Emergency and Critical Care

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Emergency and Critical Care

• Nurse Licensure Examination Review

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Basic life support (BLS)

• A means of providing oxygen to the brain, heart
  and other organs until help arrives
• Also known as CARDIOPULMONARY RESUSCITATION

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Basic life support (BLS)

• An adult is a person above age 8
• A child is any person age 1 to 8 years old
• An infant is anyone under 1 year

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Basic life support (BLS)

• The BLS follows the A-B-C principle
• A airway
• B breathing
• C circulation

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Basic life support (BLS)

• Causes of cardiac arrest
• Respiratory arrest
• Direct injury
• Drug overdose
• Cardiac arrhythmias

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Basic life support (BLS)ADULT

• STEPS in CPR First STEP!!!
• ASSESSMENT determine Unresponsiveness
• Assess for 5-10 seconds
• Shake the victims shoulder and ask are you
  okay

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Basic life support (BLS)ADULT

• STEPS in CPR Second Step
• Survey the area

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Basic life support (BLS)ADULT

• STEPS in CPR Third Step
• Call for HELP
• Activate emergency medical system
• Note for child and infant this is done LAST

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Basic life support (BLS)ADULT

• STEPS in CPR Fourth step
• Place Victim in Supine position on a flat firm
  surface
• Log roll the patient when moving

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Basic life support (BLS)ADULT

• STEPS in CPR Fifth step
• OPEN the airway
• Head tilt-Chin Lift method
• Jaw thrust maneuver if neck injury is suspected

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Basic life support (BLS)ADULT

• STEPS in CPR Sixth step
• Assess BREATHING
• Place ear over the nose and mouth
• Look for chest movement
• Perform for 3-5 SECONDS

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Basic life support (BLS)ADULT

• STEPS in CPR Sixth step
• Assess BREATHING
• If breathing place on side if no neck injury DO
  NOT move if with neck injury
• If NOT BREATHING deliver INITIALLY 2 rescue
  breath via mouth to mouth
• Then deliver 10-12 breaths/minute

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Basic life support (BLS)ADULT

• STEPS in CPR Seventh step
• Assess CIRCULATION
• Check for the carotid pulse on the side close to
  you for 5-10 SECONDS
• If with () pulse continue giving 10-12
  breaths/minute

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Basic life support (BLS)ADULT

• STEPS in CPR Seventh step
• Assess CIRCULATION
• If withOUT pulse START Chest Compression
• Correct hand placement LOWER HALF of sternum one
  hand over the other with fingers interlacing
• Depress 1 ½ to 2 INCHES
• 80-100 compressions/min

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Basic life support (BLS)ADULT

• STEPS in CPR Seventh step
• Assess CIRCULATION
• If withOUT pulse START Chest Compression
• ONE-rescuer 15 chest 2 breaths
• TWO-rescuer 5 chest 1 breath
• DO FOUR cycles and re-assess for pulse

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Basic life support (BLS)CHILD

• 1-8 years old
• AIRWAY assess unresponsiveness and keep airway
  patent by HTCL or JT
• BREATHING assess for airflow and chest movement
• If breathing maintain patent airway
• If NOT breathing deliver 2 rescue breaths by
  mouth to mouth
• DELIVER 20 breaths/minute

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Basic life support (BLS)CHILD

• 1-8 years old
• CIRCULATION assess the carotid pulse
• If with pulse continue to deliver 15-20
  breaths/minute
• If WITHOUT pulse start chest compression
• Correct hand placement lower half of sternum
  using heel of ONE HAND
• DELIVER 1 to 1 ½ inches
• 80- 100 chest compressions/min
• 51 (do 20 cycles ? EMS)

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Basic life support (BLS)INFANT

• Less than 1
• Determine unresponsiveness
• AIRWAY Place head of infant in NEUTRAL position
• BREATHING assess for rise-fall of chest and
  airflow
• If breathing maintain patent airway
• If NOT breathing initiate 2 rescue breathing
  via mouth to mouth and nose
• DELIVER 20 breaths/min SLOWLY

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Basic life support (BLS)INFANT

• Less than 1
• CIRCULATION assess for pulse The BRACHIAL pulse
  is utilized!!
• If with pulse continue to deliver 20 breaths/min
• If WITHOUT pulse, start chest compression
• Correct hand placement just below the nipple
  line in the sternum using 2-3 fingers of one
  hand!!
• DELIVER ½ to 1 inch depth
• 100 chest com/min
• 51 ratio (do 20 cycles? EMS)

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AIRWAY Obstruction

• Incomplete
• Crowing sound is heard? encourage to cough
• Complete
• Clutching of the neck
• Ask Are you choking?
• Perform Heimlichs

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AIRWAY Obstruction

• Complete
• If patient becomes unconscious
• Place supine on flat surface
• Perform tongue-jaw lift maneuver
• FINGERSWEEP to remove object
• Open airway and attempt ventilation
• Perform Heimlich while supine
• Reattempt ventilation
• SEQUENCE TJL? finger-sweep ?rescue breaths?
  Heimlichs? TJL

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AIRWAY Obstruction

• Pediatric considerations
• CHILD NEVER DO Blind Finger sweep

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AIRWAY Obstruction

• Pediatric considerations
• INFANT never DO blind finger-sweep
• Give five back blows in the interscapular area
  and turn the infant with head lower than trunk
  then deliver chest thrust below the nipple line

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AIRWAY Obstruction

• Obstetric considerations
• Hand is placed over the middle part of sternum
  backward chest thrust
• If unconscious place pillow below the RIGHT
  abdomen to displace uterus

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Shock

• An abnormal physiologic state where an imbalance
  exists between the amount of circulating blood
  volume and the size of the vascular bed.

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Pathophysiology of Shock

• 1. Cellular effects of shock
• In the absence of oxygen, the cell will undergo
  Anaerobic metabolism to produce energy source and
  with it comes numerous by-products like lactic
  acid
• The cell will swell due to the influx of Na and
  H20, mitochondria will be damaged, lysosomal
  enzymes will be liberated, and then cellular
  death ensues.

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Pathophysiology of Shock

• 2. Organ System Responses
• When the patient encounters precipitating causes
  of shock, the circulatory function diminishes?
  there is decreased cardiac output? Hypotension
  and decreased tissue perfusion will result

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Shock Stages

• There are three stages of shock
• Compensatory stage
• Progressive stage
• Irreversible stage

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Shock Stages

• THE COMPENSATORY STAGE OF SHOCK
• In this stage, the patients blood pressure is
  within normal limits.
• Patients blood is shunted from the kidney, skin
  and GIT to the vital organs- brain, liver and
  muscles
• Manifestations of cold clammy skin, oliguria and
  hypoactive bowel sounds can be assessed.
• Medical management includes IVF and medication
• Nursing management includes monitoring of tissue
  perfusion vital signs, reduction of anxiety,
  administering IVF/ordered medications and
  promotion of safety

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• THE PROGRESSIVE STAGE OF SHOCK
• In this stage, the mechanisms that regulate blood
  pressure can no longer compensate and the mean
  arterial pressure falls.
• The overworked heart becomes dysfunctional. Heart
  rate becomes very rapid (as high as 150 bpm)
• Blood flow to the brain becomes impaired, the
  mental status deteriorates due to decreased
  cerebral perfusion and hypoxia.
• Laboratory findings will reveal increased BUN and
  Creatinine. Urinary output decreases to below 30
  mL/hour.

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Shock Stages

• THE PROGRESSIVE STAGE OF SHOCK
• Decreased blood flow to the liver impairing the
  hepatic functions. Toxic wastes are not
  metabolized efficiently, resulting to
  accumulation of ammonia, bilirubin and lactic
  acids.
• The reduced blood flow to the GIT causes stress
  ulcers and increased risk for GI bleeding.
• Hypotension, sluggish blood flow, metabolic
  acidosis (due to accumulation of lactic acid),
  and generalized hypoxemia can interfere with
  normal blood function.

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Shock Stages

• THE IRREVERSIBLE STAGE OF SHOCK
• This stage represents the end point where there
  is severe organ damage that patients do not
  respond anymore to treatment. Survival is almost
  impossible to maintain.
• Despite treatment, the BP remains low, anaerobic
  metabolisms continues and multiple organ failure
  results.
• Medical management is the use of life supporting
  drugs like epinephrine and investigational
  medications.

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Assessment of Shock

• Assessment Findings
• Skin Cool, pale, moist in hypovolemic and
  cardiogenic shock
• Warm, dry, pink in septic and neurogenic
  shock
• Pulse
• Tachycardia, due to increased sympathetic
  stimulation
• Weak and thready
• Blood pressure
• 1. Early stages may be normal due to
  compensatory mechanisms
• 2. Later stages systolic and diastolic blood
  pressure drops.

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Assessment of Shock

• Assessment Findings
• Respirations rapid and shallow, due to tissue
  anoxia and excessive amounts of CO (from
  metabolic Acidosis)
• Level of consciousness restlessness and
  apprehension, progressing to coma
• Urinary output decreases due to impaired renal
  perfusion
• Temperature decreases in severe shock (except
  septic shock).

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Management of Shock

• Nursing Interventions
• Management in all types and phases of shock
  includes the following
• Basic life support
• Fluid replacement
• Vasoactive medications
• Nutritional support

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Management of Shock

• A. Maintain patent airway and adequate
  ventilation.
• B. Promote restoration of blood volume
  administer fluid and bloodreplacement as ordered
• C. Administer drugs as ordered
• D. Minimize factors contributing to shock.
• E. Maintain continuous assessment of the client.
• F. Provide psychological support reassure client
  to relieve apprehension, and keep family advised
• G. Provide Nutritional support

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Hypovolemic Shock

• This is the MOST common form of shock
  characterized by a decreased intravascular volume
• Risk factors external Fluid Losses
• Trauma, Surgery, Vomiting, Diarrhea, Diuresis, DI
• Risk factors internal fluid shifts
• Hemorrhage, Burns, Ascites, Peritonitis,
  Dehydration

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Hypovolemic Shock

• Decreased blood volume? decreased venous return
  to the heart? decreased stroke volume? decreased
  cardiac output? decreased tissue perfusion
• Assessment findings cold clammy skin,
  tachycardia, mental status changes, tachypnea

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Hypovolemic Shock

• MEDICAL MANAGEMENT
• The major medical goals are to restore
  intravascular volume, to redistribute the fluid
  volume, and to correct the underlying cause of
  fluid loss promptly

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Hypovolemic Shock

• NURSNG MANAGEMENT
• Primary prevention of shock is the most important
  intervention of the nurse.
• General nursing measures include- safe
  administration of the ordered fluids and
  medications, documenting their administration and
  effects. The nurse must monitor the patient for
  signs of complications and response to treatment.
  Oxygen is administered to increase the amount of
  O2 carried by the available hemoglobin in the
  blood.

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Cardiogenic shock

• This shock occurs when the hearts ability to
  contract and to pump blood is impaired and the
  supply of oxygen is inadequate for the heart and
  tissues
• Risk factors Coronary factor- Myocardial
  infarction
• Risks factors NON coronary
• Cardiomyopathies
• Valvular damage
• Cardiac tamponade
• Dysrhythmias

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Cardiogenic shock

• Precipitating factors? will cause decreased
  cardiac contractility? Decreased stroke volume
  and cardiac output? leading to 3 things
• Damming up of blood in the pulmonary vein will
  cause pulmonary congestion
• Decreased blood pressure will cause decreased
  systemic perfusion
• Decreased pressure causes decreased perfusion of
  the coronary arteries leading to weaker
  contractility of the heart

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Cardiogenic shock

• ASSESSMENT FINDINGS Angina, hemodynamic
  instability, dysrhythmias
• MEDICAL MANAGEMENT
• The goals of medical management are to limit
  further myocardial damage and preserve and to
  improve the cardiac function by increasing
  contractility.
• NURSING MANAGEMENT
• The nurse prevents cardiogenic shock by early
  detection of patients at risk.
• Safety and comfort measures like proper
  positioning, side-rails, and reduction of
  anxiety, frequent skin care and family education.

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Circulatory shock

• This is also called distributive shock. It occurs
  when the blood volume is abnormally displaced in
  the vasculature.
• Septic Shock
• Neurogenic Shock
• Anaphylactic Shock

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Circulatory shock

• Massive arterial and venous dilation? allows
  pooling of blood peripherally? maldistribution of
  blood volume? decreased venous return? decreased
  stroke volume? decreased cardiac output?
  Decreased blood pressure? decreased tissue
  perfusion.

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Circulatory shock

• Risk factors for Septic Shock
• Immunosuppression
• Extremes of age (lt1 and gt65)
• Malnourishment
• Chronic Illness
• Invasive procedures

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Circulatory shock

• Risk factors for Neurogenic Shock
• Spinal cord injury
• Spinal anesthesia
• Depressant action of medications
• Glucose deficiency

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Circulatory shock

• Risk factors for Anaphylactic Shock
• Penicillin sensitivity
• Transfusion reaction
• Bee sting allergy
• Latex sensitivity

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SEPTIC SHOCK

• This is the most common type of circulatory shock
  and is caused by widespread infection.
• The HYPERDYNAMIC PHASE
• High cardiac output with systemic vasodilatation.
  
• The BP remains within normal limits.
• Tachycardia
• Hyperthermic and febrile with warm, flushed skin
  and bounding pulses

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SEPTIC SHOCK

• The HYPODYNAMIC or irreversible phase
• LOW cardiac output with VASOCONSTRICTION
• The blood pressure drops, the skin is cool and
  pale, with temperature below normal.
• Heart rate and respiratory rate remain RAPID!
• The patient no longer produces urine.

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SEPTIC SHOCK

• MEDICAL MANAGEMENT
• Current treatment involves identifying and
  eliminating the cause of infection. Fluid
  replacement must be instituted to correct
  Hypovolemia, Intravenous antibiotics are
  prescribed based on culture and sensitivity.

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SEPTIC SHOCK

• NURSING MANAGEMENT
• The nurse must adhere strictly to the principles
  of ASEPTIC technique in her patient care.
• Specimen for culture and sensitivity is
  collected. Symptomatic measures are employed for
  fever, inflammation and pain. IVF and medications
  are administered as ordered.

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Neurogenic Shock

• This shock results from loss of sympathetic tone
  resulting to widespread vasodilatation.
• The patient who suffers from neurogenic shock may
  have warm, dry skin and BRADYCARDIA!

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Neurogenic Shock

• MEDICAL MANAGEMENT
• This involves restoring sympathetic tone, either
  through the stabilization of a spinal cord injury
  or in anesthesia, proper positioning.

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Neurogenic Shock

• NURSING MANAGEMENT
• The nurse elevates and maintains the head of the
  bed at least 30 degrees to prevent neurogenic
  shock when the patient is receiving spinal or
  epidural anesthesia.

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Anaphylactic Shock

• This shock is caused by a severe allergic
  reaction when a patient who has already produced
  antibodies to a foreign substance develops a
  systemic antigen-antibody reaction

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Anaphylactic Shock

• MEDICAL MANAGEMENT
• Treatment of anaphylactic shock requires removing
  the causative antigen, administering medications
  that restore vascular tone, and providing
  emergency support of basic life functions.
• EPINEPHRINE is the drug of choice given to
  reverse the vasodilatation

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Anaphylactic Shock

• NURSING MANAGEMENT
• It is very important for nurses to assess history
  of allergies to foods and medications!
• Drugs are administered as ordered and the
  responses to the drugs are evaluated.

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Triage

• trier- to sort
• To sort patients in groups based on the severity
  of their health problem and the immediacy with
  which these problems must be addressed

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Triage in the E.R.

• Berners
• Emergent
• Urgent
• Non-urgent

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Triage in DISASTER!

• NATO
• Immediate
• Delayed
• Minimal
• Expectant

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Triage

• 1. Emergent
• Patients have the highest priority
• With life-threatening condition
• 2. Urgent
• Patients with serious health problems
• Not life-threatening, MUST be seen in 1 hour
• 3. Non-urgent
• Episodic illness that can be addressed within 24
  hours

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Triage in Disaster
Triage category Priority Color Conditions
Immediate 1 RED Chest wounds, shock, open fractures, 2-3 burns
Delayed 2 YELLOW Stable abdominal wound, eye and CNS injuries
Minimal 3 GREEN Minor burns, minor fractures, minor bleeding
Expectant 4 BLACK Unresponsive, high spinal cord injury
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Preparing for terrorism

• Recognition and Awareness
• Use of personal protective equipments
• Decontamination of contaminants

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Biological Weapons

• ANTHRAX
• Drug of choice is Ciprofloxacin or Doxycycline
• SMALLPOX
• Supportive

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Chemical Weapons

• Organophosphates
• Supportive care
• Soap and water
• Atropine
• Pralidoxine
• Cyanide
• Sodium nitrite, Amyl Nitrite, Methylene Blue
• Sodium thiosulfate
• Hydrocobalamin

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CYANIDE POISONING
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Radiation
Alpha Particles Cannot penetrate skin Causes local damage
Beta Particles Moderately penetrate the skin Can cause skin damage and internal injury if prolonged
Gamma Particles Penetrate skin Can cause serious damage X-ray is an example
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Thank you very much!!!!