Jam Mikka G.

Rodriguez
1. Airway Obstruction

An airway obstruction is a blockage in any part of the airway. The airway is a complex system of tubes
that conveys inhaled air from your nose and mouth into your lungs. An obstruction may partially or
totally prevent air from getting into your lungs.

a. Nasopharyngeal Insertion

Step by step:

 As necessary, clear the oropharynx of obstructing secretions, vomitus, or foreign material.

 Determine the appropriate size of the airway. When held against the side of the face, a
correctly sized airway will extend from the tip of the nose to the tragus of the ear. Measure the
length of the airway to ensure it does not cause obstruction.
 Open the nares to reveal the nasal passage. Inspect both nares to determine which side is
wider.
 Lubricate the nasopharyngeal airway with water-soluble lubricant or anesthetic jelly such
as lidocaine gel.
 Insert the airway posteriorly (not cephalad) parallel to the floor of the nasal cavity, with the
bevel of the tip facing toward the nasal septum (ie, with the pointed end lateral and the open end
of the airway facing the septum). Use gentle yet firm pressure to pass the airway through the
nasal cavity under the inferior turbinate.
 If you encounter resistance, try rotating the airway slightly and re-advance. If the tube still will
not pass, try inserting it into the other nostril.
 Advance the airway straight back until the flange is resting at the nostril opening.

b. Oropharyngeal Insertion

Step by step:

 As necessary, clear the oropharynx of obstructing secretions, vomitus, or foreign material.

 Determine the appropriate size of the oropharyngeal airway. Hold the airway beside the
patient’s cheek with the flange at the corner of the mouth. The tip of an appropriately sized
airway should just reach the angle of the mandibular ramus.
 Next, begin inserting the airway into the mouth with the tip pointed to the roof of the mouth
(ie, concave up).
 To avoid cutting the lips, be careful not to pinch the lips between the teeth and the airway as
you insert the airway.
 Rotate the airway 180 degrees as you advance it into the posterior oropharynx. This technique
prevents the airway from pushing the tongue backwards during insertion and further
obstructing the airway.
 When fully inserted, the flange of the device should rest at the patient’s lips.
 Alternatively, use a tongue blade to depress the tongue as you insert the airway with the tip
pointed to the floor of the mouth (ie, concave down). Use of the tongue blade prevents the
airway from pushing the tongue backward during insertion.
Jam Mikka G. Rodriguez

c. Endotrachial Intubation

Endotracheal intubation is done to: Keep the airway open in order to give oxygen, medicine, or
anesthesia. Support breathing in certain illnesses, such as pneumonia, emphysema, heart failure,
collapsed lung or severe trauma. Remove blockages from the airway.

Materials:

 Endotracheal (ET) tube

 Laryngoscope
 Stylet
 Syringe, 10 mL (to inflate ET tube balloon)
 Suction catheter (eg, Yankauer)
 Carbon dioxide detector (eg, Easycap)
 Oral and nasal airways
 Ambu bag and mask attached to oxygen source
 Nasal cannula

Nursing responsibilities for the patient with an artificial airway:

 maintaining correct tube placement

 maintaining proper cuff inflation
 monitoring oxygenation and ventilation
 maintaining tube patency
 assessing for complications
 providing oral care and maintaining skin integrity
 fostering comfort and communication.

2. Hemorrhage

If someone is bleeding heavily, the main aim is to prevent further blood loss and minimize the effects of
shock (see below).

First, dial 999 and ask for an ambulance as soon as possible.

If you have disposable gloves, use them to reduce the risk of any infection being passed on.

Check that there is nothing embedded in the wound. If there is, take care not to press down on the
object.

Instead, press firmly on either side of the object and build up padding around it before bandaging, to
avoid putting pressure on the object itself.

If nothing is embedded:

 apply and maintain pressure to the wound with your gloved hand, using a clean pad or dressing
if possible; continue to apply pressure until the bleeding stops 
Jam Mikka G. Rodriguez
 use a clean dressing to bandage the wound firmly
 if bleeding continues through the pad, apply pressure to the wound  until the bleeding stops and
then apply another pad over the top and bandage it in place; don't remove the original pad or
dressing, but continue to check that the bleeding has stopped 

If a body part, such as a finger, has been severed, place it in a plastic bag or wrap it in cling film and
make sure it goes with the casualty to hospital.

Always seek medical help for bleeding unless it's minor.

If someone has a nosebleed that hasn't stopped after 20 minutes, go to your nearest accident and
emergency (A&E) department.

3. Hypovolemic Shock

Is a life-threatening condition that results when you lose more than 20 percent (one-fifth) of your body's
blood or fluid supply. This severe fluid loss makes it impossible for the heart to pump enough blood to
your body.

Successful management of the patient in shock includes the following:

o Identification of patients at risk for developing shock

o Integration of the patient’s history, physical examination,
o and clinical findings to establish a diagnosis
o Interventions to control or eliminate the cause of the
o decreased perfusion
o Protection of target and distal organs from dysfunction
o Provision of multisystem supportive care

 General management strategies begin with ensuring that the patient has a patent airway.
Once the airway is established, either naturally or with an endotracheal tube, oxygen delivery
must be optimized. Supplemental oxygen and mechanical ventilation may be necessary to
maintain an arterial oxygen saturation of 90% or more (PaO2 greater than 60 mm Hg) to avoid
hypoxemia

 Hypovolemic Shock: The underlying principles of managing patients with hypovolemic shock
focus on stopping the loss of fluid and restoring the circulating volume. Fluid resuscitation in
hypovolemic shock initially is calculated using a 3:1 rule (3 mL of isotonic crystalloid for every
1 mL of estimated blood loss).

4. Wounds

Management:

 Step 1. Wash Your Hands: Clean your hands using soap and water or hand sanitizer, then put on
disposable gloves, if possible. Do this before you touch your wound or treat someone else’s
burn, cut, or scrape. Clean, covered hands help prevent infections.
Jam Mikka G. Rodriguez
 Step 2. Apply Gentle Pressure: This step applies only if the wound is bleeding. Skip this step for
burns. Use a clean cloth or sterile gauze to gently press on the wound until bleeding stops (small
cuts and scrapes may not require pressure). Elevate (raise) the affected part, if possible.
If blood oozes through the cloth or gauze, leave the covering on the wound. Place another clean
piece on top and continue to apply pressure.
 Step 3. Rinse with Water: You don’t need hydrogen peroxide or iodine products to thoroughly
clean a simple cut or scrape. Just follow these steps:
o Rinse the wound in clear water to loosen and remove dirt and debris.
o Use a soft washcloth and mild soap to clean around the wound. Do not place soap in the
wound. That can hurt and cause irritation.
o Use tweezers to remove any dirt or debris that still appears after washing. Clean the tweezers
first with isopropyl alcohol. Do not pick at the wound. If the wound cannot be cleaned, call a
doctor.

If you have a burn, rinse the area under cool (not cold) water for 10 to 15 minutes. Or place a cool cloth
on the burn for the same length of time. See your doctor if any large form. Go to the emergency room
right away if you have any major burns.

 Step 4. Use an Antibiotic Cream or Ointment: Over-the-counter skin antibiotics,

like Neosporin or Polysporin, help keep the skin moist and ward off infection. It is not always
necessary to use these if you have a minor cut or scrape. But applying a thin layer can boost
your body’s natural healing process and reduce scarring. Doctors may recommend using a
topical antibiotic if you have burn blisters that break open.
 Step 5. Bandage the Wound

You do not need to bandage every wound! If you have a minor scrape or cut, clean it, and leave it alone.
Otherwise, place a clean, sterile, nonstick bandage on the wound after cleaning it. This helps keep out
germs. You can find a variety of bandages and tape at your local drugstore. Paper tape may be less
irritating to sensitive skin. Change the bandage at least once a day or when it is wet or dirty. Be extra
careful to cover any cuts or wounds on areas that tend to get dirty or germy, like your hands or feet. You
also want to bandage any wound that would rub on clothing, such as a cut on your knee. Always cover
large wounds.

For Wound Cleansing Solution:

o Normal saline
o Sterile Water
o Tap water
o Antiseptics/antimicrobials should only be used
o where there are clinical indications, for example, infection or critical colonization

5. Trauma

The management of trauma patients begins with the primary survey (also commonly referred to as
Advanced Trauma Life Support, or ATLS). The primary survey consists of 5 steps (ABCDE approach) that
are performed in order.
Jam Mikka G. Rodriguez
 Airway assessment (and cervical spine stabilization)

o If appropriately answering questions, patient has a patent airway (at least for the

moment)
o Observe patient for signs of respiratory distress 
o Inspect mouth and larynx for injury or obstruction 
o Assume cervical spine injury in blunt trauma patients until proven otherwise 
o If patient is unconscious (and therefore unable to protect their airway) or in respiratory
distress, the threshold for intubations very low.
o Patients may be intubated or ventilated with the anterior portion of the cervical
collar removed, or with their neck manually stabilized.
o Patients with burn injuries and evidence of respiratory involvement are often intubated
out of precaution.
o If orotracheal intubation is difficult, perform a cricothyrotomy. 

 Breathing

o Assess oxygenation status with pulse oximetry.

o Inspect and auscultate chest wall for injuries. 
o In unstable patients, do not delay treatment of tension pneumothorax or hemothorax in
favor of imaging.

 Circulation (and hemorrhage control) 

o Assess circulatory status by palpation of central and peripheral pulses 

 Blood pressure should be measured if it can be done expediently, but it can be skipped if it
would delay the rest of the primary survey.
o Place two large-bore intravenous lines (at least 16 gauge) for blood typing and
crossmatch, and resuscitation (if needed).
 If intravenous line placement is not possible or difficult, intraosseous line should be used
instead.
o Control on-going hemorrhage with manual pressure or tourniquets.
o Emergency thoracotomy may be performed in patients with recent loss of pulses
(especially in patients with stab wounds to the chest).
o If patient is hypotensive, administer a bolus of intravenous saline. 
 If history of hemorrhage or on-going hemorrhage, transfuse type O blood.
 If significant hemorrhage and persistent hemodynamic instability, transfuse
plasma, platelets and red blood cells at 1:1:1 ratio. 
o Focused Assessment with Sonography for Trauma (FAST)exam is usually
performed, especially for hemodynamically unstable patients
 May be performed during the secondary survey in hemodynamically stable patients.
o Some patients may require emergent reversal of anticoagulation
o Remember hypovolemic shock due to hemorrhage requires loss of ∼ 1.5 L of blood.
Keep in mind the compartments where large amounts of blood may go:
 Outside (external hemorrhage)
 Thoracic cavity
 Pelvic cavity
Jam Mikka G. Rodriguez
 Abdominal cavity
 Thighs (e.g., multiple femur fractures)
 See Shock LC

 Disability (and neurological evaluation) 

o Assess patient's Glasgow Coma Scale score 

 See Glasgow Coma Scale (GCS)
 A GCS score < 8 is an indication for intubation
o Assess pupillary size
o If patient is interactive, assess motor function and light touch sensation.

 Exposure (and environmental control) 

o Undress patient completely.
o Examine body for signs of occult injury, including patient is back.
o If patient is hypothermic, cover with warm blankets and warm intravenous fluids.
o Palpate for vertebral tenderness and rectal tone.

6. Crash Injuries

What to do in the event of a road accident

The following is a step by step approach as guidance should you be the first on scene at an accident:

First steps:

 When approaching an accident scene, it is really important to ensure your own safety. Make
sure that all traffic has stopped. Ensure everyone is aware that there has been an accident
otherwise there may be additional casualties.
 Be aware of oncoming traffic to ensure that is not posing an additional danger. Note if there is
any fuel spillage or potential fire risk – turn off car ignitions if possible. Put on vehicle hazard
lights and use a warning triangle if there is one available.
 If other people are around; get them to phone the emergency services. If you are on your own,
assess the situation and treat any life-threatening conditions first.
 Quickly establish how many vehicles have been involved. Assess the occupants of all the vehicles
to ensure no one has life threatening injuries.

Check the quiet ones first:

 People screaming, crying, and making a noise must be breathing – your initial priority is
therefore to check anyone quiet and not moving.
 Quickly check if quiet casualties are responsive: – if there is no response check if they are
breathing. If they are unresponsive and breathing, ensure they are in a position where they are
leaning forward or to one side in a position where the airway will remain open. Move them the
Jam Mikka G. Rodriguez
minimum necessary and avoid twisting them. Keep talking to the casualty calmly as they can
hear you even if they are unconscious. Keep them warm.

Important checkpoints:

 If the person is not breathing you will need to resuscitate – if you are on your own and have not
called an ambulance – do this now and ask their advice as to the best way to resuscitate, as this
is not easy to do in a car.
 Only remove an unconscious person from a vehicle if there is an immediate danger to their life
from fire, flood, and explosion. Ask the emergency services over the phone for their advice as to
what you should do. It is very difficult to remove an unconscious person from a vehicle and
there is a major danger that you could worsen their injuries and injure yourself in the process.
 Conscious casualties should be in the care of bystanders and removed from the wreckage to a
safe area. Be aware of confused and dazed casualties who may wander into danger. Brief the
bystanders to keep the casualties warm and calm and help them to contact next of kin. Look for
any major bleeding and life-threatening injuries and treat these first.
 Note the nature of the wreckage and be aware of possible injuries as a result: bodies are softer
than metalwork, so if there is major damage to the vehicle it is possible that there could be
internal injuries to the casualty – ensure the bystanders notify you if there is any change in the
casualty’s condition.
 You should monitor anyone trapped in a vehicle carefully and notify the emergency services
immediately, this includes the exact time of the accident. If there are additional people around,
show them how to support the person’s neck to avoid them twisting as there is the possibility of
a spinal injury.
 Wear gloves and apply dressings if trying to control severe bleeding.

Be careful how and when you move them:

 Only remove a motorcyclist’s helmet if they are unconscious and there is no other way to assess
their breathing or their airway is in danger. There is usually a way of lifting the visor, it may be
sensible to loosen their chin strap.
 If a casualty has been hit by a car and they are lying on their back unconscious and breathing –
they should be carefully rolled into the recovery position to keep their spine in line. This should
ideally include the support of others to avoid twisting the spine.
 If a casualty has been hit by a vehicle or thrown from one and they are conscious in the road,
they should try to keep still. Ensure that someone is directing traffic and maintaining safety.
Support their head and neck, keep them warm and dry and wait for the emergency services.

7. Fractures

It can be difficult to tell if a person has a broken bone or a joint, as opposed to a simple muscular injury.
If you are in any doubt, treat the injury as a broken bone.

If the person is unconscious, has difficulty breathing or is bleeding severely, these must be dealt with
first, by controlling the bleeding with direct pressure and performing CPR.

If the person is conscious, prevent any further pain or damage by keeping the fracture as still as possible
until you get them safely to hospital.
Jam Mikka G. Rodriguez
Assess the injury and decide whether the best way to get them to hospital is by ambulance or car. For
example, if the pain is not too severe, you could transport them to hospital by car. It is always best to
get someone else to drive, so that you can deal with the casualty if they deteriorate for example, if they
lose consciousness as a result of the pain or start to vomit.

However, if:

 they are in a lot of pain and in need of strong painkilling medication, do not move them and call
an ambulance
 it is obvious they have a broken leg, do not move them, but keep them in the position you found
them in and call an ambulance
 you suspect they have injured or broken their back, do not move them and call an ambulance

Do not give the casualty anything to eat or drink, because they may need an anesthetic (numbing
medication) when they reach hospital.

ENVIRONMENTAL EMERGENCIES
An environmental emergency is defined as a "sudden-onset disaster or accident resulting from natural,
technological or human-induced factors, or a combination of these, that causes or threatens to cause
severe environmental damage as well as loss of human lives and property."
Following a disaster or conflict, an environmental emergency can occur when people's health and
livelihoods are at risk due to the release of hazardous and noxious substances, or because of significant
damage to the ecosystem.
Climate change is having an unprecedented effect on the occurrence of natural disasters and the
associated risk of environmental emergencies. With climate change already stretching the disaster relief
system, future climate-related emergency events will generate increased and more costly demands for
assistance.
Increased interest in outdoor activities such as running, hiking, cycling, skiing, and swimming has
increased the number of environmental emergencies seen in the ED. Illness or injury may be caused by
the activity, exposure to weather, or attack from various animals or humans.

1. Heat-Induced Illnesses

Brief exposure to intense heat or prolonged exposure to less intense heat leads to heat stress.

 Heat cramps – severe cramps in the large muscle groups fatigued by heavy work.
 Heat exhaustion – prolonged exposure to heat over hours or days.
 Heatstroke – the most serious form of heat stress, results from failure of the hypothalamic
thermoregulatory processes. A medical emergency.

Interventions:

Initial

 Manage and maintain ABCs.

Jam Mikka G. Rodriguez
 Provide high-flow O2 via non-rebreather mask or BVM.
 Establish IV access and begin fluid replacement for significant heat injury.
 Place patient in a cool environment.
 For patient with heatstroke, initiate rapid cooling measures: remove patient’s clothing, place
wet sheets over patient, and place in front of fan; immerse in a cool water bath; administer cool
IV fluids or lavage with cool fluids.
 Obtain 12-lead ECG.
 Obtain blood for electrolytes and CBC.
 Insert urinary catheter.

Ongoing Monitoring

 Monitor ABCs, temperature and vital signs, level of consciousness.

 Monitor heart rhythm, O2 saturation, and urine output.
 Replace electrolytes as needed.
 Monitor urine for development of myoglobinuria.
 Monitor clotting studies for development of disseminated intravascular coagulation.

2. Cold-Related Emergencies

May be localized or systemic. Contributing factors include age, duration of expo- sure,
environmental temperature, homelessness, pre-existing conditions (e.g., diabetes mellitus,
peripheral vascular disease), medications that suppress shivering (e.g., opioids, psychotropic agents,
antiemetics), and alcohol intoxication. Alcohol causes peripheral vasodilation, increases sensation of
warmth, and depresses shivering. Smokers have an increased risk of cold- related injury because of
the vasoconstrictive effects of nicotine.

 Frostbite – a true tissue freezing that results in the formation of ice crystals in the tissues and
cells.

o Superficial frostbite – involves skin and subcutaneous tissue, usually the ears, nose, fingers,
and toes.
o Deep frostbite – involves muscle, bone, and tendon.

 Hypothermia – a core temperature below 95°F (35°C), occurs when heat produced by the body
cannot compensate for heat lost to the environment.

Interventions:

Initial

 Remove patient from cold environment.

 Manage and maintain ABCs.
 Provide high-flow O2 via non-rebreather mask or BVM.
 Anticipate intubation for diminished or absent gag reflex.
 Establish IV access with two large-bore catheters for fluid resuscitation
 Rewarm patient:
Jam Mikka G. Rodriguez
o Passive: Remove wet clothing, apply dry clothing and warm blankets, use radiant lights.
o Active external: Apply heating devices (e.g., air or fluid-filled warming blankets), use warm
water immersion.
o Active internal: Provide warmed IV fluids; heated, humidified O2. Peritoneal lavage with
warmed fluids. Extracorporeal circulation (e.g., cardiopulmonary bypass, rapid fluid infuser,
hemodialysis).

 Obtain 12-lead ECG.

 Anticipate need for defibrillation.
 Warm central trunk first in patients with severe hypothermia to limit rewarming shock.
 Assess for other injuries.
 Keep patient’s head covered with warm, dry towels or stocking cap to limit loss of heat.
 Treat patient gently to avoid increased cardiac irritability.

Ongoing Monitoring

 Monitor ABCs, temperature, level of consciousness, vital signs.

 Monitor O2 saturation, heart rate and rhythm.
 Monitor electrolytes, glucose.

3. Non-Fatal Drowning

An incident in which someone is submersed in a liquid that prevents the person from breathing air
and that results in respiratory impairment.

 Fresh water or salt water

Interventions:

Initial

 Manage and maintain ABCs.

 Assume cervical spine injury in all near-drowning victims and stabilize or immobilize cervical
spine.
 Provide 100% O2 via non-rebreather mask or BVM.
 Anticipate need for intubation and mechanical ventilation if airway is compromised (e.g., absent
gag reflex).
 Establish IV access with two large-bore catheters for fluid resuscitation and infuse warmed fluids
if appropriate.
 Obtain 12-lead ECG.
 Assess for other injuries.
 Remove wet clothing and cover with warm blankets.
 Obtain temperature and begin rewarming if needed.
 Obtain cervical spine and chest x-rays.
 Insert gastric tube and urinary catheter.

Ongoing Monitoring
Jam Mikka G. Rodriguez
 Monitor ABCs, vital signs, level of consciousness.
 Monitor O2 saturation, heart rate and rhythm.
 Monitor temperature and maintain normothermia.
 Monitor for signs of acute respiratory failure.
 Monitor for signs of secondary drowning.

4. Decompression Sickness

Also called generalized barotrauma or the bends, refers to injuries caused by a rapid decrease in the
pressure that surrounds you, of either air or water. It occurs most commonly in scuba or deep-sea
divers, although it also can occur during high-altitude or unpressurized air travel.

Interventions:

Maintaining blood pressure and administering high-flow oxygen. Fluids also may be given. The
person should be placed left side down and if possible the head of the bed tilted down.  

The optimal treatment is the use of a hyperbaric oxygen chamber, which is a high-pressure chamber
in which the patient receives 100% oxygen. This treatment reverses the pressure changes that
allowed gas bubbles to form in the blood stream. The treatment drives nitrogen back into its liquid
form so that it can be cleared more gradually from the body over a period of hours.  

Prevention:

 Dive and rise slowly in the water, and don't stay at your deepest depth longer than
recommended. Scuba divers typically use dive tables that show how long you can remain at a
given depth.

 Do not fly within 24 hours after diving.  

 Do not drink alcohol before diving.  

 Avoid hot tubs, saunas, or hot baths after diving.  

 Make sure you are well hydrated, well rested, and prepared before you scuba dive. If you
recently had a serious illness, injury, or surgery, talk to your doctor before diving.  

5. Animal and Human Bites

The most significant problems associated with animal bites are infection and mechanical destruction
of skin, muscle, tendons, blood vessels, and bone. The bite may cause a simple laceration or be
associated with crush injury, puncture wound, or tearing of multiple layers of tissue. The severity of
injury depends on animal size, victim size, and anatomic location of the bite. Animal bites from dogs
and cats are most common, with
wild or domestic rodents (e.g., squirrels, hamsters) following as the third most frequently reported
offenders.
Jam Mikka G. Rodriguez
 Dog bites – usually occur in extremities. However, facial bites are common in small children.
 Cat bites – cause deep puncture wounds that can involve tendons and joint capsules and result
in a greater incidence of infection than with dog bites.
 Human bites – also cause puncture wounds or lacerations. These carry a high risk of oral
infection from flora, most commonly staphylococcus aureus, streptococcus organisms and
hepatitis virus.

Interventions:

Initial

 Cleansing with copious irrigation

 Debridement
 Tetanus prophylaxis and analgesics PRN
 Leave puncture wounds open
 Splint wounds over joints
 Lacerations are loosely sutured
 Initial closure is used for facial wounds
 Admitted for IV antibiotic therapy when an infection is present
 Provide rabies post-exposure prophylaxis when the animal is not found or carnivorous wild
animals causes the bite

o Start the regimen with an initial, weight-based dosage of rabies immune globulin (RIG
[HyperRab S/D]) to provide passive immunity.
o Follow this with a series of five injections of human diploid cell vaccine (HDCV [Imovax
Rabies]) on days 0, 3, 7, 14, and 28 to provide active immunity

6. Snake Bites

Animals, spiders, snakes, and insects cause injury and even death by biting or stinging. Morbidity is a
result of either direct tissue damage or lethal toxins. Direct tissue damage is a product of animal
size, characteristics of the animal’s teeth, and strength of the jaw. Tissue is lacerated, crushed, or
chewed, while teeth, fangs, stingers, spines, or tentacles release toxins that have local or systemic
effects. Death associated with animal bites is due to blood loss, allergic reactions, or lethal toxins.
Injuries caused by select insects, ticks, animals (e.g., dogs, cats), and humans are described here.

Interventions:

While waiting for medical help:

 Move the person beyond striking distance of the snake.

 Have the person lie down with wound below the heart.
 Keep the person calm and at rest, remaining as still as possible to keep venom from spreading.
 Cover the wound with loose, sterile bandage.
 Remove any jewelry from the area that was bitten.
 Remove shoes if the leg or foot was bitten.

Do not:
Jam Mikka G. Rodriguez

 Cut a bite wound

 Attempt to suck out venom
 Apply tourniquet, ice, or water
 Give the person alcohol or caffeinated drinks or any other medications


7. Spider Bites

Animals, spiders, snakes, and insects cause injury and even death by biting or stinging. Morbidity is a
result of either direct tissue damage or lethal toxins. Direct tissue damage is a product of animal
size, characteristics of the animal’s teeth, and strength of the jaw. Tissue is lacerated, crushed, or
chewed, while teeth, fangs, stingers, spines, or tentacles release toxins that have local or systemic
effects. Death associated with animal bites is due to blood loss, allergic reactions, or lethal toxins.
Injuries caused by select insects, ticks, animals (e.g., dogs, cats), and humans are described here.

 Black widow spider - hourglass marking on its belly.

 Brown recluse spider - a violin-shaped marking on its back, but this mark can be hard to see.

Interventions:

Brown recluse bites:

 Rest, ice and elevation has been shown to work for most patients. Other possible treatments
include the use of dapsone, steroids, hyperbaric oxygen, and antibiotics. A tetanus booster
should be given to the patient based on immunization history.
  Use of nanocrystalline silver showed to be beneficial in brown recluse cases with faster healing,
reduced inflammation, and less pain.
 Patients who have severe tissue damage, necrosis, or systemic effects will usually be admitted to
the hospital. Those patients may need IV antibiotics, fluid and electrolyte replacement, and
renal status monitoring.
 Wound care may include surgical excision and grafting. Nurses must maintain good hand
hygiene and frequently assess the patient for worsening condition.

Black widow bites:

 Application of ice to slow down the neurotoxin.

 Constrictive clothing and jewelry should be removed from the extremity.
 The patient’s ABCs should be monitored until transport to a hospital is accomplished.
 Pain control
 Opiates work well for pain relief and benzodiazepines are utilized for muscle cramping.
 Vital signs need to be monitored closely for signs of respiratory depression and hypertension.

8. Tick Bites

Emergencies associated with tick bites include Lyme disease, Rocky Mountain spotted fever, and tick
paralysis. The infected tick or the release of neurotoxin causes the disease. Ticks release neurotoxic
venom if the tick head attaches to the body.
Jam Mikka G. Rodriguez

Interventions:

 Safe removal of the tick using tweezers or forceps to grasp the ick close to the point of
attachment and pull upward in a steady motion.
 After removal, clean the skin with soap and water
 Do not use hot match, petroleum jelly, nail polish, or other products to remove the tick

o May cause a tick to salivate thus increasing the risk for infection.

 Antibiotics for infection:

o Doxycycline (Vibramycin) – lime disease; rocky mountain spotted fever

o Ceftriaxone (Rocephin) – monoarticular arthritis; meningitis; neuropathies

POISONING

1. Carbon Monoxide Poisoning

 Carbon monoxide poisoning may occur because of industrial or household incidents or attempted
suicide. It is implicated in more deaths than any other toxin except alcohol.
 Carbon monoxide exerts its toxic effect by binding to circulating hemoglobin and thereby
reducing the oxygen-carrying capacity of the blood. Hemoglobin absorbs carbon monoxide 200
times more readily than it absorbs oxygen.
 Carbon monoxide–bound hemoglobin, called carboxyhemoglobin, does not transport oxygen
 Because the CNS has a critical need for oxygen, CNS symptoms predominate with carbon
monoxide toxicity. A person suffering from carbon monoxide poisoning may appear intoxicated
(from cerebral hypoxia).
 Other signs and symptoms include headache, muscular weakness, palpitation, dizziness, and
confusion, which can progress rapidly to coma. Skin color, which can range from pink or cherry-
red to cyanotic and pale, is not a reliable sign. Pulse oximetry is also not valid, because the
haemoglobin is well saturated.
 It is not saturated with oxygen, but the pulse oximeter reads the saturation as such and presents
the false impression that the patient is well oxygenated and in no danger. Exposure to carbon
monoxide requires immediate treatment.

Management

 Goals of management are to reverse cerebral and myocardial hy-poxia and to hasten elimination
of carbon monoxide. Whenever a patient inhales a poison, the following general measures apply:

o Carry the patient to fresh air immediately; open all doors and windows.
o Loosen all tight clothing.
o Initiate cardiopulmonary resuscitation if required; administer oxygen.
o Prevent chilling; wrap the patient in blankets.
o Keep the patient as quiet as possible.
o Do not give alcohol in any form.
Jam Mikka G. Rodriguez
 In addition, for the patient with carbon monoxide poisoning, carboxyhemoglobin levels are
analyzed on arrival at the ED and before treatment with oxygen if possible.
 Then 100% oxygen is administered at atmospheric or hyperbaric pressures to reverse hypoxia
and accelerate the elimination of carbon monoxide. Oxygen is administered until the
carboxyhemoglobin level is less than 5%.
 The patient is monitored continuously. Psychoses, spastic paralysis, ataxia, visual disturbances,
and deterioration of mental status and behavior may persist after resuscitation and may be
symptoms of permanent brain damage.
 When unintentional carbon monoxide poisoning occurs, the health department should be
contacted, so that the dwelling or building in question can be inspected. A psychiatric
consultation is warranted if poisoning was determined to be a suicide attempt.

2. Skin Contamination Poisoning

 Skin contamination injuries from exposure to chemicals are challenging because of the large
number of offending agents with diverse actions and metabolic effects.
 The severity of a chemical burn is determined by the mechanism of action, the penetrating
strength and concentration, and the amount and duration of exposure of the skin to the chemical.

Management

 The skin should be drenched immediately with running water from a shower, hose, or faucet.A
constant stream of water should continue as the patient’s clothing is being removed.
 The skin of health care personnel assisting the patient should be appropriately protected if the
burn is extensive or if the agent is significantly toxic or is still present. Prolonged lavage with
generous amounts of tepid water is important.
 In the meantime, attempts to determine the identity and characteristics of the chemical agent are
necessary for future treatment.
 The standard burn treatment appropriate for the size and location of the wound (antimicrobial
treatment, debridement, tetanus prophylaxis as prescribed) is instituted. The patient may require
plastic surgery for further wound management. The patient is instructed to have the affected area
reexamined at 24 and 72 hours and in 7 days because of the risk for underestimating the extent
and depth of these types of injuries.

3. Food Poisoning

 Food poisoning is a sudden illness that occurs after ingestion of contaminated food or drink.
 Botulism is a serious form of food poisoning that requires continual surveillance.

Management

 The key to treatment is determining the source and type of food poisoning. If possible, the
suspected food should be brought to the medical facility and a history obtained from the patient
or family.
 Food, gastric contents, vomitus, serum, and feces are collected for examination. The patient’s
respirations, blood pressure, sen-sorium, CVP (if indicated), and muscular activity are monitored
closely.
Jam Mikka G. Rodriguez
 Measures are instituted to support the respiratory system. Death from respiratory paralysis can
occur with botulism, fish poisoning, and other food poisonings.
 Because large volumes of electrolytes and water are lost by vomiting and diarrhea, fluid and
electrolyte balance is also an important area to assess. Severe vomiting produces alkalosis, and
severe diarrhea produces acidosis.
 Hypovolemic shock may also occur from severe fluid and electrolyte losses. The patient is assessed
for signs and symptoms of fluid and electrolyte imbalances, including lethargy, rapid pulse rate,
fever, oliguria, anuria, hypotension, and delirium. Weight and serum electrolyte levels are
obtained for future comparisons.
 Measures to control nausea are also important to prevent vom-iting, which could further
exacerbate fluid and electrolyte imbalances. An antiemetic medication is administered
parenterally as prescribed if the patient cannot tolerate fluids or medications by mouth.
 For mild nausea, the patient is encouraged to take sips of weak tea, carbonated drinks, or tap
water. After nausea and vomiting subside, clear liquids are usually prescribed for 12 to 24 hours,
and the diet is gradually progressed to a low-residue, bland diet.

SUBSTANCE ABUSE

1. Acute Alcohol Intoxication

 Alcohol is a psychotropic drug that affects mood, judgment, behavior, concentration, and
consciousness. Many heavy drinkers are young adults or people older than 60 years of age.
 There is a high prevalence of alcoholism among ED patients. Because patients who abuse
alcohol return frequently to the ED, they often frustrate and tax the patience of the health care
professionals who care for them.
 Their management requires patience and thoughtful, accurate, long-term treatment.
 Alcohol, or ethanol, is a direct multisystem toxin and CNS depressant that causes drowsiness,
incoordination, slurring of speech, sudden mood changes, aggression, belligerence, grandiosity,
and uninhibited behavior.
 In excess, it also can cause stupor, coma, and death. In the ED, the patient is assessed for head
in-jury, hypoglycemia (which mimics intoxication), and other health problems.
 Possible nursing diagnoses include ineffective breathing pattern related to CNS depression and
risk for violence (self-directed or directed at others) related to severe intoxication from alcohol.

Management

 Treatment involves detoxification of the acute poisoning, recovery, and rehabilitation.

Commonly, the patient uses mechanisms of denial and defensiveness. The nurse should
approach the patient in a nonjudgmental manner, using a firm, consistent, accepting, and
reasonable attitude.
 Speaking in a calm and slow manner is helpful because alcohol interferes with thought
processes. If the patient appears intoxicated, hypoxia, hypovolemia, and neurologic impairment
must be ruled out before it is assumed that the patient is intoxicated. Typically, a blood
specimen is obtained for analysis of the blood alcohol level.
 If drowsy, the patient should be allowed to sleep off the state of alcoholic intoxication. During
this time, maintenance of a patent airway and observation for symptoms of CNS depression are
essential.
Jam Mikka G. Rodriguez
 The patient should be undressed and kept warm with blankets. On the other hand, if the patient
is noisy or belligerent, sedation may be necessary. If sedation is used, the patient should be
monitored carefully for hypotension and decreased level of consciousness.
 Additionally, the patient is examined for alcohol withdrawal delirium and for injuries and organic
disease, such as head injury, seizures, pulmonary infections, hypoglycemia, and nutritional
deficiencies, that may be masked by alcoholic intoxication.
 People with alcoholism suffer more injuries than the general population. Also, acute alcohol
intoxication is the cause of trauma for many nonalcoholic patients. Pulmonary infections are
also more common in patients with alcoholism, resulting from respiratory depression, an
impaired defense system, and a tendency toward aspiration of gastric contents.
 The patient may show little in-crease in temperature or white blood cell count. The patient may
be hospitalized or admitted to a detoxification center to examine problems underlying
substance abuse.

2. Alcohol Withdrawal Syndrome

 Alcohol withdrawal syndrome (AWS) is an acute toxic state that occurs because of sudden
cessation of alcohol intake after a bout of heavy drinking or, more usually, after prolonged
intake of alcohol.
 Severity of symptoms depends on how much alcohol was ingested and for how long. Delirium
tremens may be precipitated by acute injury or infection (pneumonia, pancreatitis, hepatitis)
and is the most severe form of AWS.
 Patients with AWS show signs of anxiety, uncontrollable fear, tremor, irritability, agitation,
insomnia, and incontinence. They are talkative and preoccupied and experience visual, tactile,
olfactory, and auditory hallucinations that often are terrifying.
 Autonomic overactivity occurs and is evidenced by tachycardia, dilated pupils, and profuse
perspiration. Usually, all vital signs are elevated in the alcoholic toxic state. Delirium tremens is a
life-threatening condition and carries a high mortality rate.

Management

 The goals of management are to give adequate sedation and support to allow the patient to rest
and recover without danger of injury or peripheral vascular collapse.
 A physical examination is performed to identify preexisting or contributing illnesses or injuries
(e.g., head injury, pneumonia). A drug history is obtained to elicit information that may facilitate
adjustment of any sedative requirements
 Baseline blood pressure is determined because the patient’s subsequent treatment may depend
on blood pressure changes.
 Usually, the patient is sedated as directed with a sufficient dosage of benzodiazepines to
establish and maintain sedation, which reduces agitation, prevents exhaustion, prevents
seizures, and promotes sleep.
 The patient should be calm, able to respond, and able to maintain an airway safely on his or her
own.
 A variety of medications and combinations of medications are used (for example,
chlordiazepoxide [Librium], lorazepam, and clonidine).
 Haloperidol or droperidol may be administered for severe acute AWS. Dosages are adjusted
according to the patient’s symptoms (agitation, anxiety) and blood pressure response.
Jam Mikka G. Rodriguez
 The patient is placed in a calm, non-stressful environment (usually a private room) and observed
closely. The room remains lighted to minimize the potential for illusions and hallucinations.
Homicidal or suicidal responses may result from hallucinations.
 Closet and bathroom doors are closed to eliminate shadows. Some-one is designated to stay
with the patient as much as possible. The presence of another person has a reassuring and
calming effect, which helps the patient maintain contact with reality.
 Any visual misrepresentations (illusions) are explained, to orient the patient to reality. Fluid
losses may result from gastrointestinal losses (vomiting), profuse perspiration, and respiration
(hyperventilation).
 In addition, the patient may be dehydrated because of alcohol’s effect of decreasing antidiuretic
hormone. The oral or intravenous route is used to restore fluid and electrolyte balance.
 Temperature, pulse, respiration, and blood pressure are recorded frequently (every 30 minutes
in severe forms of delirium) in anticipation of peripheral circulatory collapse or hyperthermia
(the two most lethal complications). Phenytoin (Dilantin) or other antiseizure medications may
be prescribed to prevent or control repeated withdrawal seizures.
 Frequently seen complications include infections (e.g., pneumonia), trauma, hepatic failure,
hypoglycemia, and cardiovascular problems. Hypoglycemia may accompany alcohol withdrawal,
because alcohol depletes liver glycogen stores and impairs gluconeogenesis; many patients with
alcoholism also are malnourished.
 Parenteral dextrose may be prescribed if the liver glycogen level is depleted. Orange juice,
Gatorade, or other forms of carbohydrates are given to stabilize the blood glucose level and
counteract tremulousness.
 Supplemental vitamin therapy and a high-protein diet are provided as prescribed to counteract
vitamin deficiency.
 The patient should be referred to an alcoholic treatment center for follow-up care and
rehabilitation.

VIOLENCE, ABUSE AND NEGLECT

1. Family Violence, Abuse and Neglect

Family and intimate partner violence (IPV) is a pattern of coercive behavior in a relationship that
involves fear; humiliation; intimidation; neglect; or intentional physical, emotional, financial, or sexual
injury

 If abuse or neglect is suspected, first report it to a physician, nurse practitioner, or physician

assistant. Notifying a supervisor may also be required, depending on the workplace.
 If the victim is with a suspected abuser, the exam should take place without that person in the
room.
 Nurses should provide a calm, comforting environment and approach the patient with care and
concern.
 A complete head-to-toe examination should take place, looking for physical signs of abuse.
 Thorough documentation and description of exam findings, as well as patient statements, non-
verbal behavior, and behavior/statements of the suspected abuser should also be included.

2. Sexual Assault
Jam Mikka G. Rodriguez
Sexual assault is any act of a sexual nature performed in a criminal manner, as with a child or with a
nonconsenting adult, including rape, incest, oral copulation, and penetration of genital or anal opening
with a foreign object.

 The examiner must provide psychological support and referral to the appropriate resources,
treat physical injuries, collect legal evidence, document pertinent history, perform a thorough
head-to-toe physical examination, give prevention of unwanted pregnancy, and provide
prevention of and screening for STDs.
 The clinician must be mindful that the ED record also constitutes legal evidence. Treatment and
documentation must be accurate and meticulous.
 Postsexual assault prophylaxis are as follows: Ceftriaxone 250 mg IM in a single dose,
plus azithromycin 1 g PO in a single dose, plus metronidazole 2 g PO in a single dose or tinidazole
2 g PO in a single dose.
 HPV vaccination is recommended for female survivors aged 9–26 years and male survivors aged
9–21 years. The vaccine should be administered to sexual assault survivors at the time of the
initial examination, and follow-up dose administered at 1–2 months and 6 months after the first
dose.
 Update tetanus status when necessary.
 Evaluate the patient's hepatitis B immunization status.
 Offer a consultation with a sexual assault counselor in the ED.
 Refer the patient to a sexual assault center for aftercare and community resources. Given the
long-term emotional and psychosocial impact of sexual assault on the victim, aftercare is vital.
 Consultation with social services to provide access to such services that may exist in the region.

3. Human Trafficking

Human trafficking, a modern form of slavery, is generally divided into several categories: forced sexual
exploitation, forced labor, and domestic servitude. Victims of forced sexual exploitation may have to
work in a variety of settings, including but not limited to prostitution, exotic dancing, pornography,
and/or as mail order brides. Victims of forced labor work for little or no money, often for long hours, and
without appropriate safety measures or compensation. Female victims of forced labor are also often
sexually exploited.

 Establish privacy. Once you think that a patient might be a victim of trafficking the most
important step is to try and examine them privately in a comfortable and non-threatening
environment while also assuring them of confidentiality.
 Establishing trust and rapport is the next crucial step. The goal is to let the patient feel safe to
discuss their situation without judgment.
 Have a team discussion to come up with an action plan. The patient is asked whether you can
help them to find a safe place to go to immediately. The exact nature of the assistance must be
clearly explained.
 Nurses should examine their own perceptions of human trafficking so they do not inadvertently
impose those perceptions and leave the individual feeling more victimized and/or criticized.
Respect and non-judgment are key components of the interview and care encounter.
 Nurses should take leadership roles in these initiatives. Improvements in screening,
identification, and treatment will ultimately lead to safer, healthier women.

PSYCHIATRIC EMERGENCIES
Jam Mikka G. Rodriguez

1. Overactive

 This medical assessment generally requires multiple laboratory tests, which increases
throughput time, and may result in ED boarding, a phenomenon with far-reaching negative
consequences for patients and negative financial consequences for the ED housing them.
 The medical condition of the patient needs to be assessed for risk to life and admitted to the
ICU under escort until the medical condition stabilizes. At the earliest opportunity he is
referred for assessment by a psychiatrist.

2. Post-Traumatic Stress Disorder

Post traumatic stress disorder can occur after someone experiences or witnesses a traumatic event,
such as physical or sexual assault, an accident, war, natural disaster, or unexpected death of a loved
one. Feelings of fear, shock, anger, anxiety, and guilt are prolonged and interfere with the ability to
function socially, at work, and in relationships.

 The person must be experiencing a certain number of symptoms in four specific categories: re-
experiencing; avoidance; persistent negative alterations in cognitions and mood; and
alterations in arousal and activity.
 Cognitive therapy. A type of talk therapy, cognitive therapy helps patients recognize and
modify potentially harmful thinking patterns, such as fears that traumatic events will recur.
 Exposure therapy (ET). Used to help PTSD patients reduce flashbacks and nightmares, ET lets
patients safely face frightening situations and memories until they are better able to cope with
them. Exposures can be real or imagined. Virtual reality technology can also be used for ET.
 Eye movement desensitization and reprocessing (EMDR). Used in conjunction with exposure
therapy, EMDR therapy involves a series of guided eye movements that help patients process
traumatic memories and manage their reactions.
 Psychopharmacology. PTSD symptoms can be treated with any of multiple types of
medications, including antidepressants and anti-anxiety drugs. Prazosin has been identified as
a possible aid in reducing or suppressing nightmares in some people with PTSD, but its efficacy
is still being studied.

3. Depression

Depression (major depressive disorder) is a common and serious medical illness that negatively affects
how a person feels, the way they think and how they act. Depression causes feelings of sadness and/or a
loss of interest in activities you once enjoyed. It can lead to a variety of emotional and physical problems
and can decrease your ability to function at work and at home.

 Provide for patient’s physical needs. Assist with self-care and personal hygiene. Encourage
patient to eat. Give warm milk or back rubs at bedtime to improve sleep.
 Plan activities for times when the patient’s energy level peaks.
 Assume active role in initiating communication. This can be done by sharing observation of
patient’s behavior, speaking slowly and allowing ample time for him to respond, encouraging
him to talk and write down feelings, and by providing a structured routine which may include
noncompetitive activities.
Jam Mikka G. Rodriguez
 Avoid feigned cheerfulness, but don’t hesitate to laugh with him and point out the value of
humor.
 Record all observations and conversations with the patient because these are valuable in
evaluating his response to treatment.
 Discuss the need for medication compliance. Review adverse effects with the patient.

4. Suicide

Suicidal behavior includes suicidal ideation (frequent thoughts of ending one's life), suicide attempts
(the actual event of trying to kill one's self), and completed suicide (death occurs). Suicidal behavior is
most often accompanied by intense feelings of hopelessness, depression, or self‐destructive behaviors
(parasuicidal behaviors).

 Patients being evaluated for suicidal thoughts or behaviors should not be allowed to leave the
ED until the evaluation is complete and should be protected from self-harm while in the ED.
 Placing the patient in a private room without access to potentially dangerous objects (e.g.,
belts, shoelaces, or sharp medical instruments).
 Mechanical or chemical restraints can be traumatic to the patient and impair rapport, so ED
providers should first try to verbally de-escalate agitated patients.
 Providers should advocate for a written ED policy concerning care of suicidal patients to clarify
pathways and support provider actions, including use of constant observation, personal
searches by security staff, or restraints.
 A “focused medical assessment” which implies absence of medical issues aims to identify
medical issues requiring emergent or urgent treatment.