Emergent Conditions

OVERVIEW AND ASSESSMENT

Emergency medicine is the care, diagnosis, and treatment of unforeseen illness or injury. It is provided to patients with conditions ranging from minor to serious or life-threatening. The philosophy of emergency care includes the concept that an emergency is whatever the patient or family considers it to be. Emergency nursing is a dynamic and evolving practice that deals with unstable, undiagnosed patients usually presenting unexpectedly. See Standards of Care Guidelines 35-1, page 1198.

Emergency Assessment

When first contacting an emergency patient, it is essential that a systematic approach is used to ensure all factors are identified. Usually, the most dramatic injuries are distractors and are not immediately life-threatening. The primary and secondary surveys provide the emergency nurse with a methodical approach to help identify and prioritize patient needs.

Primary Survey

The initial, rapid ABCD (airway, breathing, circulation, and neurologic disability) assessment of the patient is meant to identify
life-threatening problems. If conditions are identified that present an immediate threat to life, you are required to stop and take corrective action prior to moving on to the next steps.

STANDARDS OF CARE GUIDELINES 35-1

Emergency Assessment and Intervention

When a patient presents with a potentially life-threatening condition, proceed swiftly with the following:

Call for help.
Ensure the area is safe for you to enter, with no live electric current, hazardous materials, dangerous persons or other threats.
Remove the patient from potential source of danger, such as live electric current, water, or fire. If hazardous materials are present, consult a MSDS book for decontamination procedures.
Determine whether patient is conscious.
Assess for adequate airway, breathing, and circulation in systematic manner. If any of these are absent, or inadequate, begin basic life support.
Assess pupillary reaction and level of responsiveness to voice or touch, as indicated.
If the patient is unconscious or has sustained a significant head injury, assume there is a spinal cord injury and maintain C-spine stabilization.
Undress the patient to assess for wounds and skin lesions as indicated. Control any hemorrhage, as needed.
When help arrives, assist with further assessment and transport, as needed.

This information should serve as a general guideline only. Each patient situation presents a unique set of clinical factors and requires nursing judgment to guide care, which may include additional or alternative measures and approaches.

A—Airway: Does the patient have an open airway? Is the patient able to speak, swallow, or cry? Check for airway obstructions such as loose teeth, foreign objects, bleeding, vomitus, or other secretions. Immediately treat anything that compromises the airway. Never do a blind finger sweep of an airway.
B—Breathing: Is the patient breathing adequately? Assess for equal rise and fall of the chest (check for bilateral breath sounds), respiratory rate and pattern, skin color, use of accessory muscles, adventitious breath sounds, integrity of the chest wall, and position of the trachea. All major trauma patients require supplemental oxygen via a nonrebreather mask at 12 to 15L/min. Dress any penetrating chest injuries with occlusive dressings.
C—Circulation: Is circulation in immediate jeopardy? Can you palpate a central pulse? What is the quality (strong, weak, slow, rapid)? Is the skin warm and dry? Is the skin color normal? Obtain a blood pressure (BP; in both arms if chest trauma or dissecting aortic aneurysm is suspected). Is there any major bleeding?
D—Disability: Assess level of consciousness and pupils (a more thorough neurologic survey will be completed in the secondary survey). Assess level of consciousness using the AVPU scale:
- A—Is the patient alert? Are they looking at you and responding?
- V—Does the patient respond to voice? Do they open their eyes or respond when you call them?
- P—Does the patient respond to painful stimulus? Do they respond to sternal rub or nailbed pressure?
- U—The patient is unresponsive even to painful stimulus.

Secondary Assessment

The secondary assessment is a brief, but thorough, systematic assessment designed to identify all injuries. The steps include Expose/environmental control, Full set of vital signs, Five interventions, Facilitate family presence, and Give comfort measures. If your emergency department (ED) has enough staff, these interventions may be assigned to multiple staff members and performed simultaneously.

Expose/environmental control: It is necessary to remove all of the patient’s clothing in order to identify all injuries. You must then prevent heat loss by using warm blankets, overhead warmers, and warmed intravenous (IV) fluids unless induced hypothermia is indicated. If your facility has a dedicated Trauma/Resuscitation room, keeping the temperature turned up aids in preventing heat loss.
Full set of vital signs:
- Obtain a full set of vital signs including BP, heart rate, respiratory rate, temperature, and oxygen saturation.
- As stated previously, obtain BP in both arms if chest trauma or dissecting aortic aneurysm is suspected.
- Institute continuous cardiac monitoring.
- Assess Glasgow Coma Scale (GCS) (see page 483) and pain scores.
Five interventions:
- Vascular access with two large-bore IV catheters, if possible.
- Pulse oximetry to measure the oxygen saturation; consider capnography to measure end-tidal carbon dioxide (EtCO₂); noninvasive ultrasonic cardiac output monitor; and 12-lead electrocardiogram (ECG).
- Indwelling urinary catheter (do not insert if you note blood at the meatus, blood in the scrotum, or if you suspect a pelvic fracture).
- Gastric tube (if there is evidence of facial fractures, insert the tube orally rather than nasally).
- Laboratory studies frequently include type and cross matching, complete blood count (CBC), urine drug screen, blood alcohol, electrolytes, prothrombin time and partial thromboplastin time, arterial blood gas (ABG), and pregnancy test, if applicable.
Facilitate family presence: Family presence is important during unexpected, potentially life-threatening events. They often have information that is critical in formulating the correct treatment plan. It is important to assess and respect the family’s needs and wishes. If any member of the family wishes to be present during the resuscitation, it is imperative to assign a staff member to that person to explain what is being
done and offer support. Resuscitation rooms are often loud and appear chaotic. Assigning a staff member to any family wishing to be present can do much to alleviate their anxiety and assure them that everything is being done to help their loved one. If a family member does not wish to be present, providing them with a quiet area to wait and assigning a staff member as a contact person or liaison can be helpful.
Give comfort measures: These include verbal reassurances as well as pain management as appropriate. Do not forget to give comfort measures to the family as well as the patient during the resuscitation process.

History

Obtain prehospital information from emergency personnel, patient, family, or bystanders using the mnemonic MIVT.
- M—Mechanism of injury: It is helpful to understand the mechanism of injury to anticipate probable injuries. It is particularly helpful in motor vehicle accidents to know such information as external and internal damage to the car (or at least if the car was drivable after the accident), if the patient was ejected, if they were wearing a seat belt, if airbags were deployed, and the period of time elapsed before the patient received medical attention.
- I—Injuries sustained or suspected: Ask prehospital personnel to list any injuries that they have identified. Most prehospital providers will have completed a rapid trauma survey, including looking for DCAP/BTLS (deformities, contusions, abrasions, punctures/burns, tenderness, lacerations, and swelling)
- V—Vital signs: What were the prehospital vital signs?
- T—Treatment: What treatment did the patient receive before arriving at the hospital and what was the patient’s response to those interventions?
If the patient is conscious, it is essential to ask him what happened. How did the accident occur? Why did it happen? A fall, for example, may not be a simple fall—perhaps the patient blacked out and then fell. If the patient is conscious and time permits, explore the chief complaint through the OPQRST mnemonic.

O—Onset: When did they first notice symptoms? Was today the first time? Has it been ongoing? Is it getting progressively worse?

P—Provokes, Palliates, Precipitates: What makes the symptoms better or worse?

Q—Quality: How would they describe the discomfort? Burning, throbbing, aching, and like an electric shock are all commonly used to describe the quality of pain.

R—Region, Radiates: Can the patient point to the pain with one finger? Does it move or shoot anywhere?

S—Severity, associated Symptoms: How do they rate their symptom? Is it accompanied by anything else such as numbness, tingling, or nausea?

T—Timing: Have the symptoms been constant or do they come and go? How often?
Obtain past medical history from the patient or a family member or friend; it may be helpful to utilize the mnemonic SAMPLE to assist in organizing history information:

S—Signs and symptoms, including chief complaint and OPQRST.

A—Allergies to foods and medications.

M—Medications, including herbal supplements and over-the-counters.

P—Past medical and surgical history.

L—Last oral intake.

E—Events leading up to the incident.

Plus any history of alcohol or illicit drug use.

Head-to-Toe Assessment

The head-to-toe assessment begins with assessment of the patient’s general appearance, including body position or any guarding or posturing. Work from the head down, systematically assessing the patient one body area at a time.

Head and face.
- Inspect for any lacerations, abrasions, contusions, avulsions, puncture wounds, impaled objects, ecchymosis, or edema. Hair can hide injuries, so take time to do a complete inspection. Scalp lacerations also tend to bleed profusely, further obscuring the area from quick inspections.
- Gently palpate for crepitus, crackling, or bony deformities.
- Inspect ears and nares for any bleeding or drainage, if present, check for Halo sign.
Neck (ensure proper C-spine stabilization is maintained).
- Inspect for any punctures, lacerations, contusions, swelling, tracheal deviation, JVD, or subcutaneous emphysema.
- Check for stomas or Medic Alert tags.
- Gently palpate for midline cervical tenderness.
Chest.
- Inspect for breathing effectiveness, paradoxical (uneven) chest wall movement, disruptions in chest wall integrity (lacerations, punctures, subcutaneous emphysema).
- Auscultate for bilateral breath sounds and adventitious breath sounds.
- Auscultate heart tones (muffled).
- Gently palpate for bony crepitus or deformities.
Abdomen/flanks.
- Inspect for lacerations, abrasions, contusions, avulsions, puncture wounds, impaled objects, ecchymosis, edema, scars, eviscerations, or distention.
- Auscultate for the presence of bowel sounds.
- Gently palpate for rigidity, guarding, masses, or areas of tenderness.
Pelvis/perineum.
- Inspect for lacerations, abrasions, contusions, avulsions, puncture wounds, impaled objects, ecchymosis, edema, or scars. Look for blood at the urinary meatus and vagina in
  females. Look for priapism in males (which could indicate spinal cord injury).
- Gently palpate for pelvic instability or tenderness (do not rock the pelvis).
Neurologic/spinal (maintaining proper stabilization).
- Reassess mental status.
- Gently palpate for midline bony spinal tenderness.
- Check for paresthesias and determine sensory level.
- Check motor function and sphincter tone.
Extremities.
- Inspect skin color and temperature. Look for signs of injury and bleeding. Does the patient have movement in all four extremities? Touch the patient on a distal extremity and ask them to identify the part you are touching.
- Gently palpate peripheral pulses, any bony crepitus, or areas of tenderness.
- Check capillary refill.
- Gently palpate extremities for compartment firmness or signs of compartment syndrome.

Focused Assessment

Any injuries that were identified during the primary and secondary surveys require a detailed assessment, which will typically include a team approach and radiographic studies.

Emergency Triage

Triage is a French verb meaning “to sort.” Emergency triage is a subspecialty of emergency nursing, which requires specific, comprehensive educational preparation. The goal of an efficient triage system is to rapidly connect a patient with the proper level of care (such as fast-track or urgent care) and the correct resources in the shortest amount of time. Upon entering an ED, patients are greeted by a triage nurse, who will perform a rapid assessment, to include a general impression, chief complaint, immediate or potential life threats, and pertinent history, and then make a decision about the patient’s acuity and the resources needed. These decisions can often be difficult if the patient has an altered mental status, is intoxicated, or is otherwise impaired. Thus, the primary role of the triage nurse is to make acuity and disposition decisions and set priorities while maintaining awareness for potentially violent or communicable disease situations. Secondary triage decisions involve the initiation of triage extended practices, such as the ordering of standardized labs or radiology studies. With the waiting times in EDs due to overcrowding becoming an increasing problem, the accuracy of the triage nurse in assigning acuity level is of critical importance. With extended wait times, triage is a continually ongoing process, with the triage nurse frequently reevaluating those who are waiting for changes in condition and updating their status, as needed.

Priorities of Care and Triage Categories

Standardized 5-level triage systems, such as the Australasian Triage Scale, Canadian Triage and Acuity Scale, and the Emergency Severity Index, have been developed and proven through research to possess utility, validity, reliability, and safety. All three systems utilize similar time frames and are evidence based (the Manchester Triage System is a consensus-based algorithm approach, which utilizes longer time frames).

Triage Level 1—Immediately Life-Threatening or Resuscitation

Conditions requiring immediate clinician assessment. Any delay in treatment is potentially life- or limb-threatening. These are the patients that are in active danger of dying if there is no immediate intervention and will require admission.
Includes conditions such as:
- Airway or severe respiratory compromise.
- Cardiac arrest.
- Severe shock.
- Symptomatic cervical spine injury.
- Multisystem trauma.
- Altered level of consciousness (LOC) (GCS < 10).
- Eclampsia.
- Acute mental status changes or unresponsiveness.

Triage Level 2—Imminently Life-Threatening or Emergent

These are conditions that are not in immediate danger, but have the potential to deteriorate rapidly if not treated.
Conditions include:
- Head injuries.
- Trauma.
- Conscious overdose.
- Severe allergic reaction without airway compromise.
- Chemical exposure to the eyes.
- Chest pain without hemodynamic instability.
- Back pain.
- GI bleed with unstable vital signs.
- Stroke with deficit.
- Severe asthma without airway compromise.
- Abdominal pain in patients older than age 50.
- Vomiting and diarrhea with dehydration.
- Fever in infants younger than age 3 months.
- Acute psychotic episode.
- Severe headache.
- Any pain greater than 7 on a scale of 1 to 10.
- Any sexual assault.
- Any neonate age 7 days or younger.

Triage Level 3—Potentially Life-Threatening/Time Critical or Urgent

Conditions requiring urgent care-level activities with stable vital signs, but have the potential to deteriorate and utilize multiple resources.
Conditions include:
- Alert head injury with vomiting.
- Mild to moderate asthma.
- Moderate trauma.
- Abuse or neglect.
- GI bleed with stable vital signs.
- History of seizure, alert on arrival.

Triage Level 4—Potentially Life-Serious/Situational Urgency or Semi-urgent

Stable conditions that use few resources.
Conditions include:
- Alert head injury without vomiting.
- Minor trauma.
- Vomiting and diarrhea in patient older than age 2 without evidence of dehydration.
- Earache.
- Minor allergic reaction.
- Corneal foreign body.
- Chronic back pain.

Triage Level 5—Less/Nonurgent

Stable conditions that utilize little to no resources.
Conditions include:
- Minor trauma, not acute.
- Sore throat.
- Minor symptoms.
- Chronic abdominal pain.

Psychological Considerations

Serious illness or trauma is an insult to physiologic and psychological homeostasis; it requires physiologic and psychological healing. Both patients and families experience high levels of anxiety when being treated in the emergency department. It is important for the emergency nurse to recognize, understand, and alleviate these anxieties whenever possible.

Approach to the Patient

Understand and accept the basic anxieties of the acutely ill or traumatized patient. Be aware of the patient’s fear of death, disablement, and isolation.
- Personalize the situation as much as possible. Speak, react, and respond in a warm manner, reassure, but remain realistic and do not patronize the patient.
- Give explanations on a level that the patient can grasp. An informed patient can cope with psychological/physiologic stress in a more positive manner.
- Accept the rights of the patient and family to have and display their own feelings.
- Maintain a calm and reassuring manner—helps the emotionally distressed patient or family to mobilize their psychological resources.
- Include the patient’s family or significant others if the patient wishes.
- Encourage the patient or family to reach out to their support system. Often friends, other family members, or clergy can be of great comfort.
Understand and support the patient’s feelings concerning loss of control (emotional, physical, and intellectual). If possible, giving the patient options and choices can help alleviate some of their feelings of helplessness.
Treat the unconscious patient as if conscious. Touch, call by name, and explain every procedure that is done. Avoid making negative comments about the patient’s condition.
- Orient the patient to person, time, and place as soon as he or she is conscious; reinforce by repeating this information.
- Bring the patient back to reality in a calm and reassuring way.
- Encourage the family, when possible, to touch the patient and aid in orienting the patient to reality.
Be prepared to handle all aspects of acute illness and trauma; know what to expect and what to do. When in doubt, stop, take a deep breath, and refocus. This alleviates the nurse’s anxieties and increases the patient’s confidence.

Approach to the Family

Inform the family where the patient is and give as much information as possible about the treatment he or she is receiving.
Consider allowing a family member to be present during the resuscitation. Assign a staff person to the family member to explain procedures and offer comfort.
Recognize the anxiety of the family and allow them to talk about their feelings. Acknowledge expressions of remorse, anger, guilt, and criticism.
Allow the family to relive the events, actions, and feelings preceding admission to the ED.
Deal with reality as gently and quickly as possible; avoid encouraging and supporting denial.
Assist the family to cope with sudden and unexpected death. Some helpful measures include the following:
- Take the family to a private place.
- Talk to all of the family together so they can mourn together.
- Assure the family that everything possible was done; inform them of the treatment rendered.
- Avoid using euphemisms such as “passed on.” Show the family that you care by touching, offering coffee.
- Allow family to talk about the deceased—permits ventilation of feelings of loss. Encourage family to talk about events preceding admission to the ED.
- Encourage family to support each other and to express emotions freely—grief, loss, anger, helplessness, tears, disbelief.
- Avoid volunteering unnecessary information (eg, patient was drinking).
- Avoid giving sedation to family members—may mask or delay the grieving process, which is necessary to achieve emotional equilibrium and prevent prolonged depression.
- Be cognizant of cultural and religious beliefs and needs.
- Encourage family members to view the body if they wish— to do so helps to integrate the loss (cover mutilated areas).
  - Prepare the family for visual images and explain any legal requirements.
  - Go with family to see the body.
  - Show acceptance of the body by touching to give family permission to touch and talk to the body.
  - Spend a few minutes with the family, listening to them.
  - Allow the family some private time with the body, if appropriate.
Encourage the ED staff to discuss among themselves their reaction to the event to share intense feelings for review and for group support. Organize a formal debriefing session for staff if warranted by circumstances of the event.

Pain Management

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage and is also associated with significant morbidity. Pain inhibits immune function and has detrimental effects on cardiovascular, respiratory, GI, and other body systems. Over 60% of patients report pain on arrival at ED, making pain the most common patient complaint. It is imperative to adequately assess, monitor, and relieve pain in the ED. Despite this, significant evidence-practice gaps continue to be identified with underestimation and undertreatment of pain, as well as gaps in pain documentation, despite available clinical practice guidelines. In general, geriatric patients tend to have their pain underestimated and undertreated more frequently than younger adults do. Pain may be somatic or visceral, acute or chronic, or centrally or peripherally generated.

Primary Assessment

ABCD.
Evaluate pain using the OPQRST mnemonic.
Assess pain score using a pain rating tool, such as the numeric rating scale, visual analogue scale, Wong-Baker FACES pain scale (see page 1447), FLACC (faces, legs, activity, cry, and consolability) behavioral scale, verbal rating scale, or Abbey pain scale.

Primary Interventions

Pain is always subjective. Never doubt that a patient has pain based on how they look.
Establish a supportive relationship with the patient.
Respect the patient’s response to pain and its management.
Educate the patient regarding methods of pain relief, preventive measures, and expectations.
Establish a baseline pain level, as well as a pain level the patient would consider tolerable.
Administer pharmaceutical and nonpharmaceutical pain control.
Monitor the patient’s response to and effectiveness of treatment.
If initial interventions do not bring pain down to the tolerable level, explore other options.
Always reassure your patient and let them know you take their pain seriously.

CARDIOPULMONARY RESUSCITATION AND AIRWAY MANAGEMENT

Cardiopulmonary Resuscitation

Cardiopulmonary resuscitation (CPR) is a technique of basic life support for the purpose of oxygenating the brain and heart until appropriate, definitive medical treatment can restore normal heart and ventilatory action. Management of foreign-body airway obstruction or cricothyroidotomy may be necessary to open the airway while CPR is performed.

In 2010, there were many changes made to the CPR guidelines. The emphasis is now on performing good, high-quality chest compressions, with a minimum of interruptions, in an effort to not only preserve life but prevent anoxic brain injuries as well. The traditional “look-listen-and-feel” for breathing has been eliminated, as well as the A-B-C order for assessing the unresponsive patient. For the lay public, the focus has changed to a compressions-only resuscitation model, with no interruptions to deliver breaths. For the professional provider, airway, breathing, and circulation are all still important parts of the resuscitation effort; however, A-B-C has become C-A-B, or circulation, airway, then breathing. All efforts begin with good, high-quality chest compressions. See Procedure Guidelines 35-1.

Indications

Cardiac arrest.
- Ventricular fibrillation.
- Ventricular tachycardia.
- Asystole.
- Pulseless electrical activity.
Respiratory arrest.
- Drowning.
- Stroke.
- Foreign-body airway obstruction.
- Smoke inhalation.
- Drug overdose.
- Electrocution/injury by lightning.
- Suffocation.
- Accident/injury.
- Coma.
- Epiglottitis.

PROCEDURE

Nursing Action			Rationale
Responsiveness
1.	Determine unresponsiveness: tap or gently shake patient while shouting, “Are you okay?”		1.	Prevents injury from attempted resuscitation on a person who is not unconscious.
2.	Activate emergency medical service (call local emergency telephone number or 911) if outside facility.		2.	Obtain help as soon as possible.
3.	Place the patient supine on a firm, flat surface. Kneel at the level of the patient’s shoulders. If he or she has suspected head or neck trauma, he or she should not be moved unless it is absolutely necessary (eg, at the site of an accident, fire, or other unsafe environment).		3.	Enables the rescuer to perform rescue breathing and chest compression without changing position.
Circulation-Airway-Breathing
Determine if a pulse is present while checking for signs of breathing
1.	Palpate the carotid or femoral pulse for no more than 10 seconds, while looking for signs the patient is attempting to breathe. If pulse is not palpable, start chest compressions.		1.	Cardiac arrest is recognized by a lack of palpable pulses in the central arteries of a nonresponsive, apneic patient. For patients who are apneic but have a clearly palpable central pulse, begin rescue breathing with a BVM device or pocket mask at a rate of 1 breath every 5-6 seconds.
External Chest Compressions
Chest compressions consist of a sequence of rhythmic applications of pressure over the lower half of the sternum, which provides circulation to the vital organs
1.	Kneel as close to the side of the patient’s chest as possible, placing the heel of one hand on the lower half of the sternum, taking care to avoid the xiphoid process. Fingers may be interlaced or extended but care must be taken to keep them off the chest.		1.	Ensure the main force of the compression is on the sternum by placing the long axis of the hand on the long axis of the sternum.
2.	Keep your arms straight and your elbows locked. Ensure your shoulders are directly over your hands and quickly and forcefully depress the patient’s sternum straight down to a depth of at least 2 inches.		2.	Keeping your arms straight and your elbows locked allows a greater force to be delivered with each compression and aids in preventing fatigue
3.	Deliver 30 compressions at a rate of at least 100 compressions a minute. Always allow for complete chest recoil after each compression without taking your hands off of the chest between compressions.		3.	Allowing complete chest recoil gives the heart time and room to fill with blood. A partially compressed heart will eject less blood than one that is allowed to fill properly.
4.	Taking no more than 10 seconds, open the airway and deliver 2 breaths		4.	Total “hands-off” time between the end of one set of 30 compressions and the start of the next needs to be less than 10 seconds to ensure adequate circulation.
	a.	Head-tilt/chin-lift maneuver: Place one hand on the patient’s forehead and apply firm backward pressure with the palm to tilt the head back. Then, place the fingers of the other hand under the bony part of the lower jaw near the chin and lift up to bring the jaw forward and the teeth almost to occlusion.		a.	In the absence of sufficient muscle tone, the tongue or epiglottis will obstruct the pharynx and larynx. This supports the jaw and helps tilt the head back.
	b.	If a cervical spine injury is suspected, use the jaw-thrust maneuver: Grasp the angles of the patient’s lower jaw and, lifting with both hands, one on each side, displace the mandible forward while maintaining C-spine immobility.		b.	The jaw-thrust technique without head tilt is the safest method for opening the airway in the presence of suspected neck injury.
	c.	Perform rescue breathing by using a pocket mask or other barrier device		c.	Mouth to mouth is only done in extreme circumstances in the hospital setting.
	d.	While keeping the patient’s airway open, place the pocket mask on the patient’s face, making sure to maintain a good seal. Take a deep breath and ventilate the patient with two breaths of just enough volume to see chest rise (each over 1 second), taking a breath after each ventilation. If the initial ventilation attempt is unsuccessful, reposition the patient’s head and repeat rescue breathing.		d.	Ensuring a good seal with a pocket mask takes practice, but is essential in preventing air leakage. Full breaths are no longer required as gastric inflation can occur. Ventilate just enough to get the chest to rise.
5.	When a second rescuer arrives, have them begin compressions while you take over ventilations.		5.	The ratio of compressions to ventilations for the adult victim is 30:2 for one- and two- rescuer CPR.
6.	While resuscitation proceeds, simultaneous efforts are made to obtain and use special resuscitation equipment to manage breathing and circulation and provide definitive care.		6.	Definitive care includes defibrillation, pharmacotherapy for dysrhythmias and acid-base disturbances, and ongoing monitoring and skilled care in an intensive care unit.
7.	Utilize the automated external defibrillator (AED) or, if trained, the manual defibrillator as soon as possible. Special circumstances affecting use of AEDs include:		7.	The American Heart Association supports the use of AEDs in public places as well as medical centers.
	a.	For children <1 year of age, a manual defibrillator is preferred. If there is no manual defibrillator available, or one with pediatric dose attenuators, an adult AED may be used.		a.	For children under age 8, an AED with pediatric dose attenuators is preferred. If one is not available, a normal adult AED may be used.
	b.	The victim should not be lying in water when using an AED. Make sure the patient’s chest is dry before attaching the AED.		b.	Using an AED when patients are wet or lying in water may result in burns and shocks to the rescuer.
	c.	Do not place the AED electrode directly over an implanted pacemaker.		c.	Placing an AED pad directly over an implanted pacemaker may reduce the effectiveness of the defibrillation.
	d.	Remove any transdermal medication patches from the patient before using the AED.		d.	Placing an AED pad over a transdermal medication patch may make the defibrillation less effective and cause a burn.
8.	The four basic steps used in AED operation are:		8.	The directions provided for operation of the AED were provided by the device manufacturer. Many machines will walk you through the steps for operation once the power is turned on. Be familiar with the type of device in your facility.
	a.	Turn the power on. Always do this first to ensure the device has power
	b.	Attach the AED pads to the patient’s chest, using the diagrams on the pads to show you exactly where to place them.
	c.	Analyze the patient’s rhythm by pushing the button on the AED labeled ANALYZE. During this time, no one should touch the patient.		c.	Some AEDs will analyze automatically once the pads are connected. Touching the patient could create artifact and interfere with analysis.
	d.	Charge the AED and deliver the shock if indicated by the AED. Make sure that no one is touching the patient. Push the shock button; the AED will provide visual and voice prompts to tell you what to do.		d.	Always call “Clear” and visually check for anyone touching the patient prior to delivering a shock. When the machine delivers a shock, anyone touching the patient will feel it.

Assessment

Immediate loss of consciousness.
Absence of palpable carotid or femoral pulse; pulselessness in large arteries.
Absence of breath sounds or air movement through nose or mouth.

Induced Hypothermia Post Cardiac Arrest

In adults with persistent coma (post cardiac arrest), initiating induced hypothermia to a temperature of 89°-93° F (32° to 34° C) for 12 to 24 hours results in neuroprotection, improving neurologic function and decreasing mortality. It is also associated with beneficial hemodynamic, renal, and acid-base effects. See Procedure Guidelines 35-2, pages 1206 to 1207.

Assessment

Institute continuous cardiac monitoring. Monitor for bradycardia caused by cooling or other dysrhythmias.
Institute continuous temperature monitoring, preferably core temperature.
Frequently monitor blood pressure to avoid hypotension, particularly during rewarming.
Monitor CBC for signs of infection, since temperature will not be an accurate sign. Monitor electrolyte panel for hypokalemia caused by hypothermia. ABGs should be analyzed at patient’s actual body temperature.
Assess skin every 2 hours for pressure and cold injury.

Commercial Cooling Devices

A number of commercially available cooling devices are currently available, including cooling blankets, cooling gel pads applied to the skin, and centrally inserted heat-exchange catheters.
Cooling blankets are placed under and over the patient and cool utilizing circulated chilled water. They are easy to apply; however, they can have poor surface contact, making it difficult to maintain a targeted temperature.
Devices utilizing adhesive gel pads are also easy to apply and provide improved surface contact to facilitate rate and maintenance of cooling. Contoured cooling garments are also available.
With any surface cooling method, ice packs are often used to assist in initial cooling and then removed. Maintenance is controlled by the commercial device.
Centrally inserted heat-exchange catheters use chilled saline passed through a coiled section of catheter.
- These coils provide a large surface area for blood to pass over and heat exchange to occur.
- Normally placed in the femoral vein, these catheters allow for rapid cooling and extremely tight control without promoting shivering.

PROCEDURE GUIDELINES 35-2

Induced Hypothermia Post Cardiac Arrest

PURPOSE

Current evidence suggests that mild induced hypothermia may reduce mortality and improve neurologic outcomes in adult post-cardiac arrest patients. Cooling should be started as soon as possible to ensure optimum effectiveness.

PRE PROCEDURE

Nursing Action			Rationale
1.	Consider the inclusion criteria. All patients who are resuscitated from arrest but remain unconscious and are unable to respond to verbal command should be considered for immediate cooling.		1.	Research has shown that an improved outcome can be attained if the patient has adequate arterial circulation and oxygenation to the brain.
				a.	Research has shown improved outcomes in arrest patients who remain hemodynamically stable during the post-resuscitation period.
2.	Consider exclusion criteria. Patients should not be considered for the following reasons:		2.	There are only two absolute contraindications for therapeutic hypothermia. All others must be considered on a case by case basis
	a.	Severe preexisting conditions with DNR orders.
	b.	Active noncompressible bleeding.
PROCEDURE
Nursing Action			Rationale
1.	Provide standard advanced life support and ongoing intensive care management. All patients must be intubated and ventilated.		1.	Patient’s cardiopulmonary status is unstable.
2.	Perform and document thorough neurologic examination.		2.	The goal of the procedure is improved neurologic outcome.
3.	Measure temperature continuously, if possible, or every 15 minutes.		3.	Frequent monitoring of temperature is important to reach goal temperature quickly.
	a.	Initially, peripherally until continuous core temperature monitoring (central venous, bladder, rectal, oropharyngeal) can be instituted		a.	Central venous temperature monitoring is preferred.
	b.	As rectal core temperature monitoring may be slow to change, two sites of measurement are preferred.
4.	Begin cooling as soon as possible. This should begin in the emergency department.		4.	Internal and external cooling are required to bring down core temperature
	a.	Apply ice packs to groin, axillae, sides of chest, neck; or apply cooling blanket, wrap, or pads according to manufacturer’s instructions.
	b.	Instill 30 mL/kg of refrigerated lactated Ringer’s solution over 30 minutes through a femoral line (if patient is not in acute pulmonary edema).		b.	One liter of cold saline infused over 15 min can drop the core temperature by 1°C.
5.	Target temperature is 91.4° F (32° C). Remove ice packs once temperature is less than 91° F (33° C).		5.	There is no need to bring down the temperature below 33°C, but temperature should be kept in that range for 12 to 24 hours.
6.	Replace ice packs and consider further ice-cold lactated Ringer’s solution if temperature remains above 92.3° F (33.5° C).
7.	Use nondepolarizing neuromuscular blockade to prevent shivering. Provide sedation according to standard ICU protocol.		7.	Shivering produces heat, which will raise core temperature.
8.	Maintain patient at target temperature for a period of 12-24 hours once temperature is reached.
9.	After the targeted time has elapsed passive rewarming should occur slowly over 8-12 hours.		9.	Research has shown that the best risk/benefit ratio is at 12 hours.
10.	Monitor for complications:		10.	Complications will compromise outcome.
	a.	Hyperglycemia.
	b.	Ileus may occur at <93.2° F (34° C).
	c.	Hypovolemia and hypotension, secondary to vasodilation, may occur during rewarming.
	d.	Bleeding—this may be of increased significance in patients undergoing urgent angioplasty or thrombolytic therapy who will also receive antiplatelet agents.
	e.	Infection, especially pneumonia, during and following the procedure. Fever, one of the cardinal signs of infection, will be absent in people treated with therapeutic hypothermia.

Foreign-Body Airway Obstruction

Foreign-body obstruction of the airway may be either partial or complete. Abdominal thrusts (the Heimlich maneuver) are recommended for relieving foreign-body airway obstruction in the adult. See Procedure Guidelines 35-3, page 1208.

Assessment

Weak, ineffective cough.
High-pitched noises on inspiration.
Respiratory distress.
Inability to speak or breathe.
Cyanosis.
Hands at throat.

PROCEDURE GUIDELINES 35-3

Management of Foreign-Body Airway Obstruction
PROCEDURE
Nursing Action			Rationale
Airway obstruction with conscious patient sitting or standing
Abdominal thrusts
1.	Stand behind the patient; wrap your arms around patient’s waist, and proceed as follows:		1.	If the patient is able to speak or cough forcefully, allow them to attempt to clear their own airway.
	a.	Make a fist with one hand, placing the thumb side of the fist against the patient’s abdomen in the midline, slightly above the navel and well below the xiphoid process. Grasp the fist with your other hand.
	b.	Press your fist into the patient’s abdomen with a quick upward thrust. Each new thrust should be a separate and distinct maneuver.		b.	A subdiaphragmatic abdominal thrust, by elevating the diaphragm, can force air from the lungs to create an artificial cough intended to move and expel an obstructing foreign body in the airway.
	c.	Continue until the obstruction is cleared, help arrives, or the patient becomes unresponsive.
	d.	Should the patient become unresponsive, immediately begin CPR, checking the airway after each set of compressions and prior to attempting ventilations.		d.	The obstruction may have become dislodged during chest compressions. Only attempt to remove objects you can see. Never perform a blind finger sweep.
Airway obstruction with conscious patient standing or sitting Chest thrust
1.	Stand behind the patient with your arms under the axillae to encircle his or her chest.		1.	This technique is to be used only in advanced stages of pregnancy or in a markedly obese patient.
2.	Place the thumb side of your fist on the middle of the patient’s sternum, taking care to avoid the xiphoid process and rib cage margins.		2.	The xiphoid process can be easily injured.
3.	Grasp your fist with your other hand and perform backward thrusts until the foreign body is expelled. If the patient becomes unconscious, stop and begin CPR, as noted above.		3.	The thrusting motion is intended to relieve the obstruction.

Cricothyroidotomy

Cricothyroidotomy is the puncture or incision of the cricothyroid membrane to establish an emergency airway in certain emergency situations when placement of an endotracheal tube or laryngeal-mask airway is not possible or is contraindicated and when adequate oxygenation cannot be maintained utilizing a bag-valve-mask device with 100% oxygen. See Procedure Guidelines 35-4, page 1209.

INJURIES TO THE HEAD, SPINE, AND FACE

Head Injuries

Head injuries can include fractures to the skull and face, direct injuries to the brain (as from a bullet), and indirect injuries to the brain (such as a concussion, contusion, or intracranial hemorrhage). Head injuries commonly occur from motor vehicle accidents, assaults, or falls.

PROCEDURE

Nursing Action			Rationale
1.	Preoxygenate the patient, if possible		1.	Boosts oxygen saturation during the procedure.
2.	Extend the patient’s neck. Place a towel roll beneath the shoulders.		2.	Allows the cricothyroid membrane to be palpated readily.
3.	Attach a 10-mL syringe containing 5-mL of saline to the insertion catheter
4.	Identify the prominent thyroid cartilage (Adam’s apple) and allow your finger to descend in the midline to the depression between the lower border of the thyroid cartilage and the upper border of the cricoid cartilage (see accompanying figure).	4.	This depression represents the cricothyroid membrane.

Cricothyroidotomy, or cricothyroid membrane puncture.
5.	Scrub insertion site and maintain sterility throughout procedure.		5.	Reduces risk of infection.
6.	Provide skin tension and hold the trachea in place with the nondominant hand, using the index finger to palpate the cricothyroid membrane.		6.	Attains stability and identifies the insertion site.
7.	Place the catheter at the inferior margin of the cricothyroid membrane, in the midline of the neck, and direct it caudally at a 30- to 45-degree angle		7.	Insertion will be in direction of airway.
8.	While maintaining negative pressure on the syringe, advance the catheter through the skin and tissue until air bubbles are seen in the syringe		8.	Maintaining negative pressure prevents saline from being injected into the airway.
9.	Thread the catheter off of the needle until the hub rests on the skin surface and withdraw the needle.		9.	Insertion needle is withdrawn; flexible catheter remains.
10.	Listen for air passing back and forth through the needle synchronously with the patient’s respirations.		10.	Indicates correct positioning and opening of obstructed airway.
11.	Secure the needle with adhesive tape or sutures.		11.	Maintains stability of airway.
12.	Ventilate with bag-valve-mask device, allowing for a prolonged exhalation time.		12.	In cases of airway obstruction, prolonged exhalation times are necessary to prevent air trapping, or auto-PEEP.
13.	Prepare for tracheostomy.		13.	After the patient is stabilized, a more permanent means of ventilatory support is implemented.
14.	Potential complications: bleeding, aspiration, subcutaneous emphysema.

Concussion—a mild diffuse axonal injury resulting in a transient disturbance of neurological function that may or may not include a loss of consciousness.

Contusion—a focal injury resulting in bruising of the brain tissue. Actual small amounts of bleeding into the brain tissue associated with edema formation and possible tissue necrosis and infarction.

Intracranial hemorrhage—significant bleeding into a space or a potential space between the skull and the brain. This is a serious complication of a head injury with a high mortality due to rising intracranial pressure (ICP) and the potential for brain herniation. Intracranial hemorrhages can be classified as epidural hematomas, subdural hematomas, or subarachnoid hemorrhages, depending on the site of bleeding.

Primary Assessment

Airway: assess for vomitus, bleeding, and foreign objects. Ensure cervical spine immobilization.
Breathing: assess for abnormally slow or shallow respirations. An elevated carbon dioxide partial pressure can worsen cerebral edema.
Circulation: assess pulse and bleeding.
Disability: assess the patient’s neurologic status.

Primary Interventions

Open the airway using the jaw-thrust technique without head tilt. Oral suction equipment (to handle heavy vomitus) should be at hand. Make sure that you do not stimulate the gag reflex as this can cause increases in ICP.
Administer high-flow oxygen.
Assist inadequate respirations with a bag-valve-mask, as necessary. Prophylactic hyperventilation is not indicated.
Control bleeding—do not apply pressure to the injury site. Apply a bulky, loose dressing. Do not attempt to stop the flow of blood or cerebrospinal fluid (CSF) from the nose or ears; apply a loose dressing, if needed.
Initiate two IV lines. The rate of flow should be determined by the patient’s hemodynamic status.

Subsequent Assessment

History.
- Mechanism of injury.
- Presence and duration of loss of consciousness.
- Amnesia of the event.
- Position found.
LOC.
- Change in mental status is the most sensitive indicator of a change in the patient’s condition.
- GCS (see page 483).
Vital signs.
- Hypertension and bradycardia are late signs of increasing ICP.
- Patients with a head injury may have associated cardiac dysrhythmias, noted by an irregular or rapid pulse.
- Changing patterns of respiration or apnea may indicate a head injury.
- Elevated temperature—high temperatures may be associated with head injury.
Unequal or unresponsive pupils.
Confusion or personality changes.
Impaired vision.
One or both eyes appear sunken.
Seizure activity.
Periauricular ecchymosis—“Battle sign,” a bluish discoloration behind the ears (indicates a possible basal skull fracture).

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Tags: Lippincott Manual of Nursing Practice

Jul 20, 2016 | Posted by drzezo in NURSING | Comments Off

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