Ø Anterior arm = 4.

5%
Emergency and Disaster Ø Posterior arm = 4.5%
Ø Upper arm = 4.5%
Nursing Ø Forearm = 4.5%
Leg = 18%
DEFINITION OF TERMS Ø Anterior leg = 9%
EMERGENCY – serious, unexpected, and often Ø Posterior leg = 9%
dangerous situation requiring immediate action Perineum = 1%

DISASTER – sudden event, such as accident or Infant: 0 to 12 mos

natural catastrophe, that causes great damage or Head and neck = 18%
loss of life Ø Anterior head = 9%
Ø Posterior head = 9%
BURN Trunk = 36%
Ø Anterior Trunk = 18% (Chest: 9%; Abdomen:
9%)
Ø Posterior Trunk = 18%
Arm = 9%
Ø Anterior arm = 4.5%
Ø Posterior arm = 4.5%
Ø Upper arm = 4.5%
Ø Forearm = 4.5%
Leg = 14%
Parkland Formula Ø Anterior leg = 7%
• Total mL to be replaced in the first 24 hrs Ø Posterior leg = 7%
• Formula: (4mL x TBSA [rule of 9s] x BW [kg])
Example:
In the first 8 hrs = 50% (more critical → shock → fluid Gentleman that weighs 200lbs sustained different
going to the third space) degrees of burn. Superficial burn at head and
Last 16 hrs = 50% neck, partial thickness burns at chest and right
anterior leg, full thickness burn at anterior trunk and
Example: arms. What is the total mL in the first 8 hrs?
Patient 100lbs sustained 36% of burn. What is the
total mL in the first 8 hrs? 200lbs/ 2.2 = 90.90kg

100/2.2 = 45.45 kgs Head and neck: 0 (It is only superficial)

4mL x 36 x 45.45 kgs = 6545 mL total in the first 24 hrs Right anterior leg: 9
6545 mL/2 = 3272.72 mL (3273mL) Anterior trunk: 18
Arms: 18
Patient 69 kgs. Burn 40%. What is the total mL in the TSBA: 45%
first 24 hrs?
4mL x 40% x 69 kgs = 11,040 mL in the first 24 hrs 4mL x 54% x 90 kg = 16,363 first 24 hrs
16362/2 = 8,181 first 8 hrs
Patient 140 lbd. Burn 60%. What is the total in the
last 1 hrs? A 10-month old patient weighs 8 kgs. Sustained first
` degree burn at right arm. Deep partial burn at
140/ 2.2 = 63.63 kgs perineum and left leg. Full thickness at head and
4mL x 60% x 63.63 kg = 15, 271 neck. Total in the first 24 hrs?
15, 271.2/ 2 = 7,636 mL
Left leg: 14
Rule of 9’s Head and Neck: 18
Adult: TSBA: 32%
Head and Neck = 9%
Ø Anterior head = 4.5% 4 mL x 32% x 8 kg = 1,024 in the first 24 hrs
Ø Posterior head = 4.5%
Trunk = 36% Adult weighs 169 lbs sustained different degrees of
Ø Anterior Trunk = 18% (Chest: 9%; Abdomen: burn. Partial thickness burn at anterior arms and
9%) abdomen. Full thickness burn at posterior trunk and
Ø Posterior Trunk = 18% legs. Total mL in the last 16 hrs?
Arm = 9%
169/ 2.2 = 76.81 kg Priority:
1. Risk for infection (sterile technique to prevent
Anterior arms: 9 infection)
Abdomen: 9 2. Situational: (+) Circumferential burns
Posterior trunk: 18 (scab/eschar) → compartment syndrome
Legs: 36
TSBA: 72 6Ps: pain, pallor, poikilothermia, paralysis,
paresthesia, pulselessness
4 ml x 76.81 kg x 72 = 22,123 in the first 24 hrs Risk of necrosis → amputation
22,123 / 2 = 11,061 mL MANAGEMENT: Fasciotomy (to remove pressure)

PHASES OF BURN INJURY 3. Wound Debridement (Hydrotherapy/

1. FIRST PHASE whirlpool bath)
Emergent/Shock/Resuscitative → 24 to 48 hours. a. Wound healing
Problem: FLUID DEFICIT b. Promotes absorption of antibiotic
ointment that doesn’t pass the
2. SECOND PHASE eschar/scab (silver nitrate/ sulfadiazine)
Acute/diuretic →post 48hrs to 5 days – risk for
infection New Drug: Mafenide acetate - passes the eschar
(AE: Hemolytic anemia) → Prevent adverse effect,
3. THIRD PHASE apply 1/16 to 1/18 inch
Recovery → 5days – restore optimal function
RECOVERY PHASE
EMERGENT PHASE All Sx, VS, LABS are stable
Sx: ↓BP, ↑HR ↑RR (compensatory mech), ↓UO, ↑Hct Priority: Rehabilitation
(dehydrated → concentrated blood), 1. Scars: Body Image Disturbance
hyperkalemia, hyponatremia MANAGEMENT: plastic surgery
= metabolic acidosis 2. Contractures - Prevention: Extension
3. Skin Graft - Wound healing (Temporary)
Best fluid: Plain LR v Autograft – Self
v Isograft – Twin
Priority assessment: VS, UO, Hct, electrolytes v Homograft/Allograft - Human “A sounds
Answer: Urine Output (best indicator of fluid like okay”
volume replacement) then Vital Signs v Heterograft/ Xenograft - Animals “X
mong animal”
Best lab test: Hematocrit (dehydration level) Ex. Fish skin, pig skin (porcine), cow skin (bovine),
alligator skin, snake skin
Normal hct (MALE): 42-52% (0.42-0.52)
Normal hct (FEMALE):37-47% (0.37-0.47) Graft – temporary; removed when healed

Priority N/I: Fluid Replacement TRIAGE: To sort of classify patients according to

Situational: Present inhalation burn (DOB, Soot,
Singed Facial hair, bronchospasm, facial burn) =
AIRWAY
Summary of Management:
1. Fluid. (Situational: Airway)
2. Severe pain: Opioid analgesic (Morphine,
Demerol, Fentanyl)
3. WOF curlings ulcer (stress ulcer related to burn)
stress = ↑Hcl
MANAGEMENT: H2 blockers, PPI, Bismuth salts,
avoid gastric irritants
priority (concept of justice)
• Simple – within 60 sec, external scene.
Respiration within 30 sec. perfusion within 2 sec.
o CONSIDER PX STATUS ONLY
o START (Simple Triage And Rapid Treatment)
o 3 Main Groups
1. Respiration - airway, breathing problem
2. Perfusion - circulation (fluid/blood)
3. Mental status - Psych, disability
• Advanced triage - CONSIDER PX STATUS AND
RESOURCES

ACUTE/DIURETIC PHASE Types of Advanced Triage

Sx: ↑BP, ↑HR ↑RR (vascular resistance), ↑UO, ↓Hct § Internal – hospital, structured. (+) resources,
(diluted blood because of overhydration), focus is definitive care, priority is sickest > well
hypokalemia, dilutional hyponatremia
(overhydration)
§ External – pre-hospital, unstructured, limited • Create a plan - roles, tasks
resources, focus is first aid, priority is high survival 3. Response - during disaster
over low survival • Physio > Psych (Triage)
o High survival (red>yellow>green) • Activate the plan – increase
o Low survival (black) incidence of admission (incidence
Flat > long bone fracture (flat-bleeding, long- command system)
embolism) 4. Recovery - post disaster
§ Reverse triage – Disasters, massive, military • Physio > Psych
scenario (WAR, TERRORISM, NATURAL • After stability of the physio = psych first
CATASTROPHE). Obsolete resources. aid (stress, suicidal tendency, PTSD)
o Priority is most stable. (Green > Yellow >
Red > Black) A. Diffusion - informal help done within 36 hrs
o Utilitarianism – greatest good for the of disaster
greatest number. Public safety over B. Debriefing - formal help (psychometrician,
personal reasons psychologists) done after 36 hrs

Building has collapsed. 20 patients were affected.

What is the priority?
External - RED
1. Patient with unequal pupils - black Principles of Emergency Care
2. Chest pain - red • Assess - environment (for safety), patient status
3. Long bone fracture - yellow (basis for intervention)
4. Minor cuts and bruises - green • Ask for help first (team approach); outside
o Activate EMS or ERS (rationale: asking for
resources = safer)
Priority: • Intervene - patient status
External triage - 2 • Do no harm - non maleficence
Reverse triage - 4
Internal triage - 1 Types of Survey and Assessment
Primary: Rapid, establish the priority problem
20 patient rushed to the ED (Internal → shift to ü Disadvantage - incomplete
external) – 2 ü Initial assessment, unstable client - limited
time to assess
ü After primary survey = primary intervention =
stabilize the patient

Secondary - complete and thorough

ü Disadvantage: takes time
ü Done after stabilization

Primary Survey
• Airway, Breathing, Circulation, Disability
(neurologic).
• IF CARDIAC ARREST: Compression, A, B
• Primary check is LOC – RESPONSES (ALERT -
VERBAL - PAIN: NAIL BED PRESSURE > STERNAL
Goals of Emergency Care: RUB). UNRESPONSIVE
1. Prevent injury - PRIMARY (Mitigation. • Demographics – NAME, CONTACT PERSON,
Preparedness) RELIGION
2. Preserve life - SECONDARY (Response) • Pulse checking: Adult/Child – carotid. Infant –
3. Promote recovery - TERTIARY (Rehabilitation) Brachial.
• RR check – rise and fall of the chest
Phases of Disaster Management: • Skin check for perfusion – PALLOR, CYANOSIS,
1. Mitigation - before disaster JAUNDICE
• Lessen casualties/damage
• Focus: urban planning, executive Secondary Survey – Done post stabilization
decision • Assess Cephalocaudal.
2. Preparedness - before disaster • Baseline VS.
• Training and drills - most expensive • History of complaint.
phase • Diagnostics and laboratory
 • QUALITY: push hard and fast
o Adult – 30 compressions: 2 breathing.
EMERGENCY MANAGEMENT - AIRWAY o 2 man pedia rescue – 15:2
Airway management- basic/advanced
• Basic (RN) – easy to perform, BLS, Landmark – lower half of sternum (to prevent
o Jaw thrust/head thrust = POSSIBLE OR xiphoid process fracture)
PRESENT CERVICAL INJURY
o Chin lift = No CERVICAL INJURY Hand position:
Adult and >9yo – 2 hands
Tubes - SHORT Child 1-8yo – 1 hand
1. Oropharyngeal/ MOUTH GUARD (upper to Infant – 2 fingers
the hard palate then slide down to the soft Lock elbows – allow chest recoil
palate) – contraindication if with (+) gag,
vomiting, aspiration risk, (+) facial trauma. Depth:
Adult – 2-2.4 inches
2. Nasopharyngeal – contra (+) CSF leakage Child – max 2 inches
- basilar/skull fracture (risk of brain penetration) Infant – max 1.5 inches

Advanced – longer tubes, direct to the lungs. (MD)

Stop CPR IF
• Laryngeal tube – normal: patient cannot talk. If • Defibrillation – pulseless vtach, vfib
patient can talk = dislodged (MANAGEMENT: • Exhausted
bag valve mask/ambubag then report) • ERS arrival
• Endotracheal tube – normal: patient cannot talk. • Physician declared death of px
If patient can talk = dislodged (MANAGEMENT: • Px is revived/Return of Spontaneous Circulation
bag valve mask/ambubag then report) = +HR or BP
• Tracheostomy – last resort
If dislodged: open suture lines (to promote patent FIRST AID MANAGEMENT
airway) HEMORRHAGE
TYPES:
EMERGENCY MANAGEMENT - BLS • Arterial (OXYGENATED, HIGH PRESSURE) – bright
red, spurting
I. Respiratory arrest (-RR, +PR, UNRESPONSIVE) – • Venous (DEOXYGENATED, LOW PRESSURE) –
rescue breathing. Bag valve mask ideally. Mouth- dark red, oozing
mouth is not recommended; one-way valve or
face shield is ideal. Management:
1. Wear gloves
Frequency: 2. Apply pressure (Direct or Indirect - proximal
Adult and advanced airway – 10 rescue to the site)
breaths/min, 1 breath/6 sec (too much may 3. Elevate the extremity (to promote venous
compress the heart) return)
4. PNSS or BT (universal donor: type O-)
Children – 12/min, 1 breath/5 sec. if vomiting is
present, stop – left side lying – suction ANIMAL BITES
CONSEQUENCE:
5 year old with tracheostomy = 10 rescue Rabies 100% fatal, Tetanus (soil)
breaths/min S/SX:
Rabies – photophobia, aerophobia, hydrophobia
II. Cardiac arrest – (-PR, -RR, UNRESPONSIVE)
S.A.R.A.P. MANAGEMENT:
• Survey scene/responder – safety 1. Clean the wound
• Announce/introduce self – remove bystanders 2. Lower the site (to prevent travel of toxin)
• Response – AVPU (Alert, Verbal, Pain, 3. Immobilize site (to prevent further
Unresponsive), Nailbed pressure, Sternal rub circulation of toxin)
• Activate ERS – asking for help – resources (safer) 4. Cold compress (10-15 mins)
• Pulse and respiration check - max 10 seconds 5. Anti rabies and anti tetanus
(prolong CPR = lower prognosis)
MANAGEMENT: CPR – push hard and fast BEE STINGS
• INTERVENE – compress q 2min CONSEQUENCE:
• RATE: 120 max (100-120/min) Allergic (itchy, redness) – antihistamine
Anaphylactic (DOB, Bronchospasm) – epi or • Beta blockers – glucagon
bronchodilator • Calcium channel blockers – glucagon
• Digoxin – digibind/digifab
MANAGEMENT: • Heparin – protamine sulphate
1. Remove stinger (scrape with card, avoid • Iron – cefuroxime
tweezers) • Magnesium sulfate – calcium gluconate
2. Clean the wound • Nitrate – methylene blue
3. Lower the site • Opioid – naloxone
4. Immobilize site • Thrombolytics – aminocaproic acid
5. Cold compress • Warfarin – vitamin K green leafy

MARINE STINGS
CONSEQUENCE:
Severe inflammation

SSX:
Warm to touch, redness, itchy

MANAGEMENT:
1. Acetic acid/vinegar (neutralize the stinger)
2. Flush with saline water
3. Warm water 10-15 minutes

SNAKE BITES
CONSEQUENCE:
Blood clots, CNS depression

Characteristic of venomous snakes – triangular

head, pit nostril, fangs, vertical/stir eyes

MANAGEMENT:
1. Safety
2. Clean the wound
3. Constrictive bands (to prevent the travel of
venom)
4. Lower the site, immobilize (slow down
venom)
5. No warm/cold, no sucking, no cutting
6. Anti-Venom within 4-6 hrs/ASAP

POISONING
Common: TODDLERS (ORAL EXPLORERS)
PREVENTION:
1. Lock poison out of childrens’ reach
2. Avoid storage of poison at food container

MANAGEMENT:
1. Do not stimulate vomiting/ antiemetics
(syrup of Ipecac) = risk of aspiration
2. POC: Left side lying - prevent gastric
emptying
3. Activated charcoal 1-2g/kg 4 - 6 hrs
(Detoxify)
4. Gastric Lavage (Lavas - Decompression)

COMMON ANTIDOTES:
• Anticholinergics SNS – cholinergics PSNS
• Acetaminophen – N acetylcysteine
• Benzodiazepine – flumazenil