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ERDN intensive reviewer

DJ O. IÑIGO
Emergency Nursing (St. Paul University Manila)

PNLE NOVEMBER 11-12, 2023

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Emergency Response Disaster Nursing

Lecture Notes

BATCH SILNAG

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Emergency response disaster nursing

Ms. Lorelie pomen.l RN

Emergency nursing
• Issues in emergency nursing care
o Documenta4on of consent and privacy, ques.on related to admission of the
pa.ent; most of the .me nurses cannot touch the pa.ent unless consent is given.
§ Consent to care – is given by the following:
• Pa:ent
• Significant others/next to kin
• Physician – usually if the pa.ent cannot speak already due to chronic
accident such as “wasak na ang mukha”
o Principle used: Paternalism is applied when physician gives the
consent for the pa:ent.
o Documenta4on which is the hallmark and must be done if the
physician or health care worker must decide for the pa:ent.
o Things to document: this is for legal purposes since there are
.mes that we cannot wait for the families.
§ Pa:ent’s condi:on such as the level of consciousness
§ No S.O is present.
§ Monitoring
§ Treatments and :me
o Limi4ng exposure to health risks nurses are the 1st line that are exposed to the
health risk especially in the emergency room.
§ Precau:on inside the ER:
1. Standard precau:ons
o Violence in the Emergency department in the ER there are sudden violence that
occurs especially pa.ents who are agitated related to their condi.ons.
§ It is important to priority – Safety it’s a general concept which can be asked in
different ways.
o Providing holis4c care this is when nurses address not just the physiologic but also
the psychologic needs of the pa.ent.
§ Stages of crisis this are usually addressed in the emergency department.
• Anxiety related to the condi.on à denial difficult to accept the
diagnosis à remorse + guilt à anger à grief à reconcilia:on.
• Ini4al goal: reduc.on of anxiety
o In aAaining the goal – therapeu:c communica:on is the main
management too reduce the anxiety.
• Principles of Emergency care
o Emergency care – is a care that must be rendered without delay. In an, ED several
pa:ents with diverse health problems – some life-threatening, some may not
present to the ED simultaneously. One of the first principles of emergency care is
TRIAGE. This will help nurses on priori.zing the pa.ent.

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o Triage
§ French word “trier”
§ Meaning – to sort
§ Used to sort pa:ent into group based on the severity of their health problems
and the immediacy with which these problems must be treated.
• Severity means how life threatening the condi.on of the pa.ent.
• Immediacy means does the pa.ent needs immediate treatment.
§ Triage is an advanced skill. Emergency nurses spend many hours learning to
classify different illnesses and injuries to ensure that pa:ent most in need of
care do not needlessly wait.
• According to Patricia Benner – NACPE theory
o Expert nurses are in the emergency department.
• The goal of all triages is rapid assessment and rapid decision making
preferably under 5 minutes.
§ Types of triages:
• ED triage VS Field Triage some.mes ED triage can shiQ to field triage
especially when there is scarce in resources.
o ED triages used in the hospital.
§ Rou:ne triage (used on the daily basis in the hospital) –
directs all available resources to the pa:ent who are most
cri:cally ill regardless poten:al outcome.
• What makes you worst, makes you first.
o Field triage used on disaster especially mass casual.es.
§ Scarce resources must be used to benefit the most people
possible.
• Do the greatest for the greatest number. .
• Rou4ne triage
o Three categories: 3 level triages since it is the most widely used
triage system also most basic.
1. Emergent – highest priority because the pa.ent
has life-threatening condi.on.
a. These are usually when ABC (airway,
breathing, and circula.on) is
compromised.
2. Urgent – serious health problem but not
immediately life-threatening
a. Such as fever since fever is serious health
problem but not immediately life-
threatening.
3. Non-urgent – episodes illness
a. ER nurse/triage nurse – usually decides
where to triage the pa:ent.
b. Episodic illness such as the following

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i. Cold
ii. Cough
o 5-level triage
§ Emergency severity index (ESI)
• Considers factors:
o acuity refers to the severity of the
pa.ent’s illness.
o Resource refers to the hospital resources
needed to address the problem of the
pa.ent’s illness.
• Raised by PNA (Philippine nursing associa.on)
Level I Pt: requires immediate life-saving interven:ons it means the pa.ent is in life-
threatening condi.ons
Level II Pt: serious health problem; disoriented, severe pain; vital signs are in danger.
Level III Pt: mul:ple resources to be stabilized but vitals are not in danger.
Level IV Pt: 1 resource to be stabilized.
Level V Pt: no resource because pa:ent is stable.

§ Canadian triage and Acuity scale (CTAS)

• Include 4me parameters that guide how
frequently pa:ents must be reassured. à for
monitoring
Level I Resuscita4on pa.ent requires
immediate lifesaving interven.ons.
• Cardiac and respiratory
arrest
• Life and limb threatening Con4nuous nursing surveillance (1:1
trauma. nursing care)
• Unresponsive/unconscious
• Ac:ve seizure
• Shock/sepsis with signs of
hypoperfusion
• Anaphylac:c reac:on
• Respiratory failure
Level II Emergent pa.ent is in high-risk
situa.on, is disoriented, in distress
or vitals are in danger zone.
• signs of stroke
• sudden blindness q 15mins
• chest pain
• lower airway obstruc:on
• profuse bleeding
• major head trauma

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• abnormal vital signs

• suicidality irregular
assessment should occur.
• febrile infant <28 days of age
with T > 38 degree Celsius.
Level III Urgent if mul.ple resources are
required to stabilize the pa.ent but
vitals are not in the danger zone.
• abdominal pain
• ac:ve vomi:ng
• mild asthma a_acks q 30mins
• diarrhea
• vaginal bleeding usually
spoXng only. à assess for
the perineal pads.
• fever it is a sign of infec.on.
• palpita:ons
Level IV Less urgent one resource is required
to stabilize the pa.ent.
• Minor trauma
• Back pain
• Rashes q 60mins / q 1hr
• Painful urina:on
• Muscle pain
• Ankle injury
Level V Non-urgent if pa.ent is stable and
does not require any resources to be
stabilized.
• Sore throat
• Rabies vaccina:on
• Simple wound q 120mins / q 2hr
• NGT inser:on
• Sore eyes
• Prescrip:on refills
• Change in foley catheter.
• Cough/cold

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o Assess and intervene.

§ A systema:c approach to effec:vely establishing and trea:ng health priori:es
is the primary survey and secondary survey approach.
• Primary survey
o Purpose: stabilize life-threatening condi:ons
o Follow the ABCDE method:
1. A – airway related to the oxygen entering the lungs
a. Airway obstruc4on
i. Par4al obstruc4on – oxygen can s:ll enter but there is
progressive hypoxia (less oxygen in the body) and
hypercarbia (hyper in carbon dioxide in the blood). à
brain detects à compensatory mechanism occurs such
as the following:
1. Increased heart rate
2. Increased RR
à hypertrophic when too much compensa.on
à cardiac and respiratory arrest especially when
there is no rest among these organs. à DEATH
ii. Complete obstruc4on – no oxygen can enter the
body/airway movement is absent à O2 deficit in the
brain à Restlessness à UNCONCIOUS à irreversible
brain damage within 3-5 minutes.
b. Causes:
i. 3 most common
1. anaphylac:c reac:on (laryngospasm)
2. infec:on, and
3. angioedema
ii. Other causes:
1. Aspira4on of foreign subject
a. Universal distress signal – clutching of the neck
between the fingers and thumb
b. Cannot speak, breath or cough.
c. Chocking, apprehensive appearance, refusing
to lie flat, inspiratory, and expiratory stridor
can be heard during ausculta.on, labored
breathing.
d. Use of accessory muscle and flaring nostrils
e. Increased anxiety, restlessness, confusion
f. Cyanosis and decreased LOC (late sign)
i. C – confusion
ii. D – disorienta:on, dizziness,
delirium

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iii. L – lethargy – decreased interest in

environment
iv. O – obtunded – decreased response
to s:muli
v. S – stuporous – sleepy
vi. Co – Coma
2. Trauma
3. Inhala4on of chemical burns
c. Management
i. Par4al obstruc4on – pt. can breathe and cough
spontaneously. – Mgt: encourage pt to cough.
ii. Complete obstruc4on – Mgt. reposi:on pts. Head.
a. Health 4lt/chin li_

b. Jaw thrust

AQerwards assess pt. for breathing by watching for chest

movement and listening and feeling for air movement
iii. Invasive management
1. Oropharyngeal airway
a. Circular tubelike plas:c device
b. Inserted over the back fo the tongue on the
lower posterior pharynx.
c. For pt: breathing spontaneously but
unconsciously.
d. Purpose: prevents the tongue from falling
back causing obstruc:on of airway; allows
suc:oning of secre:ons

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2. Nasopharyngeal airway
a. Provide same airway access but inserted in the
nares.
b. Should be tried if a pt. does not tolerate OPA.
c. Second choice only if OPA does not work.
d. Quality and safety nursing alert.
i. In case poten:al facial trauma or
basal skull fracture, the
nasopharyngeal airway should not
be used because it could enter the
brain ac:vity instead of the pharynx.
3. Endotracheal intuba4on
a. Purpose: establish and maintain the airway in
pa:ent with respiratory insufficiency or
hypoxia

b. Indica4ons:
i. If pt. is not adequately ven:lated
with OPA and NPA
ii. Bypass an upper airway obstruc:on.
iii. Prevent aspira:on.
iv. Permit connec:on to rescu-bag or
BVM or mech vent.
v. Facilitate removal of
tracheobronchial secre:ons
d. Ques4on asked for airway assessment.
i. Can O2 enter the lungs?

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2. B – breathing
a. Provide adequate ven:la:on.
b. Pt’s who have experienced trauma must have cervical spine
protected and chest injuries assess first, immediately aher
securing airway.
i. Chest injuries such as flail chest two or more ribs are
detached from the rib cage.
ii. Rib fracture
iii. Paradoxical breathing it means reversed breathing in
which inhaling the lungs contracts while exhaling the
lings expand.
c. Ques4on asked for breathing assessment.
i. can O2 enter the blood?
3. C – circula4on
a. Any problem is a circulatory problem.
b. 3 classifica4ons of shock loss of effec.ve circula.ng blood à
vital organs failure. (HYPO-TACHY-TACHY) except for
neurogenic shock.
i. Hypovolemic (blood) – ↓ blood volume à (1)
hemorrhage, (2) dehydra:on, (3) 3rd degree burn
1. Assessment
a. Cool moist skin – cold or clammy skin
b. Decreased BP – ↓ blood volume = ↓ BP
c. Increased HR
d. Delayed Capillary refill
e. Decreasing urine volume – oliguria it is
because of (1) decreased perfusion to the
kidneys, (2) increased reabsorp.on due to the
compensatory mechanism trying to contribute
to increase the blood volume.
2. Mgt: the goals of the emergency management is
stop the hemorrhage
a. Stop or control the bleeding – stopping the
bleeding is essen:al to the care and survival of
pa:ent in an emergency or disaster situa:on.
i. Rapid physical assessment à
iden:fy the sites of bleeding à stop
the bleeding.
ii. Apply PIE: pressure, immobilize, and
elevate.
iii. Last resort: tourniquet to done
proximal to the bleeding site à

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impede blood flow à NECROSIS. à

risk for amputa.on.
b. Maintain adequate circula4ng blood volume
– establish IV line for fluid replacement this is
for rapid IV resuscita.on.
i. Insert two large IV bore catheters.
gauge Color purpose
18 Green BT/OR
20 Pink OB
22 Blue Adult IM
23 yellow Pedia
26 Purple newborn

MAKAPASADUTTTT AGREVIEWWWW ii. Obtain blood sample – for analysis,

PUTANGINAAAAA KAYAT KON AGINUM blood typing and cross matching.
iii. Fluid of choice – isotonic fluids such
as PNSS, LR, PLRS, and D5W
1. D5W is eliminated first
because it is isotonic in the
bag but has hypotonic in the
body because of its water
content.
2. PLRS is most reliable it is
because it has near
concentra:on of bodily fluids
that our body needs.
c. Prevent shock
i. Pa:ent is maintained in the shock
posi:on.
1. Supine and elevated legs –
modified Trendelenburg
elevated legs is important to
promote venous return in the
upper body and center it at
the upper body through
supine posi.on. à good
blood perfusion à good
circula.on with cerebral
perfusion
2. Complete inclina:on –
Trendelenburg it causes
cerebral conges.on because

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the venous return directly to

the brain.
ii. Quality and safe nursing alert
1. The infusion rate is
determined by severity of
blood loss and the clinical
evidence of hypovolemic
shock. Any blood replacement
therapy should be given via
warm when possible. Because
administra:on of large
amounts of blood that has
been refrigerated has a core
cooling effects that may lead
cardiac arrest and
coagulopathy
ii. Cardiogenic (heart) – ↓ cardiac output à (1) CHF, (2)
cardiac tamponade, (3) dysrhythmia
iii. Distribu4ve (blood vessels) – massive vasodila4on
1. Types of distribu4ve shocks
a. Sep4c shock – severe bacterial infec4on à
endotoxins which causes massive dila.on.
b. Anaphylac4c shock – allergens à massive
vasodila:on
c. Neurogenic shock/spinal shock – spinal cord
injury à loss of SNS à massive dila:on.
c. Ques4on asked for circula4on assessment.
i. can oxygen that is now in the blood can be distributed
to the body?
4. D – Disability related to neurologic
a. Determine neurologic disability à brain func:on is a primary
survey.
b. Tools used:
i. GCS (Glasgow coma scale)
ii. AVPU à faster neurologic assessment
1. A – alert
2. V – verbal giving verbal s.muli see if there is
answer to that verbal s.muli
3. P – pain puXng small pain to the pa.ent to see a
response
4. U – unresponsive

5. E – exposure undress the pa.ent quickly but gently

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a. Assess area of wounds of injuries.

b. Undress the pa:ent quickly but gently so that any wounds or
areas of injury are iden:fied.
c. To assess wounds immediately
• Secondary survey pa.ent is already stable or known as rou.ne
assessment.
o Complete health history
o Head-to-toe assessment (includes reassessment of airway,
breathing and VS)
o Diagnos:c and lab tes:ng
o Applica:on of morning devices (ECG, Arterial lines, urinary
catheter)
§ Normal urine output: 0.5ml – 1ml/kg/hr
o Splin:ng of suspected fractures
o Cleansing, closure, and dressing wounds
o Performance of other necessary interven:ons based on the pt/s
condi:on.
• Environmental emergencies
o Head induced illnesses.
§ Caused by prolonged exposure to environmental heat leading to loss of
electrolytes.
§ Types:
• Heat cramps – 38C
o 3 cardinal manifesta4ons:
§ Muscle cramps
§ Diaphoresis
§ Thirst it is compensatory mechanism.
o Management
§ Lie supine à so that the body is inac:ve to conserve energy
and low metabolic rate in which the head produc.on is also
decreased.
§ Cool environment – body adopts to environmental
temperature.
§ Oral sodium supplements (hydra.on) – for water reten:on
§ Oral electrolytes solu:ons
• Heat exhaus4on – >38.8C (sa sobrang init nahimatay)
o Exhibit
§ High body temp
§ Headache
§ Anxiety
§ Syncope
§ Profuse diaphoresis
§ Goose flesh or goosebumps
§ Orthostasis/orthosta:c

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o Management:
§ Lie supine.
§ Cool environment
§ IV and oral fluids – the dehydra:on is severe. ORS oral
replacement solu.on
• Heat stroke – >35C or >39.2C most priority.
o Acute serious heat induced illness.
o Acute medical emergency
o Caused by failure of the heat regula:ng mechanism of the body.
à hypothalamus
o Associated with dehydra4on.
o Most common cause:
§ Non-exer:onal prolong exposure to an environmental temp
>39.2 deg cel and a heat index of >35 deg cel.
o Risk factors
§ Non acclima:zed to heat there are not used to heat especially
those who lives in cold country.
§ Extreme ages (very young and very old) old and newborn are
sensi.ve to changes temperatures and its either they don’t
have fully developed thermoregulatory for newborn and
decreased thermoregulatory due to old age.
§ Unable to care for themselves.
§ People with chronic and debilita:ng disease
o Assessment
§ Profound central nervous system dysfunc:on, manifested by:
confusion, delirium, bizarre, behavior, coma, seizure
§ Elevated body temperature: 40.6 deg. Cel. Or higher
§ Hot, dry skin usually anhidrosis (no swea.ng) à destroyed
thermoregulatory so no compensa.on will occur.
§ Hypotension, tachycardia, tachypnea à SHOCK due to
severe dehydra.on from heat stroke
o Management
§ Main goal: reduce high body temperature as quicky as
possible.
• Remove pt.’s clothing. à change to light clothing
when the temperature is high it is in the core body,
because if its covered with clothing the heat will
not be able to go out from the core body.
• Core (internal) temperature is reduced to 39 deg.
Cel. As rapidly possible, preferably within 1hr.
§ Method
• Cool sheets and towel: con:nua:on sponging.
(Tepid sponge bath)
• Cooling blankets

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•Immersion of the pt. in a cold-water bath OPTIMAL

METHOD FOR COOLING it increases heat loss for
25%
§ During cooling procedure
• Thermoregula4on
o Conduc:on – touch
o Convec:on – air
o Evapora:on – water
• An electric fan is posi:oned so that it blows on the
pt. faster dissipa:on of heat by conduc4on and
convec4on.
• Pt. temperature is constantly monitored with a
thermostat placed in the rectal, esophagus, and
Bladder.
• Cooling process should stop at 38C in order to
avoid à Tatrogenic hypothermia.
o Hypothermia
§ Condi:on in which the core (internal) body temperature is 35C or less.
§ Cause: loss of the body’s thermoregula:on which is emergency and life-
threatening
§ Pathophysiology of normal and abnormal:
o Cold à thermoregula:on is not destroyed à (1) shivering, (2)
vasoconstric4on.
o Shivering – compensatory mechanism à ↑ heat body
produc:on
o VasoconstricHon à perfusion: vital areas
o If thermoregula.on is destroyed à hypothermia à mul.-organ
failure à (1) brain and (2) heart
o Decreased Brain funcHon due to destroyed thermoregula.on à
manifestaHons: (1) dizziness, (2) disorienta.on, (3) mental
confusion.
o Decreased cardiac funcHon due to destroyed thermoregula.on
à decreased heart rate and blood pressure à HYPOXIA à
Anaerobic metabolism which is used of lac.c acid à bloods
become acido.c below than 7.35 pH.
§ Management:
• When pa4ent is experiencing dizziness, disorienta4on, and mental
confusion.
o monitor pa:ent’s level of consciousness.
o Ensure pa:ent safety.
o Ensure pa:ent’s safety.
• When pa4ent is experiencing decreased blood pressure and
decreased heart rate

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oWarm IV fluid before transfusing to the pa:ent.

oAdminister Inotropic drugs as DOC.
oAdminister Warm humidified oxygen.
oAdminister sodium bicarbonate it is a buffer agent to address the
acido.c blood.
• When there is cardiac dysrhythmias
o Con:nuous ECG monitoring
§ Systole – contrac:on of the heart
§ Asystole – no contrac:on of the heart
• Fibrilla:on – irregular contrac:on
• Mngt: defibrilla:on – correc:ng the irregular
contrac:on. We cannot defibrillate a pa.ent
without monitoring or ECG.
o keep wet clothing.
o cold IVF
o insert urinary catheter.
o pa:ent monitoring
o rewarming
§ 2 methods of rewarming
• Internal – inside the body most of it is ac.ve or you
give something to the pa.ent.
• External – outside the body it is passive but may
also be ac.ve.
§ Ac4ve internal core rewarming method
• For moderate to severe hypothermia (less than
28C) to 32.2C)
• Includes:
o Cardiopulmonary bypass
§ The deoxygenated blood
enters the superior vena cava
from the upper body, while in
the lower body goes inside
the inferior vena cava.
§ Cardiopulmonary bypass
machine is connected to the
vena cava, so it’ll pass
thorough the machine then
goes straight to the aorta à
systemic circula.on.
§ In short, with the
cardiopulmonary bypass the
deoxygenated blood is being

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converted to oxygenated
through the machine.
o Warm fluid administra:on
o Warmed humidified oxygen by ven:lator.
o Warmed peritoneal lavage giving
something to the pa.ent.
• Monitoring for VcFib as the pa4ent’s temperature
increase from 31C to 32 is essen4al. Ventricular
fibrilla.on is most common related to old induce
cardiac dysthymias.
§ Passive ac4ve external rewarming
• For mild hypothermia (32.2C – 35C)
• Includes:
o Over the bed heaters: increase blood
because of the heat it causes vasodila.on
to the acido:c, anaerobic extremi:es,
passive rewarming.
o Forced air warming blankets (ac.ve
external rewarming)
§ WOF: extremity burn, pt may
not have effec:ve sensa:on
to feel burn.
o Drowning
§ Nonfatal drowning it is not deadly drowning.
• Survival for at least 24 hours aher submersion
• Most drowning events occur in lakes, pool, and bath tub
• Preven4on:
o Avoiding rip currents offshore
o Surrounding the pool with fencing
o Self-latching/closing gate.
o Providing swimming lessons
o Personal floata:on device
• Supervision is the best preven:on measure for drowning.
• Major complica4ons
o A_er resuscita4on: hypoxia à anaerobic metabolism à acidosis
à hypothermia
o Pulmonary injury depends on the type of fluid aspirated.
o Freshwater – results in a loss of surfactant leading to inability to
expand the lung
o Salt water – pulmonary edema from the osmo:c effects of salt
within the lungs
• Management

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o The factor with the greatest influence on survival is immediate

CPR à to prevent hypoxia
o Treatment goal: prevent hypoxia.
• Rectal probe
• Indwelling FBC to monitor U/O
• ECG monitoring
• NGT for decompression to drain the water drank by the pa.ent due to
drowning.
o Snakebites
§ Venomous snakebites are medical emergencies.
§ The most common site is the upper extremity.
§ EnvenomaHon – injec.on of poisonous material
§ Classic clinical signs of envenoma4on
• Edema
• Ecchymosis
• Hemorrhage bullae à necrosis
§ Management
• Have the person lie down
• Remove constric:ve items ring
• Provide warmth.
• Covering the wound with a light sterile dressing
• Immobilize below the level of the heart à delay system absorp:on of
venom.
• No one specific protocol of tx. of snakebite
o Generally not used during acute stage:
§ Ice, tourniquet
§ Heparin – an: coagulant
§ Cor:costeroids – immunosuppressant
o Typically, pt. is observed closely for at least 6 hours.
o The pt. is never leh una_ended.
§ An4venin – an:toxin manufactured from the snake venom and used to treat
snakebites.
• Assessment of progressive s/sx is essen:al before the administra:on of
an:venin.
• Most effec:ve given within 4 hours post bite.
• Serum sickness is a type of hypersensi4vity response: before
administering an:venin and 10gA/mins every 15 minutes thereaher,
the circumference of the affected part is measured.
o The 10gj/mins are given to ensure that the reac.on is not severe
in case there is reac.on that would occur, rather than full blast
which will cause sudden severe reac.on from the an.venin.
• Can be given IV or IM.

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• Depending on the severity of the snakebite an:venin is diluted in 500

or 1000ml NSS.
• Infusion is started slowing then aher the rate is increased a_er 10
minutes of no reac:on.
• The total dose should be infused during the first 4-6 hours aher the bite.
• The ini:al does is repeated un:l symptoms decrease.
• There are no limits to the number of an:venin vials that can be given.

Disaster nursing
• Triage categories
o In a disaster, when HCP are faced with the large number of casual:es.
o Types of triages:
§ North Atlan4c treaty organiza4on (NATO) triage system
• Most widely used triage category
• Consist of four colors
o Red (immediate)
§ Life threatening immediate affec.ng the ABC
§ Survivable with minimal interven:on resources
§ Typical condi4ons:
• Sucking chest wound
• Airway obstruc:on secondary to mechanical cause
• Shock
• Hemothorax
• Tension
• Pneumothorax
• Asphyxia
• Unstable chest and abdominal wounds
• Incomplete amputa:ons
• Open fractures of long bones
• 2nd/3rd degree burns of 15-40% total body surface.
o Yellow (delay)
§ Injuries are significant and require medical care no ABC
problems can be seen.
§ But can wait hours without threat to life or limb.
§ Typical condi4on
• Stable abdominal wounds
• Soh :ssue injuries without hemorrhage
• Maxillofacial wounds without airway compromise
• Vascular injuries with adequate collateral
circula:on
• Genitourinary tract disrup:on
• Fractures requiring open reduc:on debridement.
• External fixa:on

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• Most eyes CNC injuries

o Green (minimal)
§ Injuries are minor.
§ Walking wounded
§ Treatment can be delayed hours to days.
§ Typical condi4on
• Upper extremity fractures
• Minor burns
• Sprains
• Small lacera:ons without significant bleeding
• Behavioral disorders
• Psychological disturbance
o Black (expectant)
§ Injuries are extensive chances of survival are unlikely even
with defini:ve care
§ Typical condi4on
• Unresponsive pa:ents with penetra:ng head
injuries
• High spinal cord injuries
• Wounds involving mul:ple anatomical sites and
organs
• 2nd/3rd degree burns in excess of 60% of body
surface area
• Seizures or vomi:ng within 24 hours aher
radia:on exposure.
• Profund shock with mul:ple injuries
• Agonal respira:on
• No pulse
• No BP
• Pupils and dilated

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It wasn’t entirely true, what they say about love and dreams—that they come when
the time is right, that they wait until you’re ready. No, sometimes they arrive
unannounced, relentless and untimely, demanding to be chosen even when the world
insists you aren’t prepared. People say everything has its perfect moment, that love
will only find you when you’re whole, that dreams will only take root when you’ve
earned them. But life isn’t so kind. Love doesn’t wait until you’re strong enough to
hold it, and dreams don’t pause until you have the courage to chase them. They
arrive like waves crashing against an unsteady shore, forcing you to decide—drown
in hesitation or let yourself be carried away.

And maybe that’s the cruelest part of it all. Not the absence of love, nor the lack of
opportunity, but the way they come when you least expect them, when you are at
war with yourself, when you are still trying to understand who you are. And in that
moment, you realize: readiness is an illusion. There is no perfect time, no perfect
version of yourself that will finally be worthy. If they are here, then they are here.
And if you want them, you must decide.

Post review realization,

October 24, 2023 (4pm)