoprostol tablet 800 mcg sub lingual can be added if no response to oxytocin ● Carboprost (prostaglandin PGF2 alpha) intramuscular 250 microgram at 15 minute

intervals with maximum of 8 doses (contraindicated in asthmatics) ● Tranexamic acid 1gm iv ● Problems during or after delivery- placenta delivered with difficulty ● Peri partum and ante partum level of care- no ante partum care; peri partum care

provided by unskilled ● Obstetric History- para 5 with all previous normal deliveries. ● Past medical History- not significant ● Foleys Catheter with Condom Inflated with Saline Used for Uterine Tamponade in

PPH

Detail abdominal examination- uterus relaxed (atonic) Per-vaginal and per speculum examination - No cervical or vaginal lacerations, Uterine cavity filled with clots, relaxed uterus

14.13.6 Investigation: USG abdomen- No intrauterine retained products of placenta Blood grouping and cross match for blood transfusion


Hematology-- CBC, coagulation profile Biochemistry-- Blood sugar, KFT, LFT and electrolytes

14.13.7 Definitive Management: Oxytocin infusion 20units in 500ml of NS/RL at 60 drops per minute Misoprostol tablet 800 mcg sub lingual can be added if no response to oxy

14.13.8 Focused History: Time of delivery- 4 hours back Where and who conducted delivery- conducted by “Dai” at home Method of delivery- vaginal route Problems during or after delivery- placenta delivered with difficulty Peri partum and ante partum level of care- no ante partum care; peri partum care provided by unskilled Dai Obstetric History- Para 5 with all previous normal deliveries. Past medical History- not significant Detail abdominal examination- uterus relaxed (atonic) Per-vaginal and per speculum examination - No cervical or vaginal lacerations, Uterine cavity filled with clots, relaxed uterus

14.13.9 RESUSCITATION Initial assessment and evaluation of airway, breathing and circulation (ABC), Oxygen at 15 L/min,2 wide bore IV cannula (16/18 G),1V Fluids, ECG, pulse oximeter. Commence record chart, weigh all swabs and estimate blood loss; keep women warm and flat, empty bladder, indwelling urinary catheter

ALGORITHM FOR MANAGEMENT OF POSTPARTUM HAEMORRHAGE:

Loss of 500 ml or more blood from genital tract within 24 hours of birth or any blood loss resulting in deterioration in the woman’s vital parameters

Call for help (senior obstetrician, anaesthesiologist). Inform blood bank

RESUSCITATION

Initial assessment and evaluation of airway, breathing and circulation (ABC), Oxygen at 15 L/min,2 wide bore IV canula (16/18 G),1V Fluids, ECG, oximeter. Commence record chart, weigh all swabs and estimate blood loss; keep women warm and flat, empty bladder, indwelling urinary catheter


14.13.10 All Four steps to be proceeded simultaneously:

KFT

Foleys Catheter with Condom Inflated with Saline Used for Uterine Tamponade in PPH

Fig 12 : Condom tamponade

14.14 Steps of intrauterine condom tamponade ● Inform the patient

● Attach the condom along with the foleys catheter and fix it

● Insert the fixed catheter inside the uterus

● Fill the catheter with the sterile water /saline and make sure the filled is inside the

uterine fundus

● Monitor the vital signs

● Follow the other protocol for the PPH as drugs administration

● Document the entire procedure and the condition

● Maintain privacy throughout the procedure

Withdraw blood for investigations CBC, Coagulation profile, LFT, Blood for cross match- 4 units of Packed cell, FFP, Platelets, Cryoprecipitate

Bi manual uterine compression Empty Bladder External aortic compression

Assess cause of blood loss (The 4 T’s) Tone: Treat Lax Uterus Tissue: Check Placenta Trauma: Repair the tear Thrombin: Consider

Oxytocin infusion (20 U in 500ml NS) S/L Misoprost800 microgm Carboprost(250 microgm every 15 min max of 8 doses) Tranexamic acid I/V 1gm infusion over 10-15 mins


Picture showing the technique of using uterine tamponade :

Fig 13


14.15 Aortic compression

Fig 14

While doing the aortic compression ; ● Make fist with the dominant hand and directly t the pressure over the uterine fundus

through the abdominal wall against the vertebral Column which should compress the

inferior aorta ,with the other hand

● Feel for the femoral pulse if the femoral pulse can not be felt the compression is

effective continue the all other measures to stop the bleeding

● Follow all other intervention for PPH as per the guideline

● Using of tamponade

● Special garment

● Balloon to give compression and prevent from bleeding

● Surgical interventions

● If the interventions fails continue with the protocol and prepare for uterine artery

ligation

● Compression suture


14.16 Uterine compression Insert the dominant hand in the uterus and the other hand over the abdomen and compress the uterus in between

Uterine compression:

Fig 15


14.16.1 Nursing management of postpartum hemorrhage Assessment Action Remark

Quick assessment of ABC

Continue assessing with the ABC and

Assess the Amount of bleeding

Assess the Uterus for

consistency/laxity

Continue checking for ABC

Asses for any retained products

If bleeding is above 500ml

Aortic compression

,call for help open two large bore iv access one with RL 500ml other with oxytocin 20 unit in 500ml with 60 drops oxytocin 10 unit

,

Carbo prost 250mc as per the order -8 doses every 15 minutes if ordered for

massage the uterus vigorously

compress the uterus

start with another IV line with NS Misoprost 800mg sublingually

Repeat the oxytocin after 10minutes

Reassure the patient

Catheterize if the bladder is full

Perform the pv examination os will be open in case of retained placenta is present

Remove the retained product if present any by doing the pv

Arrange for blood

And cross matching, , send the

All the intervention to be done on fast track together if the Hb % is less than 9 even if the bleeding is lesser than 500 ml woman may go in shock so ABC

Refer the manual annexure

According to WHO pph cart to be separate within the reach of with uterine packing instrument and with oxytocin with fast access Annexure for uterine compression

Use the physiology behind the pph

Start resuscitating with immediate effect than weighting for the order as the time is important and standing direction to be available

hemorrhagic shock

Annexure for hemorrhagic shock

Reassure the women

Annexure for uterine consistency after delivery

Concealed bleeding due to the blood clot collected can occur in case of placenta


Continue monitoring ABC

Assess for any sign of infection as raise in temperature

Sub involuted uterus

Assess the laboratory investigation

report

Assess for the blood

sample with

immediate effect

compress the inferior venacava

prepare for blood transfusion

Assist for further investigation

Arrange for tamponade

rule out for DIC

O2 , 10 to 15 L by mask, check for skin temperature,

Prepare to shift the patient to emergency OT for further management as arterial ligation arterial tamponade etc as ordered

Shift to the OT for

Complete all the documentation and attach all the l investigation

Prepare for pelvic ultrasound, pelvic angiography as ordered

Continue the uterine compression

prepare ,inform the anesthetist inform the surgeon apart from the Gyne specialist ,and send the patient to OT for arterial ligation B-Lunch suture

start with the antibiotics - ordered

shift the patient to the OB Gyne ward

abruption

Removal of retained placenta have been given in

Annexure for aorta compression

Main branch blood vessel

All the activity should go together to save the mother as the bleeding is very severe than from any other source of bleeding

If the bleeding has not stopped

Massive blood loss may be due to the

Changes in the pelvic artery can lead to circulatory collapse


coagulopathy

lower vag tract injury /unhealed injury

continue monitoring the ABC

Empty the bladder

Continue with the Assessment

Assist in getting the lab investigation reports

Collect the report and intervene with the on duty doctor

Assist in intervening the report of platelet count ,fibrinogen,BT,CT,PT

Administer anti coagulation

Factor ordered tranexamic acid,

Factor V11 A as ordered

Prepare for re suturing send the

patient

continuous reassuring of the patient

is needed

needed complete the documents

Insert the urinary catheter and keep it for continuous drainage till the patient stabilizes

continue the observation monitor the vital signs

sign of shock

pallor

disorientation

iv care and finish the fluid within 20 minutes (the first two bottles or be given in a fast manner )

arrange for frozen plasma as it contains clotting factors

Annexure for abdominal aortic compression

Bleeding may be uncontrolled ,need assistant to all action will be in a quick manner further explore and management will be done in the OT

Annexure for uterine compression

If the bleeding has been controlled

doctor may be busy so report on an urgent basis

In case of case lower vag tract injury


Patient may not be preset with the visible bleeding number of times there can be internal bleeding of major type

Blood coagulation factors changes during pregnancy

● Balloon to give compression and prevent from bleeding ● Surgical interventions ● If the interventions fails continue with the protocol and prepare for uterine artery

ligation ● Compression suture ● Secondary PPH is the pph occurs after 24 hours of delivery till 6 weeks of delivery

14.16.2 Nurses Flag

Fig 16


14.16.3 Nursing management of Secondary PPH

Assessment Action Remarks Assessment Assess for the amount of bleeding ABC (,together with the help ) uterine tone uterine size palpate the abdomen for tenderness and sign of infection Assess for the lower abdomen for any blood clots Assessment for lab diagnosis Gr Rh ,blood Coagulopathy Continue assessing

Call for help IV Access with two large bore needle with 16 and 18 on and with crystalloids and other with oxytocin 20 units on it IV should finish within 15 to 20 minutes and two (bottles of 500ml )within one hour All the protocol is same as like primary PPH Withdraw blood sample Uterine compression with immediate effect Urinary catheterisation with Foleys Cather Arrange for blood as ordered If the bleeding has not stopped prepare the patient for surgical intervention for the ligation of the uterine artery Asses the cause check for any Retained products Document and continue the holistic approach

Time is important in case of pph Depending upon the duration of delivery observe for nay signs of infection All other protocol are same incase of severe bleeding Mild bleeding will be manged Through the drugs ,exploring the uterus for any retained products


14.16.4 In case of bleeding due to Coagulopathic / Hormonal cause:

Assessment Intervention Remarks Call for help All the assessment as like primary or secondary PPH Blood sample for after coagulopathic Factor V111,fibrinogen Oration2 saturation

Call for help IV Access with two large bore needle and After two bottle of crystalloids start with the blood according the order Tranexamic acid according to the order Start with the oxygen administration 10 to 15 liters till waiting for the reports

Bleeding pv due to hormonal changes and due to neoplasm DUB with severe bleeding with low hematocrit may be an emergency Follow ABC Monitor the bleeding amount confirm the diagnosis stabilize the patient and refer the case to the gyne department

14.16.5 Nursing management of bleeding due to DUB

Assessment Intervention Remarks

Assess for ABC Assess the cause of bleeding by taking a focused history Asses the vaginal tract for the condition of the lower uterine wall ,and the general condition the vulva Assist in diagnosing

Access with two large bore needle with crystalloids Draw the blood sample while starting the iv line Assist for taking the history Assist for the pv examination Prepare for the ultrasound /MRI ordered for Reassure the patient Collect all the laboratory investigation /reports When the patient is stable send to the ward for observation and for the further management

When the haemotocrit I slow the condition will be critical


14.17 SEIZURES IN PREGNANCY Seizures in pregnancy is the major complication of pregnancy as eclampsia ,or may be a case of known epilepsy in rare cases eclampsia is major complication of pregnancy present with pregnancy after 20 weeks of gestation with edema ,hypertension and high ,proteinuria , with fits edema is of generalized and pitting type and pulmonary edema also will be the manifestation so management must focus low rate of iv fluid ,major cases delivering the fetus is the only remedy if the patient is not responding to the treatment . Information to be given that priority have been given for the mother’s though some time it can be a matter of ethical dilemma All needed references as in case of an urea,with fit with hypertension needs the referral of nephrology,cardiology etc Different theory is associated with the eclampsia however it affects all major organ so a complete assessment of the entire system is essential and the knowledge of major organ involvement is needed Lab diagnosis should focus apart from the routine LFT & KFT Proteinuria

14.17.1 Objective

After the initial management trainee will be able to- ● Prevent from injury ● Reduce the blood pressure ● Control the fit /convulsion follow the mgso4 regime and antihypertensive therapy ● Prevent form complication ● Assess the pregnancy status or in labour pain ● Prepare for assisted delivery /LSCS once the patient has been stabilize

Nurses Flag


14.17.2 Scenario

A 28 year old primigravida with 36 weeks of pregnancy with convulsions since last 1 hour

Algorithm for management of eclampsia:

Magnesium sulphate regime (Pritchards) for cases of eclampsia


Table 1: Protocol for antihypertensive drugs in pregnancy

Antihypertensive Drugs

If BP ≥ threshold (DBP≥110mmHg or SBP ≥160mmHg)

Option 1 Option 2 Option 3

Labetalol Hydralazine Nifedipine

20mg IV labetalol

↓ BP in 10 min

BP ≥ threshold

give 40mg IV labetalol

↓ BP in 10 min

BP ≥ threshold

give 80 mg IV labetalol

↓ BP in 10 min

BP ≥ threshold

give 10mg IV hydralazine

5-10 mg IV

↓ BP in 20 min

BP ≥ threshold give 10 mg IV

↓ BP in 20 min

BP ≥ threshold give 20 mg IV

↓ BP in 10 min

BP ≥ threshold

labetolol 40mgIV

10 mg oral

↓ BP in 20 min

BP ≥ threshold give 20 mg oral

↓ BP in 20 min

BP ≥ threshold give 20 mg oral

↓ BP in 20 min

BP ≥ threshold

labetolol 40mgIV


14.17.3 Nursing management for eclampsia Assessment Action Remark Check for air way as there is tongue bite look for tongue fall and air way Asses for ABC Observe for seizure Coma - level of conscious Fetal Condition and FHS Signs of labour pain History of urine output Respiration Heart rate Assess for edema and type of edema Detailed assessment of the entire system to be done once the patient has been stabilized Assess for the lab diagnosis Assess for the pregnancy status Assess for any labour sign

Call for help, call the doctor on duty and the team for help, insert air way ABC monitoring, prevent from injury due to fit, raise the side rail of the bed, observe for any sign of labour FHS monitoring Take a focused history and asked for the ANC card, if carried Start IV with a large bore needle of gauge no 16 or 18 with slow flow Start with the oxygen Give the MgSO4 4gm IV Slowly followed by 5gm in each buttock to Deep IM, as in the algorithm Catheterize the patient and put for continuous drainage and observe urine output Start anti hypertensive ordered by the doctor, labetol 20 mg iv, if the doctor is delayed to reach, as per the protocol Check the FHS to make sure the condition of the fetus through Doppler CTG to be followed Draw the blood sample for KFT&LFT Collect the urine sample for albumin Monitor urine albumin chart Input output chart Detailed obstetrical examination and for labour pain Fetal monitoring and document the chart Assist for a complete assessment of each ststem Continue observing the patient If the convulsion has not stopped

Excessive fluid cannot be given due to the pulmonary edema Priority has been given for the maternal life first History taking is mandatory to plan for the comprehensive and right care Briefing about the condition will be done to the relatives /person accompanied For controlling the convulsion mg sulphate is the drug of choice Arrange the articles for physical examination to the elected system as eye an ophthalmoscope Palpation of the liver for enlargement, urine output per hour, any abnormal sound Patient can go to labour at


pelvic adequacy, and the signs of labour Assess for any complication of MgSO4 Asess the ABC Assess the level of consciousness Assessment shows no improvement and reoccurrence of convulsion Assess for the vital signs and the FHS Assess for any cardiac overload Assess the precaution taken for preventing the injury Continue the assessment

continue with the MgSO4 Monitor the knee jerk and respiratory rate daily for MgSO4 toxicity during each convulsion period Observe the onset of convulsion, duration. Prevent from injury Check for the detailed involvement of the major systems Assist for the physical examinations Assess the heart, lungs, liver, kidney, and eye Draw the blood sample for LFT, KFT, blood group, Rh, Hb% Continue the close monitoring of the patient Palpate the abdomen for gestational age, presentation, position. Assemble the articles and do the PV examination Observe the respiratory rate, should not be less than 16 per minute Observe for the urine output Urine output should not be less than 30ml /hour Examine for the knee jerk reflex Monitor the vital signs Check for the responses, to call , To stimuli and document, Glasgow coma scale Continue the observation repeat the drug dose of MgSO4 Continue the observation of the patient Auscultate for any abnormal heart sound, and for any crepitation in the lungs

any time Assist in collecting the lab report in a fast track Hammer, ophthalmoscope, good light, provision of privacy to be provided Patient can lose responsiveness If no Assist in inducing the labour regardless of the week of gestation Changes in blood vessels of the ratina, generalized edema and changes to all the systems Assessing the system for the involvement or the effect Pulmonary edema is present usually with this patient All system will be affected by eclampsia Nurse can do the assessment Priority is to save the mother and situation must be explained to the relatives Fluid to be calculated to


Administer fluid not more than 80/ml per hour IV to avoid Cardiac overload. Check the CVP Use infusion pump Assess the urine out put If any labour signs do the labour protocol and assist for the labour and delivery, be ready for assisted delivery, or any indication of LSCS to be done accordingly and be prepared for it (only in case of os fully dilated and there is a definite need to save the baby), other wise stabilize the patient and shift to the eclampsia room.

Stabilize the patient and shift to the gynae department. Prepare to receive an asphyxiated baby, continue the care, observe for PPH See that the anti hypertensive drug has been continued and asses the condition If not shift the patient to the eclampsia room/gynae critical room

Counseling to be given to the relatives and to the patient, all care and protocol to be explained, consent to be taken as needed for delivery procedures etc. Complete the documents Continue the care in the eclampsia unit of the hospital

prevent cardiac overload, checking the CVP is important

Labour process to be continued, and delivering the baby will facilitate in relieving the symptoms of eclampsia of unknow reason

Baby may have asphyxia due to various reasons and because of the drugs given to the mother

Ethical aspects and patient safety to be considered for.


14.18 PUERPERAL SEPSIS Puerperal sepsis is a condition woman undergo with infection within 42 days of delivery Infection foci can be from the genital tract ,urinary tract and from any other source ,when the hygiene and the preventive measure after delivery has not taken clinical manifestation will show Faul smelling lochia Fever Malaise Infected source can be of endogenous, autoenous, exogenous and causative organism can be anaerobes Aerobes and others infection will affect the genital tract and adjacent organs if not cared will lead to septicemia and related complication including septic shock

14.18.1 Scenario A 27 year old who has come to ED after delivery at home 10 days ago with history of pain abdomen, foul smelling discharge and breathlessness

Initial assessment Airway: Not protected (gurgling and snoring sound)

● Action- Oral suction and insertion of or pharyngeal airway. ● Breathing: RR-40/min, chest: Bilateral expiratory crepitation, SpO2-80% on room

air. ● Action Administered oxygen with oxygen mask with reservoir bag @ 15 litres/min.

SpO2 Improved to 88 % on oxygen. Intubated the trachea and started assist ventilation

● Circulation: Pulse-140/min, BP- 70 /50 mm Hg. Warm extremities

14.18.2 Focused history and examination ● Origin, duration and progress of pain- pain started over the lower abdomen 5 days ago

and became generalized (history given by mother) ● Associated symptoms-Fever, breathlessness, bleeding PV and foul smelling

discharge. Drowsiness since 1 day. ● Place and person conducting delivery- home delivery 7 days back by unskilled dai.

History of expulsion of the complete placenta ● Abdominal examination: Distention and generalized tenderness present, guarding+,

bowel sounds absent ● PS and PV examination: Foul smelling purulent discharge from os, uterus 18 weeks

size (subinvoluted)

14. 18. 3 Investigation: • USG- hyperechoeic contents seen in the uterine cavity • Cultures (Urine, blood and Vaginal swab)


• Hematology- CBC and coagulation profile • Biochemistry- KFT, LFT, blood sugar and electrolytes • ABG with lactate level (If available) • X Ray chest • X Ray abdomen erect and supine •

14.18.4 Objectives After the nursing care will be able to -

● Prevent from further infection ● Provide holistic care ● Prevent from septic shock

14.18.5 Nursing management of puerperal sepsis

Assessment Action Remark

Assess the ABC

Assess the respiration and the chest for any abnormal respiratory sound

Assess the uterus involution

Assess for the lochia

Check for abdominal tenderness

Look for any other infected foci

Take the focused history check the vital signs, pulse 140/min and BP is 80/50 mm Hg

Start the oxygen by mask

Start the IV line with two bore needle of 16 & 18 No. Allow to finish within 20 minutes

Assist in ausculting the chest

Clear the airway by suctioning

Draw sample for investigation

Continue with the septic shock management by using the shock protocol

Check for amount, colour and the odour

Bp is only 70/50 mm Hg

Has got crepitations and is having gurgling sound

Important to care to prevent from infection


Start the high antibiotic if ordered

Assess the fever

Do the fever management

Continue with the process

Stabilize the patient

Shift to the gynae ward, if stabilized. If not, continue managing with the shock management

Continue the management of the septic shock

Care

Complete the documentation

Advice for the baby, care for feeding with other source or from the milk bank, if available

Fever may be present as symptom of infection and to be managed

14.19 ASSAULT Scenario : A 18 year old girl came to ED with on-going abdominal pain, reduced appetite since last 2 days. She was accompanied by her mother Initial assessment Airway assessment: Protected (talking) Breathing:RR-20/min, chest clear, SPO2-99% on room air Circulation:Pulse-100 Detailed examination by female MO/Male MO in presence of female nurse or female Differential attendant - bruises on abdomen, inner thighs, breasts Local examination of perineum: normal


Focused history History of assault: sexually assaulted by male relative off and on since last 2 months. Last episode 3 days ago Clothes worn at the time of assault- were not available as patient had changed and washed her garments. Menstrual history- LMP 6 days ago Past medical history- not significant Prophylaxis for sexually transmitted infections Gonorrhoea - Cefixime 400 mg orally single dose (< 12 years, 8 mg/kg) Chlamydia- Doxycyclin 100 mg orally twice a day for 7 days ≥ 45 kg(2.2mg/kg if<45kg) or Azithromycin 1 g orally in a single dose Trichomoniasis - Metronidazole 2 g orally in a single dose Hepatitis B vaccination Prophylaxis for HIV (PEP) for adolescents and adults Tenofovir (TDF) 300 mg once daily Lamivudine (3TC) 300 mg once daily Efavirenz (EFV) 600 mg once daily First dose as soon as possible (preferably within 72 hours) Emergency contraception Levonorgestrel Tab 750 μg 2 stat or 1.5 mg stat as soon as possible (preferably within 72 hours) Nursing Management of Assault

● Assault is legal offence and the victim is psychologically affected and traumatized, victim may be brought by the parents as mostly the young girls are the victims

● Separate cell has been provided as’one stop centre ‘ receive the victim gently and all legal aspects to be kept in mind ,inform the police as it is legal case follow the direction of WHO given in the kit and no attempt to be done that ,the evidence may be erased ,so the nurse to be well aware about te protocol and the language for communication to be carefully used find out and record who has brought the victium ,only female nurse to be allowed to work with the victim

● Open the kit which consist of sample bottles and containers, and sheet containing the diagram of body parts to be marked carefully with any symptom of injury, mark

● All the record to be maintaned confidently and carefully, the sample to be send according to the direction

● Maintaining all the records is mandatory and to be kept under utmost safety and privacy

● Be with the victim throughout the sample collection procedure and counsel the patient ● No wash to be done before collecting the sample and clothes worn by the victim are

to be preserved

Sample document provided with the kit for marking and injury /marks of the body part body part.


14.19.1 Nursing management for sexual assault Assessment Action Remark

Assess the general appearance

Find out the responsiveness

Asses for general condition and the need for ABC support

Assess the abdominal pain

Responsiveness

Expression of the client

Assess for any external injury

Assess for the assault

Take the focused history

Find out whether the victim is conscious and responds to talking

Check the vital signs

If any need for support for ABC start the iv line and take all protocol for stabilizing the patient

Assist in assessing the client. Provide privacy, make sure that a female nurse is present during the examination

Explain the procedure, bring the kit for taking the sample

Open the kit and take the sample according to the direction given in the kit

Talk and reassure the patient and the relatives

Inform the police

Prepare the kit for sampling

Remain with the patient while taking the history by the police

Complete the documentation

Patient will be psychologically upset

Along with the sexual assault other injury or harm must have done in rare cases

Sexually assault kit to be made ready

Packet consists of set of directions and device to collect the sample. Clear direction has been given to collect the sample

Annexure

For support, presence is required


Assess for the psychological trauma

Maintain the confidentiality

Keep the legal documents carefully under lock and key

Talk and reassure with verbal and non verbal and be effective and gentle and supportive

Arrange for counseling session

Administer the drug according to the protocol

Unrepeatable psychological trauma is associated with the victim and family continuous counseling is needed

Preventive therapy is essential


14.20 MATERNAL COLLAPSE Scenario : A 30 year old, primi gravida with 8 months pregnancy is brought to the ED. She is unresponsive

Initial assessment and action Check responsiveness- patient unresponsive Call for help-a)anesthesiologist/critical care physician who can incubate and resuscitate patient; b) obstetrician who can perform perimortem caesarean section Check pulse and scan for breathing- jugular pulse not palpable, gasping movements present Start CPR with early defibrillation- CPR started (AHA 2016 guidelines) Discussion: Causes of Cardiac Arrest In Pregnancy can be memorized by the pneumonic-BEAU-CHOPS

● Bleeding ● Embolism: pulmonary, amniotic fluid ● Anaesthetic Complication ● Uterine Atony ● Cardiac disease ● Hypertension- Preeclampsia/Eclampsia ● Other: Mg toxicity ● Placental abruptio/previa ● Sepsis

The CPR should be performed as per the AHA 2016 guidelines and with manual left uterine displacement (LUD) to reduce the aorto-caval compression effect of the gravid uterus and to improve the efficacy of the chest compressions. The 15 degree tilt of the patient is not recommended any more as it hampers effective compressions. The gravid uterus compresses the inferior aorta and the large vena cava and as mentioned maximum blood flow during pregnancy goes to the uterus by increasing the circulation so blood flow to the heart can be facilitated by decreasing the compression to the large blood vessels. There are marked changes to the thoracic cavity ,as diaphragm pushes to upwards ,there is oedema in the throat , (laryngeal oedema) neck becomes short , breast size enlarges heart slightly pushes to one side oxygen need is more , so high quality resuscitation is needed by an expert and a short laryngeal scope may be used Observing for the foetal condition is also needed though the priority has been given for maternal survival Within four minutes if the mother can not be survived a perimortem caesarean to be done to save the foetus Four minutes theory to be remembered as within four minutes resuscitate the mother and if failed do the perimortem caesarean within four minutes Separate resuscitation cart and facility for caesarean facility to be there in the emergency


Any woman whose abdomen is above the umbilical level and is with the history of pregnancy to be start with the resuscitation with the same points mentioned Right communication to be done to the relatives about the mother and for the baby

Fig 17: Methods of displacement of uterus resuscitation

Remember: LEFTWARD DISPLACEMENT OF UTERUS DURING CPR EITHER WITH SINGLE HAND OR WITH BOTH HANDS Perimortem caesarean section....4 min after cardiac arrest Activation of emergency C-Section team at the onset of arrest- If there is an obvious gravid uterus Emergency C-Section may be considered at 4 min- If there is no ROSC(return of spontaneous circulation) Do not forget continuing BLS & ACLS before and after Emergency C-Section Goal-The actual delivery takes place no than longer 5 min Perimortem C-Section is done primarily to improve CPR for the mother even if the fetus is not alive. This needs institutional preparation with multidisciplinary approach


14.20.1 Nurses flag

Nursing management of shock in obstetrics Assessment Intervention Remark

Follow all the steps as in the case of shock

Assist in the management as like in the shock

Tilting of the abdomen 15 degree can be done by pushing the uterus to the side

In case of one rescuer the can be tilted abdomen can be supported with the knee to prevent from rolling back

If the mother to be shifted use the wedge /improvised wedge to tilt the abdomen to left up to 15 degree

All steps for shock apart from the main points mentioned are the same

Pregnant women can be associated with any critical problem as cardiac diseases asthma or any serious illness with pregnancy with viable uterus In all these cases woman to be treated as like any medical emergency ,prioritizing the life of the mother /woman first only if there is nay chance for the foetal survival it will be done ,continuing the pregnancy may be endanger us as incase of 3rd stage of cardiac disease to continue with the pregnancy if the pregnancy has been continued the specialist will be present in the labour room and with the observation of the specialist the delivery may take place Anticipated problem to be controlled


MO/Male MO in presence of female nurse or female attendant - bruises on abdomen, inner thighs, breasts Local examination of perineum: normal C: normal Manual removal of placenta Articles Used for examination: Procedure

ANNEXURE 1

Manual removal of placenta Pv examination article Gloves with long hand Vital sign monitoring article Inj Sytocinon /oxytocin IV fluid RL /NS Injection tray with pain killer preferably pethadine /morphine In cases of massive bleeding with arrange for blood Procedure Reassure the mother Catheterizes the bladder Start with RL /NS with 20 units of oxytocin Administer Metronidazole 500mg IV Give single dose of prophylaxis antibiotics Wear high level sterile gloves place in lithotomy position Briefly explain about the procedure Maintain aseptic technique , with the left hand hold the umbilical cord Coned and insert the right hand to the uterus by following the umbilical cord release the cord and place the left hand over the abdomen to support the funds of the uterus to avoid from uterine inversion move the finger gently to the lateral and ensure the placental edge ,with the hand keeping the fingers tightly together and by using the edge of the hand make space between the placenta and the gently move the hand around the placental bed without exerting any pressure and make sure the entire placenta has detached and deliver the placenta if the placenta is not separate from the uterine wall gently try to remove as fragments if the tissue is adherent suspect for adherent placenta Withdraw the hand from the uterus


Palpate inside the uterine cavity to ensure that all placental tissue has been removed funds of the uterus of the placenta for its completeness if missing explore and remove it Examine the woman care fully and repair any tear if If the placental fragments are remaining and due to the constriction ring or hours after delivery it may not be possible to introduce the whole hand so extract the placenta fragment by fragments Give the oxytocin up to 40 unit / increase the dose as per order or the uterotonic drug /or according to the protocol ( Tanexamic acid follow the protocol ) after the delivery of the placenta and check amount of bleeding ,uterine contraction ,and ABC ie vital signs Examine the placenta for completeness and for any abnormality Provide the sanitary pad ,and keep under observation Reassure the woman, Complete the documentation Observe for the vital signs every half an hour least for next four hours ,massage the uterus every 15 to half an hour as per the protocol Initiate the breast feeding


ANNEXURE -2

Manual removal of placenta

Figure showing the steps of manual removal of placenta

Step 1 Insert one hand following the umbilical cord Step 2 Gently separate the placenta without inducing pressure

Step 3 remove the placenta


ANNEXURE -3

FOR SEXUAL ASSAULT ● Open the packet which comes for the sexually assaulted ,which contains all the

directions for the sample collection reassure the client and a female nurse has to accompany and assist to collect the sample with all directions which includes the very careful observation and mark injuries few of the sample have been given below injuries to be marked on the given figure

● Mark the injuries as shown in the figure (in the text) ● Inspect the areas thoroughly of the victim and mark the injury as in the figure

show

Fig 18 :Sample copy of the medico legal case to be filled recommended


ANNEXURE-4

Uterine Compression

Fig 19

Steps 1. Provide privacy 2. Inform the patient and take verbal consent 3. place the dominant hand inside the uterus in conical shape to avoid discomfort

and injury 4. Other hand place over the uterine funds 5. Bring the uterine fundus in between the hand and compress 6. The assistant /call for help , should follow the other methods of controlling the

bleeding and 2nperson should care the new born if newborn is with mother


ANNEXURE -5

Fig 20

Aortic compression

Steps Provide privacy before the procedure and inform the patient about the procedure you are going to do

1 Apply down ward pressure with closed fist over abdominal aorta through abdominal wall (above the umbilicus) ie just above the umbulicus slightly to the patients left

2 With other hand palpate the femoral pulse to check adequacy of compression .If the pulse is palpable the pressure is inadequate .Pulse is not palpable –adequate a pressure and is effective

3. Maintain the compression until bleeding is controlled

4. Sample sheet of the legal document to be filled in case of assault


ANNEXURE-6

Urine for pregnancy test

Articles required ● Pregnancy test kit ● Disposable dropper ● Clean container to collect the urine

Steps

● Check the expiry date and read the instruction ● Take the sample of urine ● Remove the pregnancy test card, and place it on a flat surface ● With the help of the dropper put the 2 to 3 drop of urine in the marked space of ‘S’

and wait for 5 minutes ● If one red band appears in the result marked as R the result is negative ● If two parallel red band is present in the result window R, the test is positive ● Do the documentation and inform the mother and the concerned person

ANNEXURE 7

EQUIPMENTS LIST FOR OB & GYNE

1. Uterine packing forceps 2. Obstetrical forceps low cavity 3. Episiotomy scissors 4. Cord cutting scissors 5. Sims speculum of different size 6. Cuscus speculum 7. Vacuum delivery set 8. Artery forceps small 9. Dissecting forceps toothed and non toothed 10. Sutures 11. Resuscitation article for mother and for new born 12. Oxygen 13. Oxygen hood 14. Oxygen prongs ,prong , cannula ,mask of adult and newborn size 15. AMBU bag for both adult and new born size 16. Iv canula, 17. Needle for new born size and adult size (no 16,18, 20 ,22 ,24 26 size) 18. Blankets for new born and for mother 19. All blood samples 20. Screen /curtain for privacy providing 21. Requisition forms and file sheets /documentation sheets for newborn an for

mother 22. New born transporting incubator 23. Trolley 24. Medicine cart


Note : Medicine cart to be separate and should be placed near to the patient receiving unit

Blood should be available /blood bank to be near by as time to replace the blood is crucial since the bleeding will be massive in obstetric cases

All additional precaution to be taken to prevent infection among the newborn in case of delivery or accompanied by the new born and new born to be allowed to near to the mother ( cases have seen newborn is left at home or admitted in another hospital )

Specially trained nurse in midwifery and for newborn care to be available in the unit

Sexually assault client to be shifted to one stop centre


ANNEXURE 8

DRUGS





Bibliography

1 http//ww.ncb.nim.nib.govpub, cardiovascular changes 2 http.//www.medscape .com-2/jan2018 3 http//www.research gale.net.2778 ,8th jan 2015 pdf 4 http//ww.qafp.org.afp 5 www.nicb.nlm.gov/pumed/2297776361,mt smarj med 2012 sep/oct

79(5)555.9di101002/msj 2336 gender discrimination in health care Kent JA, Patel. V. Varela NA.

6 http//ps//acadenc..oup.com/bmb/article/67/1/205/330398 7 www.ahajournl.orgM.Sanghavi, circulation, cardiovascular physiology of pregnancy

2014 8 http//www.aafp.org/afp2007/0315/p875. httm M.D Forbes, jancie. M. Aanderson,

Duncan, eteche M.D ‘ prevention and management of Post partum hemorrhage 9 http//doi.org/10.1093/bmb/dgo16, British medical Bulletin, volume 67, issue 1,

December 2003 Pages http/wwresearch.net.2778 8thjune 2015pdf 10 http/ww.qaf.org.afp,evensen2017 01-April 2017Leenman, L.Quplan, j. Dresang, ltd,

advanced life support post partum hemorrhage prevention and treatment

11 DC Dutta Text book of obstetric sixth Edition , New central book agency Ltd pp ,’post partum hemorrhage ‘ pp 412-419 7Elizabeth Step Gilbert manual of high risk pregnancy Delivery Indian print, ISBN 978, 312

12 Myles text book Maternal health Division MOH&fp Strengthening pre service education for nursing and midwifery cadre in India,Operational guidelines January 2013

13 Halvaren, Haffman, Bradshar et all William’s gynecology, Mc Graw Hill, PP83-83 https/ww.ncb.nin.nib.govpubcardiovascular changes

14 Examination Kit for victims for sexual abuse by Indian medical association along with UNICEF,Department of women and child development Ministry of child HRD

15 WHO Manual 2003 ‘Managing complication in pregnancy a guide for midwives and doctors


Chapter 15

GROUP DYNAMICS & TEAM APPROACH

Lesson 15 Group Dynamics and Team Approach Objectives Upon completion of the lesson, the trainee would be able to:

Understand group dynamics and team approach Assess group dynamics Utilize the best from the group


Chapter 15

Group dynamics & Team approach 15.1 Core Concept

Three to eight people can form a group. Group dynamics refers to the various process (behaviors and emotions)

involved when the members of the groups interact. The emergency team is a group of persons – some who are professionals, some

support services, from different disciplines, etc. A team is a group of persons who have a common goal as well as common

objectives and support each other to achieve these. It is important that all members work in sync for the common goal of saving the

patient’s life. Each member (especially the leader) should understand the group dynamics and

use the best from each member of the group.

15.2 Importance of understanding group dynamics

15.3 How to assess the group dynamics? These tips may help understand individual decision making styles, communication styles, conflict resolution methods, individual personality styles, etc.

Whom do people look at while talking? Whom do people listen to? Who talks the most Vs who listens the most? Who is not active? Which group members support each other?

impo

rtan

ce Helps in assessing strengths and weakness of individual members

Helps in building the strengths and not allow the weakness to interfere with the group objectives.


Who makes decisions? Who seeks attention most?

15.4 How to utilize the best from the group?

These tips may help: Communicate openly and clearly Build positive work atmosphere Recognize and praise good work Be decisive and honest Delegate work to the most appropriate person Manage and resolve conflict on time Be a good role model

15.5 Team Approach

15.5.1 Members of the team

Emergency physician

EMT

Support

staff


15.5.2 Types

15.5.3 How does a nurse maintain team cohesiveness?

Meet periodicallyAddress by name

Have ‘FUN’ timeSet clear goals

Communicate clearlyDelegate clearly

Delegate based on competenciesProvide leadership support to the team

Appreciate and recognize good workIdentify and resolve early conflicts

Nurse maintainsteam cohesiveness

BY

Multi-disciplinary team

•Members depend on thediscipline. E.g. in psychiatrycare this team consists of thedoctor, the nurse, thepsychologist and the socialworker. In trauma care, itmay consist of the surgeon,anesthetist, the nurse, thephysiotherapist and theoccupational therapist.

Inter-disciplinary team

•Nurses need to work closelyand cohesively with otherstaff such as dietary section,CSSD, CLSD, pharmacy,hospital infection controlteam, etc.

Intra-disciplinary team

•- Within the nursing profession, there are various cadre of nurses such as trainees, nursing officers, senior nursing officers, nursing teachers, etc. All need to work with each other.


15.6 Scenario

Algorithm: Team approach

No Yes

It is peak hours in a busy trauma care centre. Recent changes were made in the nurses posting list. Due to this, the nursing team in the morning shift has three new nurses. The ward supervisor is aware of this and keeps a close eye on her team. Around 12 N, there is a sudden increase in number of accident cases entering the trauma care centre. Understanding that her team may require help, the ward supervisor engages in participatory observation and observes the new nurses as she assists in handling the emergency.

Patient comes to the medical emergency unit

Appreciates and recognizes

Motivates

Assess for:

Individual difficulties, counsel and work accordingly

No Group learns to improve skills

Communicates openly and clearly

Builds positive environment

Involves the group more

Encourages decision making

Assists in handling situations

Needs help

Body language

Behavior

Verbal and nonverbal cues

Activeness

Ability to handle the situation

Leader observes the group for

Received by team members and leader quickly delegates the

responsibilities for each member

Appreciates and recognizes


Chapter 16

Human aspects to consider while dealing with emergencies

Lesson 16 Human Aspects to consider while dealing with Emergencies

Objectives Upon completion of the lesson, the trainee would be able to: Engage in optimal self-care Demonstrate soft skills Handle public with sensitivity during emergencies


Chapter 16 Human aspects to consider while dealing with emergencies 16.1 Core concepts

A nurse deals with emergencies often which can be stressful. Hence, s/he needs to be in good health and engage in optimal self-care. Since humans are involved while dealing with emergencies, be it the nurse, the

doctor, the patient or the relative; it is important that human aspects are considered.

The nurse should cultivate soft skills such as active listening, good communication, be empathetic and assertive, etc. which will help in handling the public during emergencies

16.2 Optimal self-care

Eat nutritiously with sufficient fruits, vegetables and protein intake. Drink enough water (3-4 lts./day).

Sleep well. Maintain sleep-wake cycle. Stress Management

Think positively. Do problem solving and make decisions quickly in the

clinical area.Clarify with seniors/other team

members when in doubt.

Cultivate a sense of humour.Learn and engage in relaxation

techniques such as deep breathing, yoga, meditation.

Stress Management


16.3 Human approach – Cultivate soft skills

16.4 Handling public

16.4 Scenario

Take time to listen to the patient attendants

Observe them for excess anxiety and impending aggression

Clarify doubts, Address their concerns

Reassure them that their patient is being examined, observed and investigated

while simultaneously receiving emergency treatment

Train your team to interact with and respond to patient attendants

Never laugh, crack jokes when the patient is battling for life

In the emergency unit in your hospital, you are a team of 15 professionals. The team consists of 7 nurses, one casualty medical officer, two emergency medicine doctors, 4 hospital assistants and one security guard. Two nurses are new to the unit. There is a sudden rush of patients. A commotion in one end of the emergency draws your attention. Men accompanying a patient were arguing with the nurse that their patient needed immediate attention and wanted to know why the patient was not being taken for surgery.


16.5 Questions for discussion 1. Who are the persons involved in this situation?

The health professionals some of who are new recruits, hospital assistants, security guard, a patient and the public

2. What could be the causes for public aggression? Some of the possible causes are – Fear, anxiety amongst the public, No reassurance by the staff and lack of information about the patient’s condition.

3. How would you handle this situation? Educate the newly joined staff, hospital assistants and security guard about

public management during emergencies. Immediate first aid to the patient Inform the public and the patient if s/he is conscious about condition Inform the reasons why the patient is kept under observation

Algorithm: To understand how new nurses can be guided to confront emergencies and manage public.


Lesson-17

LESSION 17

The nurse confronts an emergency

Able to handle the situation

Help the person (nurse) to cope by giving the following guidance to:

Yes

Denial

Goes away

Tries to push someone else in the front

Negative thoughts such as:

‘I can’t handle this’

‘I am incapable’

Yes Yes

No No Irritable

Panicky

Scared

Anxious

Disturbance in Behavior Disturbance in Mood Disturbance in Thought

Unable to handle

LOOK FOR

Cultivate soft skills

Listen actively

Allow others to talk

Communicate clearly

Identify and prioritize the problem

Be assertive and

Deal with the public

Take time to listen to the patient attendants

Observe them for anxiety

Clarify doubts

Reassure

Never laugh or crack jokes when the patient is

Have optimal self care

Eat nutritiously

Have enough fluids

Sleep well

Cultivate hobbies

Manage stress


Chapter 17 Ethical and legal issues

Lesson 17 Ethical and Legal Issues Objectives Upon completion of the lesson, the trainee would be able to:

Understand the ethical principles Verbalize the laws that govern nursing practice Identify ethical and legal issues Make ethically and legally sound clinical decisions


Chapter 17 Ethical and legal issues

17.1 Core concept

Ethics is about the rightness or wrongness of one’s behavior and about goodness or

badness of the effects of these behaviors. Bio-ethics is to do with what is right or wrong in life and death situations which is

what nurses are concerned with. Ethical dilemma is a conflict between two situations when moral claims conflict with

each other Nurses face legal issues daily. Legal issues may be in connection to negligence, administering medication and

advocating for the patient.

Code of ethics for nurses in India is available (For further reading, refer INC website www.indiannursingcouncil.org/)

17.2 Major ethical principle


17.3 Ethical decision-making process

The nurse can follow these six steps to make decisions when faced with an ethical dilemma in the emergency unit:

17.4 Laws that govern nursing practice are

Important Acts: Nurse Practice Act, Consumer Protection Act, Mental Health Care Act, Rights of Persons with Disabilities Act, Right to Information Act


17.5 Legal Issues

There are four legal requirements that must be met for negligence to be proved:-

A standard of care exists. A breach of duty or failure to meet the standard of care has occurred. Damages or injury has resulted from the breach of duty. (This could be commission

of an inappropriate action or omission of a necessary or appropriate act). The injury or damage must result from the nurse‘s negligence.

Examples of negligent acts are:- Leaving a patient in the bed with the side rails down. The patient gets confused

during the night and falls out of bed. Committing medications errors of either omission (not giving the drug) or

commission (giving the wrong drug).


17.5.1 Examples of legal issues in various specialty emergencies

Paediatric nursing: Giving the wrong dosage of medication. Dipping the baby into

very hot water while bathing (can cause scalds) Medical-surgical nursing: Not putting up the side rails after administering intra-

muscular injection for a restless patient (The patient may fall and sustain a fracture). Giving narcotics without an order.

Emergency surgery: Wrong counting of the sponges, needles and instruments Obstetric and gynaecological nursing: Placing the wrong identification band on the

baby’s wrist. Carrying out abortion. Psychiatric nursing: Not supporting the limbs during electro-convulsive therapy

(ECT) which can cause fracture of limbs 17.6 List of do’s and don’ts as guidelines for safe practice

Do’s Don’ts

Document and report all unusual

incidents

Remove side rails from patient‘s bed unless there is an order or hospital policy to do so

Know your job description Accept money or gifts from patients

Follow policies and procedures in your workplace

Allow patients to leave the hospital or nursing home unless there is an order or a signed release

Keep your registration updated Give advice that is contrary to physician orders or the nursing


care plan

Perform procedures that you have been taught and that are within the standard scope of your practice

Give medical advice to friends and neighbors’

Protect patients from injuring themselves

Attempt to practice medicine

Remain alert and focused Witness a patient‘s will Establish and maintain rapport

with patients and family Seek and clarify orders when the

patient‘s medical condition changes Work as a licensed practical/vocational nurse in a state in which you are not licensed Practice safety with physician‘s

verbal orders

17.7 Scenario

17.8 Questions for discussion

1. What are the ethical issues you found in this case scenario? 2. Who are the persons involved in this situation? 3. How would you plan care for Mr. A based on the above information? 4. What are any thoughts / feelings that you have about this care situation? 5. How would you resolve the ethical dilemma in this situation?

Mr A, a 90 yrs. Old man is brought to the emergency with severe chest pain. He has a history of several incidents of MI over the past five years. He is restricted to bed and also suffers from severe dementia. Analyzing his history and the investigation reports, the doctor says that the prognosis is very poor but he will try to resuscitate him. His son, Mr. B requests that he does not want resuscitation and had brought Mr A to the emergency since it would be possible to get a death certificate which was necessary for making legal claims.


Answers to these questions can be found while applying the steps of the ethical decision making process as done beneath:(follow the colour coding for each step)


Algorithm: To resolve an ethical dilemma

A nurse who works in ICU gives care to three severely ill patients. Of these, two are younger adults and one is an older person. Of them, two are in urgent need of organ transplants. She can’t help them, though, because there are no available organs that can be used to save them. The older patient, however, will die without a particular medicine. If s/he dies, there is a possibility of saving the other two patients by using the organs of the older patient, who is an organ donor. What should the nurse do?

Selects Decision 1

Continuing the care as previous

Pros: The nurse may not feel guilty

Cons: May lose the 2 younger patients

Decision 2

Decision 1

Think of possible solutions as well as pros and cons

Talk to seniors

Talk to the team

Refer code of ethics

Yes

Think, consider and do the following

Ethical dilemma

Decision 1: Not giving the medication to elderly patient

Not giving the medication to patient 3(older patient)

Pros: Can possibly save the other 2 patients who are younger.

Cons: Losing the patient 3 and psychological effect on nurse


Further reading

1. Benjamin Martin & Curtis Joy. Ethics in Nursing – Cases, Principles, and Reasoning. 2010. IVth edition, Oxford. ISBN – 13:978-0195380224, ISBN – 10: 0195380223

2. Franz M. Timothy. Group Dynamics and Team Interventions – Understanding and Improving Team Performance. 2012. Wiley-Blackwell Publications.

3. Guido W Ginny. Legal and Ethical Issues in Nursing. 2005. Prentice Hall. 4th Edition.

4. McCabe Catherine, Timmins Fiona. Communication Skills for Nursing Practice. 2013. Palgrave publishers, Ireland, 2nd Edition

5. Melia M Kath. Ethics for Nursing and Healthcare Practice. 2013. Sage Publications.