Lesson 3.

1: EMERGENCY CART

“E”– Cart
Located in designated areas where medical emergencies and resuscitation is needed
Purpose: to maximize the efficiency in locating medications/supplies needed for
emergency situations.
Drawer 5: Contains respiratory supplies such as oxygen tubing, a flow meter, a face
shield, and a bag-valve-mask device for delivering artificial respirations
Drawer 4: Contains suction supplies & gloves
Drawer 3: Contains intravenous fluids
Drawer 2: Contains equipment for establishing IV access, tubes for laboratory tests,
and syringes to flush medication lines.
Drawer 1: Contains medications needed during a code such as epinephrine, atropine,
lidocaine, CaCl2 and NaHCO3
The back of the cart usually houses the cardiac board.
Assessment and Intervention in the ER

The Primary Survey: Focuses on stabilizing life-threatening conditions; employs

the ABCD Method

The ABCD Method

Airway - Establish the airway
Breathing - Provide adequate ventilation
Circulation - Evaluate & restore cardiac output by controlling hemorrhage,
preventing & treating shock, and maintaining or restoring effective circulation
Disability - Determine neurologic disability by assessing neuro function using the
Glasgow
GLASGOW COMA SCALE

Eye opening response Spontaneous 4

To voice 3

To pain 2

None 1

Verbal response Oriented 5

Confused 4

Inappropriate words 3

Incomprehensible sounds 2

None 1

Motor response Obeys command 6

Localizes pain 5

Withdraws 4

Flexion 3

Extension 2

None 1
Emergency Drug Doses
Assessment and Intervention in the ER
Assessment and Intervention in the ER
Assessment and Intervention in the ER
Assessment and Intervention in the ER
Assess and Intervene: The Secondary Survey
includes:

•A complete health history & head-to-toe assessment

•Diagnostic & laboratory testing
•Application of monitoring devices
•Splinting of suspected fractures
•Cleaning & dressing of wounds
•Performance of other necessary interventions based on the patient’s
condition.
A. General Guidelines

Maintain adequate airway, breathing and cardiac output

- Patients who ingested large amounts of TCA may require intubation immediately even
if mental status has not yet occurred.
- Perform gastric lavage
- Induce emesis for patients with alkali ingestion
- Contact local poison control center at UP College of Medicine 524-1078, 524-5651 loc
2311
- East Ave Med Ctr 928-0611
- Consider possibility of suicide
- All female with chemical ingestion should undergo pregnancy test
B. Principles of Decontamination

∙ External Decontamination
- Wash skin with soap and water
- Remove cloths
- Keep warm, use blankets

Gastric Lavage
contraindications includes strong ingestion of strong acids, alkalis, petroleum and distillates.
- Airway must be protected with endotracheal tube unless awake, alert and has a gag reflex
- Position head on one side of he bed to prevent aspiration
- If the patient has severe DOB stat intubation
- Perform gastric lavage unless overdose with acid
- Lavage is useful within two hours of ingestion
Activated Charcoal
GASTRIC LAVAGE

∙ - Always consider giving charcoal after emesis or lavage until specifically contraindicated
- Multiple doses of charcoal in (+) metamphetamine, phenothiazines, digoxin, theophylline,
phenobarb, and organophosphates
- Activated charcoal is not effective for alkalis, cyanide, mineral acid and ferrous sulfate

Cathartics
- contraindicated with infants (risk for dehydration), intestinal obstruction, electrolyte imbalance
- sodium sulfate is contraindicated in HPN and heart failure
Forced Diuresis

∙ forced neutral diuresis may be helpful for isoniazid, bromide and ethanol intoxification
- make sure to monitor electrolytes
- forced alkaline diuresis may be useful for Phenobarbital, salicylates and lithium using sodium
bicarbonate.

C. Guidelines for Nurses

- when antidotes are ordered, it is meant to be given immediately or at least reasonably within the
hour in some cases. They are not given when it is the convenient dosing period for the nurses.
Lesson 3.1 Specific Substance Ingestion

∙ Acid Ingestion
- provide airway control, ventilation, circulatory support, and fluid resuscitation
- wash the oral cavity (controversial)
- emesis, lavage and charcoal are contraindicated
- secure serial CBC and cros-matching
- maintain NPO
Lesson 3.1 Specific Substance Ingestion

∙ Alkali Ingestion
- immediately rinse oral cavity
- administer oxygen and IVF
- secure serial CBC, CXR, and monitor electrolytes
- esophagoscopy and gastroscopy should be performed immediately if there is drooling, stridor
and painful swallowing
Lesson 3.1 Specific Substance Ingestion

∙ Amphetamine/ Metamphetamine Toxicity

- start charcoal and cathartics
- emesis has no role
- WOF for seizure, psychosis, agitation, hypertensive crisis, arrhythmias
- Secure ABG, CBC with PC, PT, PTT, RBS, BUN, Crea, Na, K, UA
- Diazepam and Phenytoin for seizure
- Beta-blockers, Lidocaine for dysrythmias
Anticoagulant Overdose

∙ Secure lab results such as CBC with PC, PT, PTT and Creatinine

- For Heparin: Give protamine sulfate at 1mg iv for every 50-100 units of heparin infused in the
preceeding 2 hours, dilute in 25-50ml fluid over 10 minutes

- For Warfarin: perform gastric lavage and give activated charcoal if recently ingested; give vitamin k
5-10 mg every 8-12 hours; give FFP 2-6units for severe bleeding
∙ Diazepam Overdose
- Place NGT and do gastric lavage
- Protect airway
- Instill activated charcoal, followed by repeated doses of 20-25 gm via NGT
- Secure RBS, ABG, ECG and CXR
- Watched out for hypotension, CNS and respiratory depression and withdrawal syndrome such
as agitation, seizure, restlessness and insomnia.
∙ Digitalis Overdose
- considered NGT insertion and gastric lavage
- secure digitalis assay, CBC, Ca, K, Mg, CXR and ECG/ cardiac monitor
- the treatment goal would be to correct hypokalemia. Hypomagnesemia or hypocalecemia.
- The doctor may prescribe charcoal and cathartics
- Watch out for hypotension; fluid challenge my be instituted
- For arrythmias, lidocaine may be given
∙ Ethanol Toxicity
- maintain adequate airway, ventilation, circulation and administer oxygen
- Thiamine is useful to protect/ prevent liver damage
- Phynetoin my be given in cases of seizure, but make sure to give it SIVP and hook the patient to
the cardiac monitor
∙ Narcotic Overdose
- maintain airway, ventilation and circulation
- may start on Naloxone 2mg every 5 minutes , max 10mg IV, IM SQ
- Activated charcoal if (+) for bowel sounds and cathartics
- Watch out for signs of pneumonia, infections and rhabdomyolysis
- Watch out for complications such as seizure, pulmonary edema and hypotension
∙ Hydrocarbon/ Kerosene Ingestion
- Respiratory support
- Treatment is not required in the absence of symptoms
- Promote gastric emptying
- Remove contaminated clothing and wash affected skin with soap and water.
- Provide supplemental oxygen
- secure CBC, ABG abd CXR
Isoniazid Overdose
∙ Hydrocarbon/ Kerosene Ingestion
- place an NGT and do gastric lavage is clean
- watch out for seizure, lactic acidosis may give sodium bicarbonate
- consider mannitol administration for forced diuresis
- secure CBC, RBS, K, ABG
∙ Narcotic Overdose
- maintain airway, ventilation and circulation
- may give naloxone 2.0mg q 5 minutes initially max of 10mg IV, IM SQ
- start activated charcoal if (+) with BM and cathartics
- watched out for complications, PNA, hypotension, and seizures is (+) norpethidine
∙ Insecticides/ Pesticides
Therapeutics
1. Decontamination
- make he patient rinse with alkaline or baking soda (10gm in 100cc)
- change cloths and wash the patient with gloves
- insert NGT and do gastric lavage wih activate charcoal
2. Activated charcoal
3. Antidote
4. In cases of seizure; consider Phenytoin
5. wof for hypoglycemia
6. Give mannitol if with good urine output
- secure CBC, RBS, ABG, SGOT and SGPT
∙ Paracetamol Overdose
- Insert NGT
- Activate charcoal about 30-100mg and then remove via NGT suction prior to acetylcysteine
- Sodium Sulfate to induce vomiting
- Antidote: N-acetylcysteine (NAC) . the initial administration would be 150mg/kg body weight
infused in 200ml 5% dextrose over 15 minutes followed by IV infusion of 50mg/kg in 500ml of 5%
dextrose water
- NAC is very effective in preventing paracetamol-induced hepatotoxicity when administered;
when administered with in 8 hours from the time of ingestion, the better. But beyond 8 hours, the
protective effect diminishes progressively as the treatment interval increases
∙ Salicylate Poisoning
Diagnostics:
- CBC, K, RBS, ABG and UA
- PT, PTT, SGOT, SGPT and alk Posh with 48 hours post ingestion

∙ Therapeutics:
- Stabilize respiratory and cardiac functions
- Avoid diluting the gastric contents since this may incease gastric absorption
- Consider NGT insertion
- Give activated charcoal 1gm/ kg body weight every 6 hours
Salicylate Poisoning

Diagnostics:
- CBC, K, RBS, ABG and UA
- PT, PTT, SGOT, SGPT and alk Posh with 48 hours post ingestion
Therapeutics:
- Stabilize respiratory and cardiac functions
- Avoid diluting the gastric contents since this may incease gastric absorption
- Consider NGT insertion
- Give activated charcoal 1gm/ kg body weight every 6 hours

- Sodium sulfate 15-30 gm in 100cc H20 orally if tolerated or with NGT with every other doses of

activated charcoal to prevent charcoal constipation or fecal impaction

- To increase urine ph, consider sodium bicarbonate
- Glucose and KCl should be infused with other fluids
Treatment Plan
- if with dehydration and hypokalemia, manage with vigorous and with electrolyte replacement
- Cerebral edema can be best avoided using hypertonic rehydration solution
- Alkaline diuresis to maintain urinary ph at approx 8
- Monitor urine output
- Assess hydration status
- Watch closely for signs of fluid overload
- Hemodialysis is indicated for initial salicylate level of >160ml/dl or with profound acidosis of below 7;
or when there is renal failure, severe CNS dysfunction, pulmonary edema or deterioration despite
supportive therapy
Other Treatments
- Acidemia: NaHCO3
- Seizure: Diazepam
- Pulmo Edema: treat with high concentration of oxygen, furosemide and PEEP
- Cerebral Edema: treat with hyperventilation and osmotic diuresis with Mannitol
Other Treatments
- Acidemia: NaHCO3
- Seizure: Diazepam- Pulmo Edema: treat with high concentration of oxygen, furosemide and PEEP
- Cerebral Edema: treat with hyperventilation and osmotic diuresis with Mannitol