Introduction to Emergency Nursing Concepts

1. Introduction to Emergency Nursing Concepts Anuradha Perera (B.Sc.N)special

2. Prehospital Care and Transport • The time from injury to definitive care is a determinant of survival, particularly those with major internal hemorrhage. • Careful attention must be given to the airway with cervical spine immobilization, breathing and circulation. (ABC’s)

3. Continued… • Full spinal mobilization is being challenged and reexamined: • Asking: Is full spinal mobilization necessary in all trauma patients? • How appropriate is the assessment of prehospital assessment? • Concerns over the high false positive rate that occurs with prolonged spinal immobilization.

4. Trauma • The fourth leading cause of death for ALL ages. • Nearly ½ of all traumatic incidents involve the use of alcohol, drugs or other substance abuse. • Is predominantly a disease of the young and carries potential for permanent disability.

5. Systems Approach to Trauma • An organized approach to trauma care that includes: • Prevention, access, acute hospital care, rehabilitation, and research.

6. Trimodal Distribution of Death • First peak- seconds to minutes from time of injury to death—severe injuries: lacerations of the brain, brainstem, high spinal cord, heart aorta, large blood vessels. • Second peak- minutes to several hours: subdural, epidurdal hematomas, hemopneumothorax, ruptured spleen, lacerated liver, pelvic fractures, other injuries associated with major blood loss.

7. Third peak-occurs several days to weeks after the initial injury: most often the result of sepsis and multiple organ failure. At this stage, outcomes are affected by care previously provided.

8. Trauma Triage • Minor trauma: single system injury that does not pose threat to life or limb and can be appropriately treated at a basic emergency facility. • Major trauma: serious multi system injuries that require immediate intervention to prevent disability.

9. Mechanism of Injury • Is vital to the initial assessment and may raise suspicions about the patients injury pattern. • Blunt vs. penetrating injury

10. Blunt Trauma • Most often results from vehicular accidents, but may occur in assaults, falls from heights, and sports related injuries. • May be caused by accelerating, decelerating, shearing, crushing, and compressing forces.

11. Blunt Trauma, cont. • Coup-contra coup injury • Body tissues respond differently to kinetic energy…low density porous tissues and structures, such as lungs, often experience little damage because of their elasticity.

12. Blunt Trauma cont. • The heart , spleen and liver are less resilient often rupturing or fragmenting. • Often, overt external signs are not apparent…making the mechanism of injury most important to the practitioner performing the physical examination.

13. Penetrating Trauma • Results from the impalement of foreign objects into the body. • More easily diagnosed because of obvious injury signs. • Stab wounds are usually low velocity…the direct path, the depth and width determine injury. • Women tend to have trajectories in a downward motion, men in an upward force.

14. Penetrating Trauma cont. • Ballistic trauma may be either low or high velocity injuries. • Missiles or bullets that come into contact with internal structures that produce a change in in pathway release more energy and result in more injury than a direct pathway.

15. Penetrating Trauma, cont. • Injuries sustained from penetrating objects must be assessed for the potential for infection from the debris carried by the penetrating object.

16. Disaster / Mass Casualty Triage Concepts • Most severe injuries in mass trauma events are fractures, burns, lacerations, and crush injuries. • Most common injuries are eye injuries, sprains, strains, minor wounds and ear damage.

17. Mass Casualty: Who is at risk? • Anyone in surrounding area. • Rescue workers and volunteers.

18. Disaster Triage • www.bt.cdc.gov/masstrauma/index.asp • www.nyerrn.com/simulators

19. Pre-Hospital Care and Transport • The time from injury to definitive care is a determinant of survival. • Careful attention is given to C-spine immobilization, breathing and circulation…(ABC’s)

20. Current Guidelines on C-Spine Immobilization • Although it has been challenged, C-spine immobilization is still the protocol for trauma patients until diagnostically cleared (X-Ray)

21. Additional Pre-Hospital Measures • Occlusive dressings to open chest wounds • Needle thoracotomy to relieve tension pneumothorax • Endotracheal intubation • Cricothyrtomy

22. Research has indicated INCREASED mortality with IV fluids BEFORE hemorrhage control. • Transport is not delayed to start IV access!

23. TransportHow is it decided? • Travel time • Terrain • Availability of air or ground transport • Capability of personnel • Weather

24. Emergency Care PhasePreparation • Trauma team at receiving hospital responds before arrival of patient • Report has been transmitted • Preparations are initiated based on report.

25. Initial Patient Assessment • Clinical presentation • Physical assessment • History of traumatic event • Pre-existing illness

26. Primary Survey • Most crucial assessment tool in trauma care • 1-2 minutes MAX! • Designed to identify life threatening injuries ACCURATELY • Establish priorities • Provide simultaneous therapeutic interventions.

27. Resuscitation Phase • Secondary Survey:

28. EFGHI = • E- Expose the patient • F- *Full set of vital signs, *five interventions (cardiac monitor, pulse oximetry, urinary catheter, NG if not contraindicated, lab studies) • G- giving comfort measures…pain control, reassurance to patient and family • H- history/ head to toe assessment • I- inspect for hidden injuries-log roll patient to inspect posterior aspect.

29. Sequence of Diagnostic Procedures • Influenced by: • Level of consciousness • Stability of patient’s condition • Mechanism of injury • Identified injuries

30. Maintain Airway Patency • Essential to trauma management • EVERY trauma patient has potential for airway obstruction • Most common obstruction: Tounge • Other common causes: blood or vomitus, secretions, structural impairment, depressed sensorium, absent gag reflex

31. How to open the airway? • Jaw thrust or chin lift!!! • These maneuvers do not hyperextend the neck or compromise the integrity of the C-spine

32. Maintaining the airway • Simple, simple!! • Nasopharyngeal airway • Oropharyngeal airways

33. Definitive Nonsurgical Airway • Endotracheal intubation-Complete control of the airway • Nasotracheal intubation—INDICATED for the spontaneously breathing patient..CONTRAINDICATED in the patient with facial, frontal sinus, basilar skull or cribriform plate fractures.

34. Choice of Airway management • Familiarity of procedure • Clinical condition of the patient • Degree of hemodynamic stability • A PATENT AIRWAY IS THE CORNERSTONE OF SUCCESSFUL TRAUMA RESUSCITATION

35. A LIFE THREATENING CONDITION EXISTS • Altered mental status (agitation) • Cyanosis( nail beds and mucous membranes) • Asymmetrical chest expansion • Use of accessory muscles/abdominal muscles • Sucking chest wounds • Paradoxical movements of the chest wall • Tracheal shift • Distended neck veins • Diminished or absent breath sounds

36. Impaired Gas Exchange • Follows airway obstruction as the nest most crucial problem for the trauma patient. • Reasons: decreased inspired air, retained secretions, lung collapse or compression, atelectasis, accumulation of blood in the thoracic space.

37. Decreased Cardiac Output/Hypovolemia • Acute Blood loss—MOST common cause in acute trauma • May be external or internal

38. Treatment • PASG- anti-shock garment (pneumatic anti-shock garment) • When inflated, PASG compresses the legs and abdomen, resulting in increased venous return and SVR(systemic vascular resistance) preventing further blood loss into the abdomen and legs. • Elevates systemic pressure by shunting a small amount of blood into central circulation. • CAN be a detriment, elevates BP, and in the event of hemorrhage without DEFINITIVE control can be fatal.

39. Additional Causes of Decreased Cardiac Output • (impaired venous return to the heart) • Tension Pneumothorax • Pericardial Tamponade (from decreased filling and ventricular ejection fraction)

40. Priority Interventions • Patent airway • Maintaining adequate ventilation • Adequate gas exchange • Then: • Control hemorrhage, replace circulating volume, restore tissue perfusion

41. Control of External Hemorrhage • Direct Pressure • Elevation • Compression of pressure points (arteries, veins) • AVOID tourniquets…can compromise loss of circulation and loss of limb

42. Control of Internal Hemorrhage • Identification and correction of underlying problem.

43. Fluid Resuscitation • Venous Access and Volume infused are key. • Two large bore IV’s 14-16 gauge. (never less that 18, that is the smallest to give blood through rapidly and not have hemolysis) • Forearm and anti-cubital veins are preferred • Central lines are more beneficial as resuscitation MONITORING tools

44. Fluid Resuscitation Cont… • A pulmonary artery catheter may be inserted in the critical care unit to monitor volume. • RULE: Venous access with largest bore catheter possible. • Isotonic fluids are used INITIALLY • Ringer’s Lactate is first choice followed by Normal Saline

45. Fluid Resuscitation Cont… • Large bore catheters, short tubing, rapid infuser devise that warms fluids and blood. • An initial bolus of 2 liters of fluid is used unless there is contraindication… • 3:1 rule= 3mls of crystalloid for each 1ml of blood loss. • INITIAL response to fluid challenge is urine output..should =50 ml in adult, LOC, heart rate, BP and capillary refill.

46. Three Response Patterns • Rapid Response- respond quickly to fluid challenge and remains stable at completion of bolus. • Transient Response- responds quickly but declines when fluids are slowed (indicates continued blood loss) **Non Response- fail to hemodynamically respond to crystalloid and blood…require immediate surgical intervention.

47. Decision to give Blood • Based on patients response to initial fluid. • ** if unresponsive to fluid, type specific blood is given, IF LIFE THREATENING…may give O negative. • ***Crossmatched, type specific should be given as soon as possible.

48. Auto-transfusion • Collection of blood from the patients intra-thoracic injuries is anti-coagulated and filtered and administered to the patient. • SAFE, carries no compatibility problems, no risk of transmitted disease.

49. During resuscitative phase • Imperative to locate etiology of hemorrhage: • Chest and pelvis, extremity X-rays • Abdominal ultrasound • Abdominal CT can be used but in the case of hemodynamic instability Peritoneal lavage is the quick, invasive test of choice

50. Peritoneal Lavage • Insertion of lavage catheter directly into the abdomen • Aspiration of greater than 10 mls blood and patient goes directly for surgery. • If less than 10 mls of blood, 1 liter of warmed NS is infused into peritoneal cavity, then drained and sent for cell counts, amylase, bile, food particles, bacteria, fecal matter.