ERDN
CISM – critical incident stress management
Defusing – occurs immediately after critical event (discuss incident)
De briefing – 1 to 10 days after event (discuss feelings after incident)
Triage
1. Emergent – highest priority
2. Urgent – serious health problems but not immediately life threatening
3. Non urgent – walking wounded
Emergency severity index – assigned based in acuity and resource needs
Level 1 – requires immediate life saving intervention
Level 2 – high risk situations in severe pain
Level 3 – multiple resource are required to stabilize patient
Level 4 – one resource required
Level 5 – does not require any resource
Team Triage (aka provider in triage – PIT)
- Managed by triage nurse and physician
Routine triage – in ER all available resources are directed to the most critically ill
Field triage – disaster scarce sources must be used to benefit most people possible
Shock – lost of effective circulating blood volume
a. Septic – inability of the blood to carry oxygen due to the build up / introduction of poisons
- Caused by carbon monoxide or sepsis
b. Hypovolemic – loss of fluid from the blood caused by serious blood loss, burns, N/V and DHN
c. Anaphylactic – massive release of histamines and redistribution of blood from core to surface.
- Caused by an allergic reaction
d. Cardiogenic – irregular / absent functioning of the heart preventing normal effective circulation.
- Caused by cardiac arrest, electrocution, poisoning / overdose
e. Spinal / Neurogenic – flaccid paralysis below level of injury; loss of control over the dilation and
contraction of blood vessels resulting in a drastically lowered blood pressure.
- Only shock who has Hypo brady brady
Wound – injury to soft tissue from minor tears to severe crushing injuries
1. Laceration – skin tear with irregular edges and vein bridging
2. Avulsion – tearing away of tissue from supporting structures
3. Abrasion – denuded skin
4. Ecchymosis / contusion – blood trapped under surface of skim
5. Hematoma – tumor like mass of blood trapped under skin
6. Stab – incision of skin with well defined edges caused by a sharp instrument
- Usually deeper than long
7. Cut – incision of skin with well defined edges; typically longer than deep
8. Patterned – representing the outline of object
Wound cleansing – clipping of hair, cleansing with NSS or polymer agent. Povidone iodine is for initial
cleansing of external area.
Mngt – infiltrated with local intradermal or anesthetic thru wound margins / regional block
- Clean and debride wound, irrigate gently with sterile isotonic saline solution
Small bleeding vessels are clamped or tied
1. Primary closure – suture, staple or glue wounds. Begins when subcutaneous fat is brought
together. The subcuticular layer is closed and finally epidermis is closed
2. Delayed primary closure – if tissue has been lost or theres high potential for infection
- Done by covering thin layer of gauze covered by an occlusive dressing. Then its splinted,
sutured, immobilized, elevated, given antibiotics and tetanus toxoid. WOF: infection
Compartment syndrome – decreased circulation
5P’s – pulseless, painful, poikilothermia (hot spots), paresthesia and paralysis
Referred pain – ex. Pain in left shoulder (ruptured spleen), right shoulder (lacerated liver)
Collection of forensic evidence – documentation of wounds, mechanism of injury, time of event and
collection of evidence
Trauma – un/intentional wound or injury inflicted
1. Multiple trauma – single catastrophic event but 2 or more organ is damaged
2. Blunt trauma – extra abdominal injuries to the chest, head and extremities
Mgt – ABC, immobilization, log rolling and cervical collar for spine injury
3. Penetrating trauma – extends into internal cavity; viscera protrudes
Mgt – NPO, cover with sterile saline and stomach contents are aspirated
4. Infection predisposition – exposure to exogenous bacteria at the time of injury
s/sx – aspiration of vomitus (iatrogenic infection)
mngt – prophylaxis, tetanus toxoid, broad spectrum antibiotics
Crush injuries – caught between opposing forces (ex. Vehicle, building)
WOF – hypovolemic shock, SCI , AKI and ATN
Mngt – splint, monitor serum lactic acid, elevate, fasciotomy, analgesic, anxiolytic, debridement,
hyperbaric oxygen chamber
Classic triad of rhabdomyolysis (toxic syndrome / skeletal muscle injury)
1. Myalgia (muscle cramps)
2. Generalized muscle weakness
3. Dark urine
Dx – serum CK – most sensitive indicator. If blood level is >6000 IU/L (px has AKI)
Heat Induced Illnesses
1. Heat stroke – acute medical emergency; failure of heart regulating mechanism of the body
- Inability to maintain cardiac output, associated with DHN
Ex. Temp of greater than 39C (environmental cause)
Exertion heat stroke – strenuous physical activity
s/sx – CNS dysfunction, inc temp (>40.6C), dry skin, anhidrosis, tachypnea
3 Cardinal manifestation – Muscle cramp, Diaphoresis, thirst
Mngt – CAB, reduce core temp in 1hr, cool sheets/towel and cool water bath immersion
Cooling process should stop at 38C. most accurate site: rectal
2. Heat exhaustion / heat cramps
Mngt – position px supine in a cool environment, provide IV/oral fluids and oral sodium supplements
Frostbite – trauma from exposure yo freezing temperatures. Can cause venous stasis,
thrombosis, embolism
s/sx – hard, cold and insensitive to touch, may appear mottled blue white in color
mngt – remove wet clothing and jewelry, sterile gauze or cotton between affected fingers and toes to
prevent maceration (panit panit). DO NOT MASSAGE (can dislodge clot)
Whirpool bath – aid circulation and debridement
Disaster Emergency
Earthquake - Initial shock may last from a few seconds to almost a minute followed by
Aftershocks which are lesser in intensity than the first.
Tsunami - Not a single wave, but a series of waves
- Not all earthquakes cause tsunamis, but many do.
- Do not stay in low-lying coastal areas after a local earthquake has occurred.
Typhoons - big swirling mass of wind and rain. Central area is called the eye.
Classification of Tropical disturbances
1. Depression - Maximum wind is less than 63 km. Per hour
2. Tropical Storm- Maximum wind speed rangers 63 to 87 kmhr.
3. Severe Tropical storm - Maximum wind speed rangers from 88 to 117 kmhr..
4. typhoon -Maximum wind speed is 118km/hr
Storm Warning Signal:
Signal No. 1 - Winds up to 60 km/hr maybe expected within 24 to 36 hours.
Signal No 2 - Winds from 60- 100 km/hr maybe expected within 24 hours.
Signal No.3 - Winds in excess of 100 km/hr
BURNS
Remember – this causes Hyponatremia and Hyperkalemia
- normal system is PISO, but with burns, sodium is loss therefore potassium (which is a major
cation; inside the cell) gets out because body compensates sodium loss by opening the sodium-
potassium pump where little amount of sodium inside the cell is released together with
potassium.
1st degree – partial thickness burn; painful, epidermis; sunburn, redness
2nd – partial thickness; painful, dermis, blisters / vesicles
3rd – full thickness: painless (burned nerve endings) subcutaneous, white in color
4th – full thickness; painless, muscles and bones; charcoal color and leather consistency
Phases of burns
Emergent phase – 2nd, 3rd and 4th degree burn; BSA of 15%
- First 48-72hrs of burns. Cell and blood vessel are damaged (contains potassium and H2o acid
inside)
- 1st 48 hrs – Intravenous to Interstitial. After 48 hrs – IS to IV
There is edema, hyponatremia, hyperkalemia and hypovolemia (WOF: hypovolemic shock)
Give LR solution – to correct metabolic acidosis
Whole head – 9
Posterior and anterior trunk – 36
Arm – 9 each (18)
Leg – 18 each (36)
Private – 1
Parkland Formula: 4ml of LR x KG (weight) x TBSA (% of burn)
Ex. Given is 45kg with 32.5% of burn
4ml x 45 x 32.5
= 5850ml / 24hrs
24hr fluid replacement
1st 8hrs (give 50%) = 2925
2nd 8hrs / 16hrs (give 50% of the first) = 1462.5
Acute phase – onset of cell repair; potassium comes back inside (hypokalemia)
WOF: fluid overload and Complication – CHF, Sepsis, Infection
Rehabilitation – starts when wound is closed; can cause scar hyperthrophy
Mgt – wear compression garment under the clothes
Avoid direct sunlight - to prevent dark pigmentation
