NCM 218 PRELIMS

2 GROUPS OF EMERGENCY:
I.​ Medical emergencies
-​ All acute psychological crises that
are NOT directly caused by
4J - FIRST SEMESTER traumatic impact to the body
TOPIC
-​ E.g. CKD, cardiac arrest, status
TOPIC OUTLINE
I.​ EMERGENCY
asthmaticus, gouty arthritis
II.​ TYPES OF EMERGENCY II.​ Traumatic emergencies
III.​ 2 GROUPS OF EMERGENCY -​ Physiological crises that are directly
IV.​ 4 UNIVERSAL GOALS OF AN ER NURSE
V.​ GOALS OF EMERGENCY NURSING caused by an impact to the body &
VI.​ SCOPE AND PRACTICE OF EMERGENCY generally requires surgical
NURSING
VII.​ EMERGENCY TEAM
intervention
VIII.​ GENERAL PRINCIPLES OF EMERGENCY -​ E.g. blunt abdominal trauma,
MANAGEMENT fractures
IX.​ EMERGENCY DEPARTMENT
X.​ POSITION STATEMENT OF EMERGENCY
NURSES ASSOCIATED ON DIFFERENT ISSUES NOTES:
XI.​ HAZARDS ●​ Penetrating wound- no point of exit
●​ Perforating wound- with point of entry and exit

EMERGENCY
●​ Sudden, urgent, usually unforeseen EMERGENCY NURSING
occurrence requiring immediate action ●​ Care for patients in the emergency/ critical
●​ Medical/ surgical condition requiring phase of their illness/ injury
immediate/ timely intervention to prevent ●​ Skilled in dealing with people in the phase
permanent disability when a diagnosis has not yet been made
●​ Care given to patients with urgent & critical and the problem is not known
needs ●​ Patients may range from birth to geriatric
●​ Condition is considered an emergency FOUR UNIVERSAL GOALS OF AN EMERGENCY
NURSE:
situation until it is stable/ no longer
Care Provider
threatened client’s integrity/ well being
Advocate- patient’s voice
TYPES OF EMERGENCIES
Manager (of the team)
1.​ Danger to Health
Educator
-​ Not immediately threatening to life
GOALS OF EMERGENCY NURSING
-​ Might have serious implications for
○​ To establish a partnership with the patient/
the continued health & well-being
relatives
2.​ Danger to Life
○​ To achieve a level of independence in the
-​ Can cause immediate danger to life
patient appropriate to the illness/ injury
of people
○​ To enable individual to avoid ill-health/ injury
-​ Flooding, motor/ vehicular accidents,
through self-care, health education &
dog bites
environment safety
3.​ Danger to Environment
○​ To ensure maximum effectiveness of
-​ Do not immediately endanger life,
nursing & medically prescribed treatment is
health/ property, but do affect the
observed
natural environment & creatures
SCOPE & PRACTICE OF EMERGENCY
living within it NURSING:
-​ e.g. ○​ Assessment, analysis, nursing diagnosis,
4.​ Danger to Property planning, implementation of interventions,
-​ Do not threaten any people but outcome identification, and evaluation of
threatens property human responses of individuals in all ages
 ○​ Care that’s complicated by the limited ○​ Do a head-to-toe assessment before
access to medical history and the episodic initiating first aid measures
nature of the health care ○​ Obtain data from the patient- secure
○​ Triage & prioritization consent
○​ Emergency operations preparedness ○​ Avoid unnecessary handling/ moving of
EMERGENCY TEAM victim
●​ ER Resident Doctors ○​ Do not transport victim until all first aid
●​ ER Response Team measures have been carried out
●​ Triage Nurse
●​ ER Nurse NOTES:
●​ Nursing Assistant/ Aide ●​ HACT- HIV/ AIDS Core Team
●​ MI
●​ Other Personnel ○​ Make the patient lie down
○​ Admitting staff ●​ NPO within 2 hours of vomiting
○​ Post Graduate Interns (PGI) ●​ “-statins”- for high cholesterol
○​ Medical/ Respiratory/ Nursing
Students EMERGENCY DEPARTMENT
○​ Respiratory Therapists ➢​ Major Goals:
○​ Medical Technologist ○​ To preserve life
○​ To prevent deterioration before more
NOTES: definitive treatment can be given
●​ Triage Nurses- according to services in SPH (3) ○​ To restore patient to useful living
○​ 1- Pedia & Surgery ○​ To determine extent of injury/ illness
○​ 1- OB, IM, FaMed
○​ 1- OPD ○​ To establish priorities for the initiation
of treatment
CARE OF EMERGENCY PATIENTS:
EMERGENCY NURSE
●​ Specialized education, training, experience ➢​ Main Goal:
& expertise in assessing and identifying ○​ Recognize life-threatening illness/
patients’ health care problems in crisis injury
situations ➢​ Priority
●​ Focused on giving timely care to their ○​ Initiating interventions to reverse/
patients prevent a crisis before making a
medical diagnosis
FUNCTIONS OF AN EMERGENCY NURSE: ●​ Process begins with first contact with patient
establishes priorities ●​ Prompt identification of patients who need
monitors & continuously assesses patients immediate treatment
who are acutely ill and injured ●​ Determining appropriate interventions are
supports & attends to families essential nurse competencies
supervises allied health personnel POSITION STATEMENT OF EMERGENCY NURSES
ASSOCIATED ON DIFFERENT ISSUES
educates patients & families within the ACCESS TO HEALTHCARE
limited high pressure environment a)​ All individuals must have equitable access
to comprehensive health care services
GENERAL PRINCIPLES OF EMERGENCY b)​ All factors impeding access to quality health
NURSING: care must be removed
○​ Remain calm & think before acting
c)​ The use of emergency department for
○​ Identify oneself as a nurse to victim &
primary care & for non-urgent needs should
bystander
be alleviated by expanding primary &
○​ Do a rapid assessment for priority data
preventive health care services
(ABC)
d)​ The lack of appropriately prepared nurses &
○​ Carry out lifesaving measures as indicated
nurse education deepens health disparities
by the priority assessment
 e)​ Emergency nurses must be actively HAZARDOUS MATERIAL (HAZMAT) EXPOSURE
involved in research; and -​ Comprehensive and multidisciplinary
f)​ Emergency nurses must maintain ongoing approach shall be taken for the prevention
continuing education of hazmat exposure
POSITION STATEMENT OF EMERGENCY NURSES ●​ Efforts toward an all- hazards approach
ASSOCIATED ON DIFFERENT ISSUES mitigation, planning, & response of
●​ ENA recognizes the contributions of clinical hazardous material exposure shall be
nurse specialists & nurse practitioners in undertaken
emergency care settings ●​ The development of appropriate hazmat
●​ Advanced practice registered nurses have exposure guidelines should be based on
a broad depth of knowledge and expertise in evidence-based practice
their specialty area and manage complex ●​ Emergency care personnel shall be
clinical and systems issues prepared and knowledgeable regarding the
ALL HAZARDS recognition and management of patients
●​ All hazard planning should begin at home
exposed to or contaminated with hazardous
●​ Response to a mass casualty event should
material
be organized & coordinated as to maximize
●​ Emergency departments and their
the number of lives saved
associated hospitals shall be prepared to
●​ Essential to integrate responding entities
receive and care for contaminated patients
using a common framework applicable to
●​ Emergency departments and their
all-hazards
associated hospital’s staff shall use the
●​ All-hazards planning include utilizing a
appropriate personal protective equipment
coordinated community-wide plan that links
(PPE) for the management of hazmat
local, state, regional, and national resources
exposure
●​ Active participation of community-wide drills
●​ Best practice is the regionalization and
in preparing for, responding to, and
standardization of equipment, supplies,
recovering from all-hazards incidents is
education, and hands-on training as it
essential
pertains to the care of contaminated
●​ All-hazards planning must involve care of
patients
individuals across all ages and diverse
populations
NOTES:
●​ Volunteer responders should participate & ●​ CBRNE (Chemical, Biological, Radiological,
deploy as requested individual, group, or Nuclear, and Explosives)
team
●​ Situations arise during a disaster when it PATIENT SATISFACTION IN THE EMERGENCY
may become necessary to provide care DEPARTMENT
using altered care standards and/or in an ●​ The primary customers of the emergency
altered or less than ideal environment department are patients, families and
●​ Development of basic and advanced significant others.
continuing education courses and training is ●​ Respect for the diversity of patients,
essential to prepare emergency nurses in families, and significant other are inherent in
the care and treatment of all-hazards emergency nursing practice
patients ●​ The actions and interactions of the
●​ Content of all-hazards disaster medicine emergency nurse consistently demonstrate
and emergency response should be efforts to meet customers’ need for respect,
included in core curricula for emergency dignity and quality care
nurses and other health care professionals ●​ The emergency department is a unique
●​ Emergency nurses should be involved in health care delivery system and that
research related to disaster instruments to measure customer service,
 quality of care, and patient satisfaction must -​ Must be presented in a language in
recognize that uniqueness cc the client understands the
●​ Standardized measurement and monitoring implications of any treatment
of customer service quality of care, and -​ By being informed:
patient satisfaction should be an on-going ❖​ Client have the right to refuse
process within the emergency department any treatment or procedures
and at the national level -​ However consent is valid only if
●​ The dissemination of accurate information to client is of adult years and of sound
the public about emergency department MIND
services is critical to the perceptions of -​ But not all adults can give consent
patients and their families concerning the especially if HYPOXIC,
care they can expect to receive INTOXICATED OR ALTERED
●​ Continuing education on customer service LEVEL OF CONSCIOUSNESS
may improve both patient and staff ●​ Emergency Doctrine
satisfaction with emergency department -​ Emergency treatment can be
care delivery provided under this doctrine
●​ Research is needed to measure patient -​ The client would be able to consent
outcomes related to the quality of care in to this IF ABLE because the
emergency departments alternative would have been death or
disability
ISSUES IN EMERGENCY NURSING CARE -​ This removes the need for obtaining
ETHICO-MORAL informed consent before emergency
●​ Advance Directives treatment and care are initiated
-​ Documents that indicate what is to ●​ Right to Privacy and Confidentiality
be done for a patient in extreme who -​ Not allowing unauthorized person
is no longer able to give or withhold into the hospital area
permission for medical treatment -​ Not disclosing private facts
-​ Usually written to avoid prolonging ●​ Mandatory Reporting
and inevitable, often painful or -​ Laws require hospitals, nurses and
non-sentient dying process physicians as well to notify
●​ Do not Resuscitate order appropriate locale, state or agencies
-​ A physician order in the hospital when incidents occur
chart informing other medical -​ E.g. Communicable disease:
personnel that they should not meningitis, meningococcemia, food
institute CPR in the event of poisoning
cardiopulmonary arrest ●​ Physical Evidence and Chain custody
●​ Duty to Act -​ All evidence must be recorded
-​ Duty of a party to take necessary during examination
action to prevent harm to another -​ Should be maintained in its natural
party or the general public condition
-​ Breach of duty to act may make a -​ E.G. Clothing- paper bag to
party liable for damages depending prevent decomposition
on the circumstances and -​ Bullet- MD usually marks the bottom
relationship between the parties of the buller and referred to the latter
●​ Consent to treatment - Thru informed during investigation of trial. They are
consent placed in a sealed bag, labeled and
-​ Means that the client is given to proper authorities
knowledgeable of ALL treatments -​ Gunshot wound- photograph and
and procedures and AGREE to describe the wound
these before implementation
 -​Specimen are obtained for legal confidential as to provide privacy to
purposes the patient
-​ Sexual assault victim- tested for
alcohol level by proper person must CULTURAL
be documented on this clinical ●​ Sociocultural differences between patient
records and provider may result in
●​ Transfer Laws miscommunication, distrust, poor treatment
-​ Nurses should be aware of the adherence, and worse outcome
hospital transfer policies,guidelines ●​ Improperly trained clinicians may resort to
and protocols stereotyping and even biased or
-​ This is done because of lack of discriminatory treatment of patients based
facilities or medical expertise on race, ethnicity, or social status
-​ Stabilization, documentation and
specific guidelines must be observed ADDITIONAL ISSUES IN EMERGENCY
-​ Receiving institution must accept the NURSING CARE
DOCUMENTATION OF CONSENT AND PRIVACY
transfer
●​ Consent to examine and treat the patient is
-​ Transfer will not endanger the
patient is part of the ED record
patient
●​ The patient needs to give consent for
-​ Qualified personnel in attendance
invasive procedures (e.g. angiography,
and proper medical equipment
lumbar puncture)
should be available
●​ Unconscious or in a critical condition and
unable to make decisions -
REASONS FOR MEDICAL ERRORS
DOCUMENTATION
1.​ Poor training of healthcare staff
●​ THE NURSE MUST DOCUMENT:
2.​ Patient overcrowding and doctor
-​ The patient’s is unconscious and
3.​ Patient medical history is mystery to
brought to the ED without family or
attending staff/personnel
friends
4.​ Unsanitary or ill equipped facilities
-​ Monitoring patient’s condition
5.​ Inefficient or effective record keeping
-​ All instituted treatment and the times
policies
at which they were performed
6.​ Unsafe or negligent medication distribution
-​ Response to the treatment
procedures
-​ Condition at discharge or transfer
-​ About instructions given to the
LEGAL ERRORS
●​ Common emergency room error that have patient and family for follow-up care
legal impact are the following:
1.​ Prescription drug errors or negligent LIMITING EXPOSURE TO HEALTH RISKS
●​ The risk is further compounded in the ED
administration of medication
because of common use of invasive
2.​ Failure to thoroughly assess the
treatments in patients who may have a wide
patient
range of conditions and are unable to
3.​ Performing procedures without
provide a comprehensive medical history
securing consent to the patient or
●​ All emergency health care providers must
relatives
adhere strictly to standard precautions for
●​ Documentation and Privacy
minimizing exposure
-​ Patient should be provided with a
●​ Early identification and strict adherence is
statement of the privacy
crucial
-​ Access to the medical record, both
paper and electronic, are strictly held
VIOLENCE IN THE EMERGENCY DEPARTMENT -​ Objects should not be left within
●​ Causes: patient reach; even an intravenous
-​ The effects of substance abuse, (IV) line spike can become a tool for
injury, or other emergencies violence if the patient is determined
-​ Emotionally volatile patient and -​ Courses on safety (de-escalation
families and physical restraint techniques)
-​ The environment of the ED, assist the staff with preparing for
including being subjected to long various violent situations
wait times and crowded conditions ●​ In case of gunfire in the ED, self-protection
-​ SAFETY IS THE FIRST PRIORITY is a priority
-​ PHYSICAL THREATS ARE MOST ●​ Security officers and police must gain
OFTEN ACCOMPANIED BY control of the situation first the the care is
VERBAL ABUSE, which is the most provided to the injured
common type of violence
-​ A patent or family member may PROVIDING HOLISTIC CARE
come to the ED armed ●​ Patients and families are overwhelmed by
-​ To avoid angry confrontations, anxiety because they have not have time to
members of gangs and families adapt the crisis
whole are feuding need to be ●​ They experience real and terrifying fear of
separated in the ED death, mutilation, immobilization and other
●​ The Joint Commission has strict standards assaults on their personal identity and body
regarding documentation of the reason, integrity
monitoring for safety, and ensuring the ●​ When confronted with trauma, severe
dignity of the patient who is restrained disfigurement, severe illness, or sudden
●​ Precautions to be taken to avoid injury death, the family experiences several
include the following situations: stages of crisis
-​ For prisoners, the hand or ankle ●​ The initial goal for the patient and family is
restraint (handcuff) is never anxiety reduction, a prerequisite to
released, and a guard is always effective and appropriate coping
present in the room ●​ SAFETY is of prime importance
-​ A mask can be place to the patient ●​ Close observation and pre planning are
to prevent spitting or biting essential
-​ Non restraint techniques should be ●​ Security personnel are stationed nearby in
trued when possible. E.g. talking the event that a patient or family member
with the patient, minimizing responds to stress with physical violence
environmental stimulation ●​ Possible nursing diagnosis
-​ Physical restraints are used on any -​ Anxiety or death related to uncertain
patient who is violent only as needed potential outcome of the illness or
and, if used, should be humanely trauma
and professionally given (ACEP) -​ Ineffective coping related to acute
-​ Distance should be maintained from situational crisis
the patient to avoid grabbing; -​ Grieving interrupted processes
-​ Staff should not wear items that can -​ Compromised or disabled family
be grabbed by the patient, such as coping related to acute situational
dangling jewelry and stethoscopes. crisis
-​ Furthermore, distance should be
maintained between the patient and
the door so that an escape route for
the staff member is preserved
 TWO TYPES OF INTERVENTION IN ER 6.​ Avoid giving sedation to family members
PATIENT-FOCUSED INTERVENTION 7.​ Encourage the family to view the boy if they
●​ Act confidently and competently to relieve wish
anxiety and promote sense of security 8.​ Spend time with the family, listening to them
●​ Explanations should be given that the and identifying any needs that they may
patient can understand have for which the nursing staff can be
●​ Human contact and reassuring words helpful
reduce the panic of the person who is 9.​ Allow family members to talk about the
severely injured or ill and aid in dispelling deceased and what he or she meant to
fear of unknown them. Encourage the family to talk about
●​ The patient who is unconscious should be events preceding admission to the
treated as if conscious emergency department
●​ Ensuring patient safety is a major focus in 10.​Avoid volunteering unnecessary information
critical practice settings
●​ Some of the most common sentinel event in CARDIOVASCULAR EMERGENCIES
the ED include delays to care and ●​ The absence of mechanical functioning of
medication errors the heart muscle.
●​ Common root causes for these sentinel ●​ The heart stops beating or beats abnormally
event revolve around and doesn’t pump effectively.
-​ Nurse staffing patterns ●​ If blood circulation isn’t restored within
-​ Patient volume minutes cardiac arrest can lead to the loss
-​ Speciality availability of arterial blood pressure, brain damage and
●​ Solutions to patient safety issues in the ED death.
include: CAUSES
-​ Ensuring optimal nurse staffing ●​ Acute myocardial infarction
-​ Pharmacy presence ●​ Ventricular fibrillation
-​ Rapid diagnostics turnaround times ●​ Ventricular tachycardia
●​ To minimize wait time to diagnosis and ●​ Severe trauma
fostering teamwork and support by ●​ Hypovolemia
leadership ●​ Metabolic disorders
FAMILY-FOCUSED INTERVENTION ●​ Brain injury
●​ The family is kept informed about where the ●​ Respiratory arrest
patient is, how he or she is doing and the ●​ Drowning
care that is being given ●​ Drug overdose
●​ Encouraging family members to stay with PATHOPHYSIOLOGY
the patient, when possible, also helps allay -​ Myocardial contractility stops, resulting in
their anxieties lack of cardiac output
HELPING FAMILY MEMBERS COPE WITH -​ An imbalance in myocardial oxygen supply
SUDDEN DEATH and demands follows, leading to myocardial
1.​ Take the family yo a private place ischemia, tissue necrosis and death
2.​ Talk to the family together so that they can CLINICAL MANIFESTATION
grieve together and heat the information ●​ Loses consciousness
given together ●​ Absent spontaneous respiration
3.​ Reassure the family that everything possible ●​ No palpable pulse
was done; inform them of the treatment ●​ Gasping
rendered ●​ Dilated pupil in less than a minute
4.​ Avoid using euphemisms such as “passed ●​ Pallor and cyanosis
on”
5.​ Encourage family members to support each
other and to express emotions freely
ADULT CARDIAC ARREST ALGORITHM
every 2
minutes, or
sooner if
fatigued.
●​ If no advanced
airway, 30:2
compression-v
entilation ratio
●​ Quantitative
waveform
capnography
-​ If
PETCO,
is low or
decreas
ing,
reasses
s CPR
quality.

DRUG THERAPY ADVANCED AIRWAY

●​ Epinephrine ●​ Endotracheal
IV/IO doses: 1 intubation or
mg every 3-5 supraglottic
mins advanced airway
●​ Amlodipine ●​ Waveform
IV/IO doses: capnography or
First dose: 300 capnometry to
mg bolus. confirm and
Second dose: monitor ET tube
150 mg or placement
●​ Lidocaine IV/IO ●​ Once advanced
doses: airway in place,
First dose: 1-1.5 give 1 breath every
mg/kg 6 secs (10
Second dose: breaths/min) with
CPR QUALITY SHOCK ENERGY FOR
0.5-0.75 mg/kg continuous chest
DEFIBRILLATION
compressions
●​ Push hard at ●​ Biphasic:
least 2 inches Manufacturer
(5cm) and fast recommendation RETURN OF REVERSIBLE CAUSES
(100-120/min) (eg, initial dose of SPONTANEOUS
and allow 120-200 J): if CIRCULATION
complete chest unknown, use (ROSC)
recoil. maximum available,
●​ Minimize Second and ●​ Pulse and blood ●​ Hypovolemia
interruptions in subsequent doses pressure ●​ Hypoxia
compressions should be ●​ Abrupt ●​ Hydrogen Ion
●​ Avoid equivalent ,and sustained (acidosis)
excessive higher doses may increase in ●​ Hypo-/
ventilation. be considered PETCO, hyperkalemia
●​ Change ●​ Monophasic: 360 J (typically > 40 ●​ Hypothermia
compressor mmHG) ●​ Tension
●​ Spontaneous pneumothorax
 arterial pressure ●​ Tamponade,
waves with cardiac
intra-arterial ●​ Toxins
monitoring ●​ Thrombosis,
pulmonary
●​ Thrombosis,
coronary

ADULT BLS CARDIAC ARREST

ADULT CARDIAC ARREST CIRCULAR

ALGORITHM
ADULT BRADYCARDIA ALGORITHM ADULT TACHYCARDIA WITH A PULSE
ALGORITHM

CARDIAC ARREST IN PREGNANCY IN

HOSPITAL ACLS ALGORITHM
ADULT POST CARDIAC ARREST CARE
ALGORITHM
COVID 19 BLS CARDIAC
ARREST ALGORITHM
 OUT OF HOSPITAL CARDIAC ARREST (OHCA)
CHAIN OF SURVIVAL

The First Link: RECOGNITION OF CARDIAC

ARREST & ACTIVATION OF EMERGENCY
RESPONSE SYSTEM
-​ Lay rescuers must recognize the patient's
arrest and call for help. If the victim is
unresponsive with absent or abnormal
breathing, the rescuer should assume that
the victim Is in cardiac arrest. Rescuers can
activate an emergency response (ie,
through use of a mobile telephone) without
leaving the victim’s side.

2. The Second Link: IMMEDIATE HIGH QUALITY

CPR
-​ If the lay rescuer finds an unresponsive
victim is not breathing or not breathing
normally (e.g., gasping), high quality CPR
COVID 19 BLS CARDIAC ARREST ALGORITHM shall be started immediately. The probability
(FIRST AID CPR) of survival approximately doubles when it is
initiated before the arrival of EMS.

3. The Third Link: RAPID DEFIBRILLATION

-​ It is recommended that public access
defibrillation (PAD) programs be
implemented in communities with individuals
at risk for OHCA. This would enable
bystanders to retrieve nearby AEDs and use
it when OHCA occurs.

4. The Fourth Link: BASIC AND ADVANCED

EMERGENCY MEDICAL SERVICES
-​ If provided by highly trained personnel like
Emergency Medical Technicians (EMT) and
Paramedics, provision of advanced care
outside the hospital would be possible.
5. The Fifth Link: ADVANCED LIFE SUPPORT 5. The Fifth Link: ADVANCED LIFE SUPPORT
AND POST ARREST CARE AND POST ARREST CARE

IN HOSPITAL CARDIAC ARREST (IHCA) FOREIGN BODY AIRWAY

CHAIN OF SURVIVAL OBSTRUCTION
-​ A condition when solid materials like
chunked foods, coins, vomitus, small toys,
etc are blocking the airway
Causes
1.​ Improper chewing of large pieces of food
2.​ Excessive alcohol intake
3.​ Children who are running while eating
4.​ Small children of hand-to-mouth stage left
unattended
5.​ Presence of loose upper and lower dentures
TWO TYPES OF OBSTRUCTION
Anatomical Obstruction
-​ It happens when the tongue drops back and
obstructs the throat. Other causes are acute
1. The First Link: SURVEILLANCE AND asthma, croup, diphtheria, swelling and
PREVENTION whooping cough
-​ Patients with IHCA depend on a system of
appropriate surveillance and prevention of
cardiac arrest, which is represented by a
magnifying glass in the first link.

2. The Second Link: RECOGNITION OF CARDIAC

ARREST & ACTIVATION OF EMERGENCY
RESPONSE SYSTEM Mechanical Obstruction
-​ When cardiac arrest occurs, prompt -​ When foreign objects lodge in the pharynx
notification and response to a cardiac arrest or airways, fluids accumulate in the back of
the throat.
should result in the smooth interaction of a
multidisciplinary team of professional
providers, including physicians, nurses,
respiratory therapists, and others.

3. The Third Link: IMMEDIATE HIGH QUALITY

CPR
-​ Chest compression fraction (the percent of
total resuscitation time spent compressing Universal Sign of Choking
-​ A sign wherein the victim is clutching his/her
the chest), chest compression quality (rate,
neck with one or both hands and gasping for
depth, and chest recoil), and ventilation rate breath
are fundamental metrics defining hïgh
quality CPR.

4. The Fourth Link: RAPID DEFIBRILLATION

-​ It is the cornerstone therapy for patients
who suffered cardiac arrest probably due to
ventricular fibrillation and pulseless
ventricular tachycardia.
 CLASSIFICATION OF OBSTRUCTION: SIGNS ❖​ Grasp your fist with your other hand and
MILD OBSTRUCTION press your fist into the victim’s abdomen
❖​ Good air exchange with a quick, forceful upward thrust.
❖​ Responsive and can cough forcefully ❖​ Repeat thrust until the object is expelled
❖​ May wheeze between cough from the airway or the victim becomes
❖​ May increases respiratory difficulty and unresponsive
possible cyanosis ❖​ Give each new thrust with separate, distinct
SEVERE OBSTRUCTION movement to relieve the obstruction.
❖​ Poor or no air exchange ❖​ Pregnant and obese victims
❖​ Weak or ineffective cough or no cough at all CHOKING RELIEF IN AN UNRESPONSIVE
❖​ High pitched noise while inhaling or no ADULT OR CHILD
noise at all ❖​ A choking victim’s condition may worsen,
❖​ Increased respiratory difficulty and he may become unresponsive, if you
❖​ Cyanotic are aware that the victim’s condition is
❖​ Unable to speak caused by a foreign body airway
❖​ Clutching the neck with the thumb and obstruction, you will know to look for foreign
fingers making the universal sign of choking body in the throat.
❖​ Movement of air is absent ❖​ Shout for help. If someone else is available,
CLASSIFICATION OF OBSTRUCTION: send that person to activate the Emergency
RESCUER ACTION Response System.
MILD OBSTRUCTION ❖​ Gently lower the victim to the ground if you
As long as good air exchange continues see that he is becoming unresponsive.
❖​ Encourage the victim to continue ❖​ Begin CPR
spontaneous coughing and breathing efforts ❖​ Each time you open the airway to give
❖​ Do not interfere with the victim's own breaths. Open the victim’s mouth wide. Look
attempts to expel the foreign body, but stay for the object.
with the victim and monitor his / her ➢​ After about 5 cycles or 2 minutes of
condition CPR, activate the ERS if someone
❖​ If a patient becomes unconscious and has not already done so
unresponsive, activate the emergency CHOKING RELIEF IN A RESPONSIVE INFANT
response system. ❖​ Kneel or sit with the infant in your lap
SEVERE OBSTRUCTION ❖​ If it is easy to do, remove clothing from the
❖​ Ask the victim is he / she is choking infant's chest.
❖​ If the victim nods and cannot talk, severe ❖​ Hold the infant face down with the head
airway obstruction is present and you must slightly lower than the chest, resting on your
perform the abdominal / chest thrust forearm. Support the infant’s head and jaw
❖​ If a patient becomes unconscious and with your hand. Take care to avoid
unresponsive, activate the emergency compressing the soft tissues of the infant’s
response system. throat. Rest your forearm on your lap or
CLASSIFICATION OF OBSTRUCTION: thigh to support infant
RESCUER ACTION ❖​ Deliver up to 5 back slaps forcefully
ADULT MANAGEMENT between the infant's shoulder blades, using
❖​ https://youtu.be/5kmsKNvKAvU the heel of your hand. Deliver each slap with
PEDIA MANAGEMENT sufficient force to attempt to dislodge the
❖​ https://youtu.be/gHZdBY-CkGw foreign body.
ADDITIONAL LINKS ❖​ After delivering up to 5 back slaps, place
❖​ https://youtu.be/CnbjPFwkiTQ your free hand on the infant’s back,
❖​ https://youtu.be/SwJlZnu05Cw supporting the back of the infant’s head with
ABDOMINAL THRUST WITH VICTIM STANDING the palm of your hand. The infant will be
OR SITTING adequately cradled between your 2
❖​ Stand or kneel behind the victim and wrap forearms, with the palm of one hand
your arms around the victim’s waist supporting the face and jaw while the palm
❖​ Make a fist with one hand. of the other hand supports the back of the
❖​ Place the thumb side of your fist against the infant’s head.
victim’s abdomen, in the midline, slightly ❖​ Turn the infant as a unit while carefully
above the navel and well below the supporting the head and neck. Hold the
breastbone. infant faceup, with your forearm resting on
 your thigh. Keep the infant’s head lower INHALATION INJURY
than the trunk. ●​ Results from trauma to pulmonary system
❖​ Provide up to 5 quick downward chest after inhalation of toxic substance or
thrusts in the middle of the chest, over the inhalation of gases that are nontoxic but
lower half of the breastbone
interfere with cellular respiration.
❖​ Deliver chest thrusts at a rate of about 1
second, each with the intention of creating ●​ Inhaled exposure forms include fog, mist,
enough force to dislodge the foreign body. fume, dust, gas, vapor or smoke.
❖​ Repeat the sequence of up to 5 chest ●​ Inhalation injuries commonly accompany
thrusts until the object is removed or the burns
infant becomes unresponsive. ●​ Inhalation injury is caused by inhalation of
thermal and/or chemical irritants
●​ Injuries above the vocal cords can be
thermal or chemical
●​ Whereas injuries below the vocal cords are
CHOKING RELIEF IN A RESPONSIVE INFANT usually chemical
❖​ If the infant victim becomes unresponsive, ●​ Singed facial hair or carbonaceous sputum
stop giving back slaps and begin CPR, are indicators for the presence of a smoke
starting with chest compressions. inhalation injury.
❖​ Shout for help. If someone responds, send CAUSES: CARBON MONOXIDE POISONING
that person to activate the ERS. Place the ●​ Carbon monoxide is a colorless, odorless,
infant on a firm, flat surface. tasteless gas produced as a result of
❖​ Begin CPR (starting with chest
combustion and oxidation
compressions) with 1 extra step:
➢​ Each time you open the airway, look ●​ Inhaling small amounts of gas over a long
for the object in the back of the period of time can lead to poisoning
throat. If you see an object and can ●​ Carbon monoxide is considered as a
easily remove it, remove it. chemical asphyxiant
❖​ After about 2 minutes of CPR, activate the ●​ Accidental poisoning can result from
ERS (if no one has done so) exposure to heaters, smoke from a fire or
use of a gas lamp, gas stove or charcoal
grill in a small, poorly ventilated area.
CARBON MONOXIDE POISONING
CLINICAL MANIFESTATION
A.) MILD POISONING
●​ Indicates CO level from 11% to 20%
●​ Slight shortness of breath
●​ Headache
BLIND FINGER SWEEPS ●​ Decreased visual acuity
❖​ Do not perform a Blind finger sweep, ●​ Decreased cerebral function
because it may push the foreign body back B.) MODERATE POISONING
into the airway, causing further obstruction ●​ Indicates a CO level from 21% to 41%
or injury. ●​ Altered mental status
●​ Confusion and headache
●​ Tinnitus and dizziness
●​ Drowsiness and irritability
●​ Nausea and changes in skin color
●​ Tachycardia and hypotension
●​ Stupor
C.) SEVERE POISONING
●​ Indicates a CO level from 42% to 60%
●​ Convulsion
●​ Coma
●​ Generalized instability TREATMENT
●​ FINAL STAGE ●​ Assessment of the patient’s ABC is the first
○​ CO level reaches 61% to 80% step.
resulting in DEATH ●​ Obtain the history of the exposure and
CAUSES: CHEMICAL INHALATION attempt to identify the toxic agent of
●​ A wide variety of gases may be generated exposure.
when materials burn. ●​ Immediately provide oxygen to the patient
●​ The acids and alkalis produced in the ●​ Upper airway edema requires emergent ET
burning process can produce chemical intubation
burns when inhaled ●​ Bronchodilators, antibiotics and IV fluids
●​ The inhaled substances can reach the may be prescribed
respiratory tract as insoluble gases and lead ●​ Chest physiotherapy may assist in the
to permanent damage. removal of necrotic tissue
●​ Inhaling unburned chemical in a powder or ●​ Fluid resuscitation is important in
liquid form can also cause pulmonary component in managing inhalation injury,
damage. but careful monitoring of fluid status is
SIGNS AND SYMPTOMS essential because of the risk of pulmonary
●​ The most common effects of smoke or edema.
chemical inhalation includes: WHAT TO DO?
❖Atelectasis ●​ Remove the patient’s clothing
❖Pulmonary edema ●​ Establish IV access for medication, blood
❖Tissue anoxia products and fluid administration
❖Respiratory distress ( occurs ●​ Obtain laboratory specimens to evaluate
early) ❖Hypoxia ventilation, oxygenation and baseline values
CAUSES: THERMAL INHALATION ●​ Implement cardiac monitoring
●​ Pulmonary complications remain the leading ●​ Monitor for pulmonary edema
cause of death following thermal inhalation ●​ Provide oxygen
trauma ●​ Monitor fluid balance and input and output
●​ Commonly caused by inhalation of hot air or closely
steam ●​ Assess lung sounds frequently
●​ Mortality rate exceeds 50% when inhalation ●​ Provide a supportive and educative
injury accompanies burns of the skin environment
SIGNS AND SYMPTOMS ●​ Monitor laboratory studies for changes that
●​ Initial symptoms includes: may indicate multisystem complications.
❖Ulcerations
❖Erythema
❖Edema of the mouth and epiglottis
Edema may rapidly progress to
upper airway obstruction which
may have the following:
➔​ Stridor/ wheezing /
crackles
➔​ Increased secretions
➔​ Hoarseness
➔​ Shortness of breath
DIAGNOSTIC TEST
●​ Electrolytes
●​ Liver function studies
●​ BUN and creatinine
●​ CBC
●​ ABG – acid base status, ventilation and
oxygenation
●​ Cardiac monitoring- to monitor ischemic
changes
●​ ECG- common finding is depressed ST
segment (CO poisoning)
●​ Chest X-ray
NCM 218 PRELIMS
●​ Inhalation or chemical burns to head,
face, or neck areas
●​ Viral or bacterial infection
4J - FIRST SEMESTER ●​ Tenacious secretions in the airway
TOPIC ●​ Cerebral Disorders (stroke)
TOPIC OUTLINE ●​ Trauma of the face, trachea or larynx
I.​ MEDICAL EMERGENCIES
II.​ AIRWAY OBSTRUCTION
●​ Croup
A.​ PATHOPHYSIOLOGY ●​ Peritonsillar or pharyngeal abscesses
B.​ CAUSES
C.​ CAUSES IN OLDER ADULTS ●​ Epiglottitis
D.​ CLINICAL MANIFESTATIONS ●​ Acute infectious processes of the
III.​ ASSESSMENT AND DIAGNOSTIC
FINDINGS posterior pharynx
IV.​ MANAGING PARTIAL OBSTRUCTION
V.​ MANAGING COMPLETE AIRWAY
OBSTRUCTION CAUSES IN OLDER ADULTS
VI.​ HEMORRHAGE/BLEEDING
VII.​ WOUNDS ●​ Sedative and hypnotic medications
VIII.​ HYPOVOLEMIC SHOCK
IX.​ DRESSING/COMPRESS
●​ Diseases affecting motor coordination
X.​ BANDAGES (e.g., Parkinson disease)
●​ Asphyxiation (e.g., dementia, intellectual
MEDICAL EMERGENCIES disability)
AIRWAY OBSTRUCTION ●​ Atrophy of the posterior pharynx-
●​ Acute upper airway obstruction is a resulting in aspiration or difficulty
life-threatening medical emergency swallowing.
●​ Aspiration of a bolus of meat is the most
PATHOPHYSIOLOGY common cause of airway obstruction
●​ Partially or completely occluded.
●​ Partial obstruction of the airway can
CLINICAL MANIFESTATIONS
lead to progressive hypoxia,
hypercarbia, and respiratory and
PARTIAL AIRWAY OBSTRUCTION
cardiac arrest.
●​ Completely obstructed -absent air ●​ Restlessness
movement causes permanent brain ●​ Agitation and anxiety
injury or death will occur within 3 to 5 ●​ Diaphoresis
minutes secondary to hypoxia. ●​ Tachycardia
●​ The airway prevents entry of air into the ●​ Coughing
lungs- causing decrease oxygen ●​ Stridor
saturation ●​ Respiratory distress
●​ Decrease oxygen in the brain, resulting ●​ Elevated blood pressure
in unconsciousness, with death following
rapidly. COMPLETE AIRWAY OBSTRUCTION
●​ Universal choking sign- clutches throat
CAUSES with hands
●​ Common causes (vomitus, food, edema, ●​ Inability to talk
tongue, teeth, saliva) ●​ Sudden onset of choking or gagging
●​ Aspiration of foreign bodies ●​ Stridor
●​ Anaphylaxis- most common- causing ●​ Cyanosis
laryngospasm
 ●​ Wheezing, whistling or any unusual ●​ Emergency cricothyroidotomy is
breath sound that indicates breathing indicated
difficulty OROPHARYNGEAL AIRWAY
●​ Diminished breath sounds ●​ A semicircular tube or tube-like plastic
(bilateral/unilateral) device that is inserted over the back of
●​ Sense of impending doom the tongue into the lower posterior
●​ Progression to unconsciousness pharynx in a patient who is breathing
spontaneously but who is unconscious.
ASSESSMENT AND DIAGNOSTIC FINDINGS ●​ Prevents the tongue from falling back
●​ Conscious against the posterior pharynx and
○​ ask whether he or she is choking obstructing the airway.
and requires help ●​ It also allows health care providers to
suction secretions.
●​ Unconscious
○​ Inspection of the oropharynx may NASOPHARYNGEAL AIRWAY
reveal the offending object. ●​ Provides the same airway access but is
○​ Chest and neck X-rays, inserted through the nares.
laryngoscopy, or bronchoscopy, ●​ CI: potential facial trauma or basal skull
CT scan fracture
○​ Auscultation ●​ If breathing is ineffective or absent,
○​ Oxygen supplementation should bag-valve-mask ventilation is necessary
be considered immediately​

MANAGING PARTIAL OBSTRUCTION BAG-VALVE-MASK (BVM) VENTILATION

●​ Is the standard method for rapidly
●​ Patient can breathe and cough providing rescue ventilation to patients
spontaneously- wheezing between with apnea or severe ventilation failure
coughs ●​ BVM ventilation, a self-inflating bag
●​ Encouraged to coughing forcefully (resuscitator bag) is attached to a non
●​ Persistent spontaneous coughing- rebreathing valve and then to a face
leading to good air exchange exists.​ mask that conforms to the soft tissues of
the face.
MANAGING COMPLETE AIRWAY ●​ The opposite end of the bag is attached
OBSTRUCTION
to an oxygen source (100% oxygen) and
Head-Tilt Chin-Lift Maneuver & Jaw Thrust
usually a reservoir bag.
Maneuver
●​ The mask is manually held tightly
●​ Rapid assessment of airway patency,
against the face, and squeezing the bag
breathing, and circulation are foremost.
ventilates the patient through the nose
●​ Promptly assess the cause of
and mouth.
obstruction.
●​ Successful BVM ventilation requires
●​ Promptly remove objects visible in the
technical competence and depends on 4
mouth
things:
●​ ET intubation and removal of
○​ A patent airway
foreign object during insertion of
the laryngoscope enables ○​ An adequate mask seal
visualization of the obstruction ○​ Proper ventilation technique
 ○​ PEEP valve as needed to Indication:
improve oxygenation ●​ extensive maxillofacial trauma,
●​ cervical spine injuries,
ENDOTRACHEAL INTUBATION ●​ laryngospasm, laryngeal edema (after
Purpose: an allergic reaction or extubation),
●​ To establish and maintain the airway in ●​ hemorrhage into neck tissue
patients with respiratory insufficiency ●​ obstruction of the larynx.
●​ Bypass an upper airway obstruction,
●​ Prevent aspiration
NOTES:
●​ Permit connection of the patient to a
●​ A cricothyroidotomy is
resuscitation bag or mechanical
replaced with a formal
ventilator
tracheostomy when the
●​ Facilitate the removal of
patient is able to tolerate this
tracheobronchial secretions
procedure.
Indication:
HEMORRHAGE/BLEEDING
●​ Patient who cannot be adequately ●​ Abnormal internal or external blood may
ventilated with an oropharyngeal or be caused by suture failure, clotting
nasopharyngeal airway abnormalities, dislodged clot, infection,
●​ Surgical procedures-. or erosion of a blood vessel by a foreign
Medications used to facilitate
object (tubing, drains) or infection
rapid sequence intubation
process
include a sedative, an
analgesic, and a neuromuscular ●​ A rapid loss of circulation intravascular
blockade agent volume
○​ Also called BLEEDING or
Performed only by: BLOOD LOSS
●​ Those who have had extensive training ○​ Internal bleeding- refer to blood
●​ Physicians loss inside the body
●​ Nurse anesthetists ■​ Occurs when blood leaks
●​ Respiratory therapists out through a damaged
●​ Flight nurses blood vessel or organ
●​ Nurse practitioners ○​ External Bleeding- or blood loss
●​ The emergency nurse commonly assists of the body
with intubation ■​ Happens when blood exits
through a break in the
CRICOTHYROIDOTOMY (CRICOTHYROID skin.
MEMBRANE PUNCTURE) ●​ Hemorrhage that results in the reduction
●​ Cricothyroidotomy is the opening of the of circulating blood volume is the main
cricothyroid membrane to establish an cause of shock.
airway. ●​ Minor bleeding, which is usually venous,
●​ This procedure is used in emergency generally stops spontaneously-unless
situations in which endotracheal the patient has a bleeding disorder or
intubation is either not possible or has been taking anticoagulant agents.
contraindicated, ●​ Retroperitoneum, pelvis, chest, thighs
etc.
 ●​ Elevate affected part- to stop venous
Hemorrhage/Bleeding and capillary bleeding
●​ The goals of emergency management ●​ Immobilized if the affected part is
are to: extremity
○​ Control the bleeding ●​ Apply tourniquet - external hemorrhage
○​ Maintain adequate circulating cannot be controlled - until surgery can
blood volume for tissue be performed - proximal to the wound
oxygenation ●​ Patient is tagged with “T”, location &
○​ Prevent shock time at forehead
●​ traumatic amputation with uncontrollable
MANIFESTATIONS hemorrhage - tourniquet remains in
●​ Cool, moist skin (resulting from poor place until OR
peripheral perfusion ●​ Time of application and removal should
●​ Decreasing blood pressure be documented.
●​ Increasing heart rate
●​ Delayed capillary refill CONTROL OF INTERNAL BLEEDING
●​ Decreasing urine volume
○​ → HYPO TACHY TACHY - shock Manifestation:
●​ Internal hemorrhage exhibits
MANAGEMENT tachycardia, falling blood pressure,
●​ Hemmorhaging - externally or internally - thirst, apprehension, cool and moist
a loss of circulating blood results in a skin, or delayed capillary refill.
fluid volume deficits and decreased Treatment:
cardiac output ●​ packed red blood cells, plasma, and
platelets are given at a rapid rate
FLUID REPLACEMENT Definitive Treatment:
1.​ IV catheters are inserted- 2 large bore ●​ surgery, pharmacologic therapy, arterial
cannula- uninjured extremity blood gas
2.​ Blood samples are obtained for analysis, ●​ Establish baseline hemodynamic
typing, and cross-matching parameters
3.​ Replacement fluids- isotonic electrolyte ●​ Patient is maintained in the supine
solutions (e.g., lactated Ringer’s, normal position and monitored closely until
saline), colloids, and blood component hemodynamic or circulatory parameters
therapy. improve, or until he or she is transported
4.​ massive blood loss- PRBC, PLT, Clotting to the operating room or intensive care
factor unit.

CONTROL OF EXTERNAL HEMORRHAGE WOUNDS

●​ A break in the continuity of a tissue of
●​ Rapid physical assessment- identify the the body either internal or external
area of hemorrhage- cut clothing
●​ Calm the patient- anxiousness increases OPEN WOUND
BP ●​ The skin is interrupted, exposing the
●​ Apply direct, firm pressure- bleeding tissues underneath. Results from
area or the involved artery- proximal to interruption from outside (e.g. laceration
the wound
 or from inside like the fractured bone NOTES:
end tears outward through the skin ●​ NOTE: Wrap or place the
amputated part in a plastic bag.
CLOSED WOUND Place it in a cooler container so
●​ Internal injury: no open pathway to the that it is on top of a cold pack!
injured site. Results from an impact of a ●​ DO NOT IMMERSE THE
blunt object (e.g. motor vehicle AMPUTATED PART IN ICE,
accidents, falls) COOL WATER OR SALINE

FOUR MAJOR PROCEDURES IN

TYPES OF WOUNDS CONTROLLING BLEEDING

CLOSED WOUND 1.​ Direct Pressure

●​ Contusion - bleeding beneath the skin 2.​ Elevation
into the soft tissue 3.​ Pressure Points
●​ Hematoma (also called a blood tumor), 4.​ Tourniquet
caused by damage to a blood vessel
that in turn causes blood to collect under HYPOVOLEMIC SHOCK
the skin The sequence of events in hypovolemic shock
●​ Bruises begins with the following:
●​ Crash injuries ●​ Decrease in the intravascular volume
●​ This results in decreased venous return
OPEN WOUND of blood to the heart and subsequent
●​ Abrasion - simple scratches and decreased ventricular filling.
scrapes (outer skin is damage) ●​ Decreased ventricular filling results in
●​ Puncture - occurs when the skin is decreased stroke volume (amount of
penetrated by a pointed object. Can be blood ejected from the heart) and
penetrating or perforating decreased cardiac output.
●​ Laceration - a wound that occurs when ●​ When cardiac output drops, bp drops
skin, tissue, and/or muscle is torn or cut and tissues cannot be adequately
open. Lacerations may be deep or perfused
shallow, long or short, and wide or ●​ Resulting to shock
narrow. EMERGENCY CARE FOR OPEN WOUNDS
●​ Avulsion - involves a tearing off or loss
●​ Expose the wound
of a flap of skin. flaps of skin and tissues
●​ Clean the wound surface
are torn loose or pulled off completely
●​ Control bleeding
●​ Amputation - traumatic cutting or
●​ Prevent further contamination
tearing off of a finger, toe, arm or leg.
●​ Bandage the dressing in place after
bleeding has been controlled
●​ Keep patient lying still
●​ Reassure patient
●​ Care for shock
 DRESSING/COMPRESS RULES FOR DRESSING AND BANDAGES
– any material use to cover a wound that will RULES FOR DRESSING
help in:
●​ Control bleeding
●​ Controlling bleeding
●​ Use sterile or clean materials
●​ Preventing infection and contamination
●​ Cover the entire wound
●​ Absorbing blood and fluid drainage
●​ Do not remove the dressing
●​ Protecting the wound from further injury
RULES FOR BANDAGES
TYPES OF DRESSING
●​ Do not bandage too tightly or too loosely
BULKY DRESSING ●​ Do not leave loose ends
-​ thick single dressing or a build up of thin ●​ Do not cover fingers or toes
dressings for profuse bleeding, ●​ Bandage from the bottom of a limb to
stabilization of impaled objects and the top (distal to proximal) in elastic
covering of large open wounds. E.g. bandage
sanitary napkins, layers of gauze ●​ Do square knot tying and should be
clean, fast and smooth
OCCLUSIVE DRESSING
Major goals in the treatment of hypovolemic
-​ a dressing use to create an air tight seal
shock
or close an open wound of a body cavity.
Usually made of folded plastic wrap or ●​ Restore intravascular volume to reverse
bag the sequence of events leading to
inadequate tissue perfusion
LATEST TREND IN WOUND DRESSING ●​ To redistribute fluid volume
-​ Dry wound dressing - OS pack ●​ To correct the underlying cause of the
-​ Moist wound dressing - e.g. bactederm fluid loss as quickly as possible

BANDAGES ANAPHYLAXIS
- any material that is used to hold a dressing in
place. ●​ A clinical response to an immediate
Purpose: (type I hypersensitivity) immunologic
●​ Hold a dressing in place reaction between a specific antigen and
●​ Apply direct pressure over a dressing an antibody.
●​ Prevent or reduce swelling ●​ The reaction results from a rapid release
●​ Provide stability for an extremity of IgE- mediated chemicals, which can
●​ Extend (e.g. broken bones) induce a severe, life- threatening
reaction (Abbas et al., 2014)
TYPES OF BANDAGES ●​ The reaction typically occurs within
●​ Triangular Bandage minutes but can occur up to 1 hour after
●​ Roller/ Elastic Bandages exposure to antigen. It produces
●​ Muslin Binder - Abdominal Binder physical distress within seconds or
●​ Adhesive Tapes minutes after exposure.
●​ Adhesive Strips ○​ A delayed or persistent reaction
may occur up to 24 hours.
○​ The severity of the action is
inversely related to the intervals
 between exposure to the allergen ●​ Neurologic function involves changes in
and the onset of the symptoms. the level of consciousness, severe
WHAT CAUSES IT? anxiety and possibly, seizure.
●​ Serum ( horse serum) DETERIORATION
●​ Vaccines ●​ Basophils and mast cells begin to
●​ Allergen extracts release prostaglandins and bradykinin
●​ Enzymes ( L-asparginase ) along with histamine and serotonin
●​ Hormones ●​ These substances increase vascular
●​ Penicillin or other antibiotics permeability causing fluid to leak from
●​ Sulfonamides the vessels
●​ Local anesthetics ●​ Patient become confuse with cool pale
●​ Salicylates skin, generalized edema, tachycardia
●​ Polysaccharides and hypotensive thus signals rapid
●​ Diagnostic chemicals vascular collapse.
●​ Food protein FAILED COMPENSATORY MECHANISM
●​ Food additives containing sulfite
●​ Insect venom ●​ Further deterioration occur as the body’s
PATHOPHYSIOLOGY compensatory mechanisms fail to
RESPONSE TO ANTIGEN respond.
●​ Upon exposure, lgM ang lgG recognize ●​ Additional substances are released to
the antigen and bind to it. neutralize the mediators.
●​ Patient has no signs and symptoms at ●​ These event cant reverse anaphylaxis.
this stage ●​ Patient may experience hemorrhage,
RELEASED CHEMICAL MEDIATORS disseminated intravascular coagulation
●​ Activated IgE on basophils promotes the and cardiopulmonary arrest.
release of mediators including
HISTAMINE, SEROTONIN and CLINICAL MANIFESTATION
LEUKOTRIENE In the skin, the following s/s:
●​ Patient begins to have sudden nasal ●​ Well circumscribed, discrete cutaneous
congestion; itchy, watery eyes; flushing; wheals with erythematous, raised,
sweating; weakness and anxiety indented borders and blanched center
INTENSIFIED RESPONSE DISTRESS ●​ Coalesce to form giant hives
●​ Activated IgE stimulates mast cells in OTHER SIGNS AND SYMPTOMS
connective tissue along the venule walls ●​ ANGIOEDEMA
to release more histamine and ○​ that may cause patient to
eosinophil chemotactic factor of complain of a lump in his throat or
anaphylaxis (ECF-A). you may hear hoarseness or
●​ Patient may experience red, itchy skin; stridor
wheals and swelling appear. ○​ Is swelling in the deep layers of
DISTRESS the skin and other tissues
●​ In the lungs, fluids leak in to the alveoli ○​ It may be accompanied by an
thus reducing pulmonary compliance. itchy, raised rash
●​ Patient may experience tachypnea,
crowing, use of accessory muscles and
cyanosis signal respiratory distress.
 ●​ Bronchial obstruction EPINEPHRINE ADMINISTRATION
○​ wheezing, dyspnea and chest
●​ May give thru IM or IV if the patient is
tightness
severe
○​ early indication of impending
●​ SITE: Mid-outer aspect of the thigh
airway compromise leading to
(vastus lateralis muscle)
respiratory failure
●​ Ineffective if patient is taking
beta-adrenergic blockers ( Glucagon)
●​ Gastrointestinal and genitourinary
effects:
NURSING MANAGEMENT
○​ Severe stomach cramps, Nausea,
●​ Administer epinephrine as ordered
Diarrhea, Urinary urgency,
●​ Assess ABC. May begin CPR if patient
Incontinence
is in cardiac arrest
●​ Administer supplemental oxygen and
●​ Neurologic effect:
observe positive response
○​ Dizziness, Drowsiness
●​ Assess VS every 5 to 15 minutes
Headache, Restlessness, Seizure
●​ Note for continued evidence of
●​ Cardiovascular Effect
hypotension. May administer
○​ Hypotension, Shock, Cardiac
vasopressor as ordered
arrhythmias (vascular collapse)
●​ Auscultate the lungs for decreased
adventitious sounds
TREATMENT
●​ Be alert of decreased wheezing
FOCUS:
●​ May begin IV fluid replacement
1.​ Maintaining a patent airway
●​ Monitor level of consciousness
2.​ Ensuring adequate oxygenation
●​ Evaluate peripheral tissue perfusion
3.​ Restoring vascular volume
including skin color, temperature, pulses
4.​ Controlling and counteracting the effects
and capillary refill
of the chemical mediators released
●​ Institute measures to control itching
●​ Reassure the patient and stay with him
●​ Immediate administration of epinephrine
and let him relax as much as possible
( 1:1000 or 1mg/ml)
●​ Tracheostomy or endotracheal APPROACHES TO EMERGENCY CARE
intubation and mechanical ventilator to
maintain patent airway TRIAGE
●​ Oxygen therapy to increase tissue
perfusion ●​ A French word trier meaning “to
●​ Administration of histamine blockers ●​ sort,” refers to the process of rapidly
●​ Albuterol nebulizer treatment determining patient acuity.
●​ Aminophylline to treat bronchospasm ●​ Process of assessing patients to
●​ Volume expanders to maintain and determine management priorities
restore circulating plasma volume ●​ A method of prioritizing patient care
●​ IV vasopressors to stabilize blood
according to the type of illness or injury
pressure
and the urgency of the patient’s
●​ CPR to treat cardiac arrest
condition.
 ●​ Used to ensure that each patient URGENT
receives care appropriate to his needs
●​ Evacuation is required within two hours
and in a timely manner.
to save life or limb (extremities); may
OBJECTIVES OF THE TRIAGE possibility of amputation if not managed
within 2 hrs
●​ Identify patients who require immediate ●​ Delay in care may occur for a limited
care time without significant mortality;
●​ Use space and resources efficiently ●​ Can wait up to 2 hours; if more than,
●​ Facilitate patients flow in the ED may consequences na
●​ Provide assessment and reassessment ●​ Ex. visible s/s but can be delayed. Abd
of patients pain – common; pero need pa rin mag
●​ Alleviate fear and anxiety of patients or intervene like need to give meds,
visitors submitting pt to diagnostic exam to know
●​ Initiate legal responsibility cause

TRIAGE IN HOSPITAL SETING NON-URGENT

●​ Triage modality ●​ Patients have non-life-threatening

●​ THREE-TIER TRIAGE conditions and likely need only one
●​ FIVE-TIER TRIAGE resource to provide for their needs
●​ EMERGENCY HOSPITAL TRIAGE ●​ One resource like isang lab lang, isang
gamot, etc
o CATEGORY I
●​ More than 2 hours
●​ Ex. cough & cold na less than 24hrs,
o CATEGORY II
dog bites
o CATEGORY III

o CATEGORY IV FIVE-TIER TRIAGE

THREE-TIER TRIAGE -​ BASED ON ENA (EMERGENCY
NURSING ASSOCIATION) 2011
-​ Used in SPH
LEVEL 1 RESUSCITATION
EMERGENT
· This level includes patients who need
●​ Patients require immediate treatment
immediate nursing and medical attention,
within minutes or patients may die
such as those with cardiopulmonary arrest,
●​ Involves emergency cases with
major trauma, severe respiratory distress
problems in the ABC’s (airway, breathing
and seizures.
and circulation).
●​ Within 15-30 minutes · Arrest-no pulse, no breathing,
●​ Ex. unresponsive, not breathing, no unresponsive
pulse, MVA, excessive external
hemorrhage · Life and death matter already
LEVEL 2 EMERGENT ●​ CTAS1 & 2 – interchangeable; ex. if
nagtriaging then CTAS 2, if wala
· These patients needs immediate nursing namanage within 15mins, could
assessment and rapid treatment such as progress into CTAS1. Or vice versa
head injuries, chest pain, stroke, asthma
and sexual assault injuries EMERGENCY SEVERITY INDEX (ESI)

· Sometimes di pa level na life-threatening ●​ A 5-level triage system that incorporates

concepts of illness severity and resource
· Trying to prevent na maglead into use (e.g., electrocardiogram [ECG],
rescucitation na level laboratory tests, radiology studies, IV
fluids) to determine who should be
LEVEL 3 URGENT ​
treated first.
· These patients need quick attention but ●​ The Emergency Severity Index (ESI) is
can wait as long as 30 minutes for an simple to use, five-level triage
assessment and treatment, such with signs instrument that categorizes emergency
of infection, mild respiratory distress or department patients by evaluating both
moderate pain patient acuity and resources.
●​ The triage nurse estimates resource
LEVEL 4 LESS URGENT ​ needs based on previous experience
with patients presenting with similar
· Patients in this triage category can wait injuries or complaints.
up to 1 hour for an assessment and ●​ Resource needs are defined as the
treatment such as earache, chronic back number of resources a patient is
pain, upper respiratory symptoms and mild expected to consume in order for a
headache disposition decision to be reached.

LEVEL 5 NONURGENT ​ · First, assess the patient for any

threats to life (ESI-1).
· These patients can wait up to 2 hours for
an assessment and treatment such as sore Ask “Is the patient in imminent danger of
throat, menstrual cramps and other minor dying?”
symptoms.
· For ESI-2, “is this a high-risk patient
OTHER FIVE-TIER SYSTEM who should not wait to be seen”?

Manchester – uses color coding · Next, evaluate patients who do not

meet the criteria for ESI-1 or ESI-2 for
CTAS used by PH also specifically DDH;
the number of anticipated resources
classified as CTAS1, CTAS2, etc.
they may need.
●​ CTAS5 – outpatient; follow up check up
· Assign patients to ESI-3, ESI-4, or
●​ CTAS4 – dog bite, cough and cold na
ESI-5 based on this determination.
bago lang
●​ CTAS3 – abd pain, chest pain na walang · Vital signs are important. Patients
signs of radiating assigned to ESI-3 must have normal
vital signs.
 · Patients with abnormal vital signs may Pediatric Fever Considerations
be reassigned to ESI-2
●​ Pedia-prone to febrile seizures; mostly
ESI ALGORITHM outgrowned over time
●​ 1 to 28 days of age: assign at least ESI
A. Immediate life-saving intervention 2 if temp >38.0 C (100.4F)
required: airway, emergency ●​ 1-3 months of age: consider assigning
medications, or other hemodynamic ESI 2 if temp >38.0 C (100.4F)
interventions (IV, supplemental 02, ●​ 3 months to 3 yrs of age: consider
monitor, ECG or labs DO NOT count); assigning ESI 3 if: temp >39.0 C (102.2
and/or any of the following clinical F), or incomplete immunizations, or no
conditions: intubated, apneic, pulseless, obvious source of fever
severe respiratory distress, SPO2<90,
acute mental status changes, or
unresponsive.

Unresponsiveness is defined as a patient that

is either:

●​ (1) nonverbal and not following

commands (acutely); or
●​ (2) requires noxious stimulus (P or U on
AVPU) scale. AVPU – alert, verbal, pain,
unresponsive

B. High risk situation is a patient you

would put in your last open bed.

●​ Severe pain/distress is determined by

clinical observation and/or patient rating
of greater than or equal to 7 on 0-10
pain scale.
●​ severe pain to classify as ESI-2 = must
have other clinical signs

C. Resources: Count the number of

different types of resources, not the
individual tests or x-rays (examples:
CBC, electrolytes and coags equals one
resource; CBC plus chest x-ray equals
two resources).

A. Danger Zone Vital Signs

Consider uptriage to ESI 2 if any vital sign

criterion is exceeded.