NCMB418 REVIEWER - FINALS

NEUROLOGIC EMERGENCIES - Primary injury

Discussed by: Prof. Melinda Gonzales o Is the initial damage to brain that results from the
Traumatic Brain Injury traumatic event.
- Is a physical injury to brain tissue that temporarily or o May include contusions, laceration, and torn blood
permanently impairs brain function. vessels from impact, acceleration/deceleration, or
- Leading cause of traumatic brain injury foreign object penetration.
o Falls – usually in young children and older adults - Secondary injury
o Blunt force trauma o May occur hours or even days after the initial and is
o Vehicular related to collisions due primarily to brain swelling or on going bleeding.
▪ 65% are the results of car accidents
▪ 15-20% are the results of motorcycle
accidents
▪ 10% are from bicycle accidents
o Assaults – including child abuse , violence (gunshot)
o Others – sports injuries like soccer, boxing, football
or any extreme sports

ASSESSMENT FOR TBI

- The Glasgow Coma Scale (GCS)
o Which is determined when the person first arrives
at the hospital
- Loss of consciousness CLASSIFICATION ACCORDING TO LOCATION
- Post traumatic amnesia - Focal brain injury
o Which is state of confusion and memory loss right o Due to contact and causing scalp injury, it might
after a TBI present as skull fracture, contusions, and
o PTA occurs because there is an impairment in intracranial hemorrhage.
attention and concentration - Diffuse brain injury
o Due to laceration and concussions resulting in
CLASSIFICATION SYSTEM FOR PTA
DIFFUSE AXONAL INJURY and brain swelling. The
Classification Duration of GCS PTA
tearing of nerve tissue disrupts the brains regular
unconsciousness
communication metabolic processes.
Mild <30 minutes 13-15 <24hrs
TYPES OF TBI
Moderate 30 mins – 24hrs 9-12 1-7 days
- Closed brain injury
Severe >24hrs 3-8 >7 days
o Without the skull being broken or penetrated and
SIGNS AND SYMPTOMS OF MILD TBI
the brain has not been exposed.
- Loss of consciousness for a few seconds to a few minutes
▪ Example: rapid movement of the head
- Memory or concentration problems
backward an forward causes the brain to
- Headaches
move inside the skull and slam against its
- Dizziness or loss of balance
inner bone.
- Nausea and vomiting
- Open brain injury
- Difficulty of sleeping
o Open or penetrating head injury. TBI can be focal or
CLASSIFICATION ACCORDING TO OCCURRENCE
diffuse meaning damage maybe isolated to one
1 – ASV
 NCMB418 REVIEWER - FINALS
specific area of the brain in focal injuries or
widespread in the case of diffuse injuries
Brain Injury
- The most important consideration in any head injury:
- Even seemingly minor injury can cause a significant brain
damage due to obstructed blood flow and decreased tissue
perfusion.
- The brain cannot store oxygen and glucose to any significant
degree.
- The cerebral cells need an uninterrupted blood supply to
obtain nutrients.
- Irreversible brain damage and cell death occur when the
blood supply is interrupted for even a few minutes.
Cerebral Contusion
- Is any injury that causes blood to collect under the skin:
- Is a more severe injury in which the brain is bruised, with
possible surface hemorrhage.
- The patient is unconscious for more than a few seconds or
minutes.
- Clinical signs and symptoms depend on the size of the
contusion and the amount of associated cerebral edema.
- Often there is involuntary evacuation of the bowels and the
bladder.
- The patient may lie motionless, v/s are subnormal, cool, pale
skin, and the picture is somewhat similar to shock.
Cerebral Concussion
- Are specific to injuries that affect the brain and may not
involve visible bruises or any apparent structural damage.
- This is temporary loss of neurologic function which involves
period of unconsciousness lasting from a few seconds to few
minutes.
- Concussion effects varied depending on its location and
severity.
- If the brain tissue in the frontal lobe is affected, the patient
may exhibit bizarre irrational behavior.
- Temporal lobe involvement can produce temporary amnesia
or disorientation.
Intracranial Hemorrhage/Hematomas
- Most serious brain injuries, most common cause of death and
clinical deterioration after TBI
- Hematoma (collection of blood) may be:
o Epidural (above the dura)
o Subdural (below the dura)
o Intracerebral (within the brain)
- Major symptoms are frequently delayed until hematoma is
large enough to cause distortion of the brain and increased
ICP.
Epidural Hematoma
- Extradural hematoma or hemorrhage
2 – ASV
- After head injury, blood may collect in the epidural
(extradural) space between the skull and the dura
- This can result from a skull fracture that causes a rupture or
laceration between the dura and the skull inferior to a thin
portion of temporal lobe.
- Hemorrhage from the artery causes rapid pressure on the
brain
Subdural Hematoma
- It is the collection of the blood between the dura and the
brain, a space normally occupied by a thin cushion fluid
- The most common cause of subdural hematoma is trauma,
but it may also occur from coagulopathies or rupture of an
aneurysm.
- A subdural hematoma may be acute, subacute, or chronic.
Depending on the size involved vessel and the amount of
bleeding present
MANAGEMENT OF BRAIN INJURIES
- Assessment and diagnosis of the extent of injury are
accomplished by the initial physical and neurologic
examinations.
- CT scan and MRI and positron emission tomography (PET
SCAN)
- Any individual with head injury is presumed to have a cervical
spine injury until proven otherwise.
- From the scene of the injury, the patient is transported on a
board with the head and neck maintained in alignment with
the axis of the body.
- A cervical collar should be applied and maintained until
cervical spine x-rays have been obtained.
TREATMENT OF INCREASED INTRACRANIAL PRESSURE
- As the damaged brain swells with edema, a rise in ICP occurs
and requires aggressive treatment.
- Initial management is based on the principle of preventing
secondary injury and maintaining adequate cerebral
oxygenation.
- ICP; if increased – elevate the head of the bed, and
maintaining normal blood volume
- Devices to monitor ICP or drain CSF can be inserted during
surgery or at the bedside using aseptic technique
- The patient is cared for in the ICU, where expert nursing care
and medical treatment are readily available.
- SURGICAL MANAGEMENT
o Surgery is required for evacuation of blood clots,
debridement, and elevation of depressed fractures
of the skull, and suture of severe scalp lacerations.
- Medications:
o Diuretics – given IV to reduce intracranial pressure
o Anti seizures – given during first week to avoid any
additional brain damage might caused by seizure.
 NCMB418 REVIEWER - FINALS

o Coma inducing drugs – sometimes use this drugs to • Cooling blanket

put people into temporary comas because • Cold saline solution
comatose brain needs less oxygen to function. ▪ Anti-pyretic medications
- Nursing management: • Analgesics to avoid increased ICP
o Maintain normal physiologic parameters • Kept at minimum requirement
o Prevent secondary brain injury to allow neurologic exam
o Provide emotional and psychological support to o Positioning and nutrition
patient and families ▪ Elevate heat of bed at 30 degree
o Maximize recovery and rehabilitative outcomes ▪ Head and neck in neutral alignment
o Assessment/Monitoring: ▪ Ensure ET tube ties, cervical collar do not
▪ History compress the neck
▪ Mechanism of injury ▪ Enteral feeding should be initiated within
▪ Pre existing medical condition 72hrs of injury or as prescribed
▪ Medications ▪ Full caloric requirement must be given
▪ GCS ▪ Maintain normal blood glucose level
▪ LOC o Prevention of complications
▪ Pupils size and reactivity ▪ Seizure precaution and management
▪ Muscle and tone posturing ▪ Minimize noxious stimuli
▪ Vital signs ▪ Prevent secondary infections
• BP – target SBP > 100mmHg • VAP/HAP
• CVP – (8-10cm H20) ▪ Prevent pressure injuries
• ICP target is < 20 mmHg • Good skin care and pressure
▪ Intake and output monitoring use of reduction
indwelling catheters ▪ DVT precautions
o Physical exam: • ROM exercise
▪ Reflexes o Rehabilitation and family support
▪ Signs of fractures ▪ Physical therapy
▪ Occupational therapy
▪ Speech therapy
o Respiratory care: ▪ Cognitive therapy
▪ Target ABG values: ▪ Social worker referral
• PaO2 > 60mmHg ▪ Religious and spiritual support
• PaCO2 35 – 45mmHg Acute Ischemic Stroke
• pH 7.35 – 7.45 Etiology, Risk Factors, and Pathophysiology
▪ Suctioning - Stroke
▪ Use of PEEP o Is the layman’s term for Cerebrovascular accident
▪ Aspirations of precautions o This refer to brain dysfunction that is caused by
o Hemodynamic/Fluid management brain cell damage and death as a result of
▪ Avoid hypotension inadequate blood flow to brain.
• Use of isotonic fluids o Is leading cause of death and disability world wide
• Use of vasoactive drugs - Ischemic stroke
▪ Osmotherapy o The blood clot formation are usually the cause of
• Use of mannitol blockage in the blood vessel to brain that causes
• Use of hypertonic saline ischemic stroke
▪ Monitoring of volume status o The affected part no longer receives enough blood
▪ Maintain electrolyte balance or oxygen
o Maintain normothermia and analgesia o Because the brain cannot strore oxygen or glucose
▪ Temperature – 35 to 37 degree Celsius and therefore requires a constant flow of blood to
• Sponge bath supply these nutrients

3 – ASV
 NCMB418 REVIEWER - FINALS

o That part of the brain without blood flow dies - The pathophysiology of stroke varies based on the
- The blood supply to the brain can be altered through several precipitating event
different processes - Thrombosis and embolism formation result in acute ischemic
o Embolism and thrombus formation accounts for stroke
approximately 85% of all ischemic stroke Thrombosis
o Hemorrhage - It is the most common cause of ischemic stroke and is usually
o Compression or spasm of the vessels due to atherosclerosis and the formation of plaque within an
- Edema artery
o Occur in the area of ischemic or infarcted tissue and - Thrombotic comes from thrombus which is blood clot
contributes to further neuronal cell death - A thrombus then forms at the site of the plaque and causes
o If ischemic is not reversed, neuronal cell death and brain tissue ischemia along the course of the affected vessel,
infarction of brain tissue occurs which results in infarction if not quickly reversed.
o The penumbra is an area of tissue that surrounds - Edema
the core ischemic area o Often develops, further increasing ischemia by
o The penumbra receives some blood flow from compressing areas surrounding the infarct
adjacent vessels but perfusion is marginal o Patients with a history of atherosclerosis or arteritis
o If cerebral blood flow is improved, the penumbra are at highest risk for thrombotic strokes
may recover o Thrombotic strokes tend to develop during periods
RISK FACTORS of sleep or inactivity or when blood flow is less brisk
- Hypertension - Embolism
- Cardiac disease o It refers to the occlusion of cerebral vessel, most
o Coronary artery disease often by a blood clots, infectious particles, fat, air or
o Heart failure tumor
o Atrial fibrillation o Often associated with heart disease that results in
o Endocarditis bacterial vegetations or blood clots that are easily
o Patent foramen ovale detached from the wall or valves of the heart and
o Myocardial infarction then travel to the brain, lodging in the cerebral
o Carotid artery disease vessel
- Diabetes o Chronic atrial filtration, valvular disease, prosthetic
- Increased age valves, cardiomyopathy, and atherosclerotic lesions
- Male gender of the proximal aorta are common cause of
- Prior stroke embolism
- Hypercoagulability o The fragmented substance easily lodges at the
o Cancer bifurcation of the middle cerebral artery, breaking
o Pregnancy apart and traveling further into the cerebral
o High RBCs vascular system
o Sickle cell o The onset of an embolic occlusion is rapid, with
- Family history symptoms that develop without warning signs
- Dyslipidemia CLINICAL PRESENTATIONS SYMPTOMS OF STROKE
- Race (African American) - Weakness in an extremity or on side of the body
- Smoking - Sensory changes
- Obesity - Difficulty speaking or understanding speech
- Physical inactivity - Facial droop
- Alcohol or illicit drugs - Headache
- Hormone therapy - Visual changes
Transient Ischemic Attack (TIA) - Clinical presentation of stroke varies based on the area of
- This is an important warning sign for stroke ischemia or infarction
- The patient develops stroke symptoms but may resolve DIAGNOSTIC TESTS
without tissue infarction - The goal of initial diagnostic testing in an acute stroke is to
rule out the intracranial hemorrhage (ICH)
4 – ASV
 NCMB418 REVIEWER - FINALS

- Evidence of ischemia may not appear or may be very subtle - Brain injury
on standard CT scanning until 12 to 24 hours after symptom o An injury to the skull or brain that is severe enough
onset to interfere with normal functioning
- Specialized MRI scan detect areas of ischemia before they are - Brain injury (closed – blunt)
apparent on CT o Occurs when the head accelerates then rapidly
- CT angiogram detects areas of vascular abnormalities decelerates or collides with another object and
MANAGEMENT OF ACUTE ISCHEMIC STROKE brain tissue is damaged, but there is no opening
- Stroke is a medical emergency and is treated with the same through the skull and dura
urgency as acute myocardial infarction - Brain injury (open)
- The goals of treatment are to restore circulation to the brain o Occurs when an object is penetrates the skull,
when possible, stop the ongoing ischemic process, and enters the brain, and damages the soft brain tissue
prevent secondary complications in its path (penetrating injury) or when blunt
MANAGEMENT PRINCIPLES INCLUDE THE FOLLOWING trauma to the head is so severe that it open the
- Evaluation of conditions scalp, skull, dura to expose the brain
o That mimic acute ischemic stroke - Concussion
o Hypoglycemia may cause stroke like symptoms and o A temporary loss of neurologic function with no
is easily detected by using a bedside monitor to apparent structural damage to the brain
check the blood glucose - Contusion
o Toxic or metabolic disorders o Bruising of the brain surface
o Migraines - Transient ischemic attack
o Seizures o Warning signs of stroke
o Mass lesions such as brain tumors or abscesses - Penumbra
o Psychological disorders o Is an area of tissue that surrounds the core of
- Fibrinolytic Therapy ischemic area
o Must be administered to restore perfusion to the - Thrombus
affected area o Is a formation of plaque within an artery
o IV administration of rtPA recombinant tissue - Embolus
plasminogen activator can be treated within 3 hours o Refers to the occlusion of cerebral vessel, most
of the onset symptoms often by a blood clot
o Recommended dose for rtPA is 0.9 mg/kg, with 10% SPINAL CORD INJURY
of the total remainder of the dose as an infusion - Occurs when a force is exerted on the vertebral column
over 1 hour resulting in damage to the spinal cord
o Vital signs and neurologic checks are done every 15 - Damage to any part of the spinal cord or nerves at the end of
minutes for the first 2 hours, then every 30 minutes the spinal canal often causes permanent changes in strength,
for 6 hours, and then hourly until 24 hours following sensation, and other body functions below the site of the
initial treatment. injury
- Endovascular treatment SCIs can be separated into two categories
- Blood pressure management - Primary injuries
- Management of increase intracranial pressure o Are the results of the initial insult or trauma and
- Glucose management are usually permanent
- Preventing and treating secondary complications - Secondary injuries
- Preventing recurrent stroke o Are usually the result of a contusion or tear injury,
TERMINOLOGIES in which the nerve fibers begin to swell and
- Increased ICP disintegrate
o The pressure inside the skull increase; it is a mdical
emergency when this occurs suddenly
- Autonomic dysreflexia
o A life threatening emergency in spinal cord injury
patients that causes a hypertensive emergency;
also called autonomic hyperreflexia
5 – ASV
 NCMB418 REVIEWER - FINALS

CAUSES OF SPINAL CORD INJURY

- Traumatic blow to the spine causing fractures, dislocation,
crushing, or compression of one or more of the vertebrae
- Penetrating gunshot or knife wound
- Diseases/conditions: arthritis, cancer, inflammation,
infections, or risk degeneration of the spine
o Falls in elderly
o Road traffic accidents
o Sports injuries
o Violent acts
o Osteoporosis
o Cancer

SEVERITY CLASSIFICATION
- Complete
o If all sensory and all motor functions are lost below
the spinal cord injury
- Incomplete
o If some motor or sensory functions below the
affected area are still present there are varying
degrees of incomplete injury

IMPORTANT
- For suspected back and neck injury, DO NOT move the injured
person (permanent paralysis and other serious complications
may result)
- Keep the person still

6 – ASV
 NCMB418 REVIEWER - FINALS

- Place heavy towels on both sides of the neck to prevent

moving
EMERGENCY SIGNS AND SYMPTOMS
- Extreme back pain or pressure in neck, head, or back
- Weakness, incoordination or paralysis in any part of the body
- Numbness, tingling or loss of sensations in hands, fingers,
feet or toes
- Loss of bladder or bowel control
- Difficulty with balance and walking
- Impaired breathing after injury
- An oddly positioned or twisted neck or back
SIGNS AND SYMPTOMS OF SCI
- Loss of movements in the limbs CLASSIFICATION OF SEIZURE
- Loss of control over bladder - Absence (petit mal)
- Weakness or paralysis o An absence seizure causes an individual to blank out
- Difficulty in walking or stare into space for a few seconds
- Reduced sexual function o Most common in children and typically don’t cause
- Numbness any long term problems
- Atonic
o Causes sudden loss of muscle strength
o Also called akinetic seizures drop attacks or drop
seizures
- Tonic-clonic
o Sustained rhythmical jerking
o During clonic seizure, jerking of the body or parts of
the body are the main symptoms
o They can begin in one area (focal motor) or affect
both sides of the brain (generalized clonic)
o Clonic seizure movements cannot be stopped by
SPINAL CORD INJURY: MANAGEMENT restraining the person
- Promote adequate breathing and airway clearance - Myoclonic
- Improve mobility and proper body alignment o Brief shock like jerks of a muscle or group of muscles
- Promote adaptation to sensory and perceptual alterations o They occur in a variety of epilepsy syndrome that
- Maintain skin integrity have different characteristics
- Maintain urinary elimination o During myoclonic seizures, the person is usually
- Improve bowel function awake and able to think clearly
- Provide comfort measures - Idiopathic (unclassified seizures)
- Monitor and manage complications o Epileptic seizures are defined as transient signs due
o Thrombophlebitis to abnormal excessive or synchronous neuronal
o Orthostatic hypotension activity in the brain and epilepsy refers to at least
o Spinal shock two unprovoked seizures more than 24 hours apart
o Autonomic dysreflexia o The term idiopathic means a disease is unknown
SEIZURE cause
- A sudden, abnormal, excessive discharge of electrical activity DIAGNOSTICS
within the brain that disrupts the brain’s usual system for - EEG (electroencephalography) it is definitive test to diagnose
nerve condition seizure activity
- SPECT scan of choice for a diagnostic evaluation of certain
types of CNS disorders
TREATMENT
- Medication therapy
7 – ASV
 NCMB418 REVIEWER - FINALS

o Hallmark of seizure management - Medications

- Surgery o Lorazepam (Ativan) – induces respiratory
o Respective procedures or palliative corpus depression
callosotomy o Flumazenil (romazicon) – decreases respiratory
- Seizures precautions depression
- Oxygen and suction equipment at bedside o Phenytoin – via central venous line
- Re orient client upon walking o Phenobarbital – luminal
PATIENT EDUCATION DOs
- Ease the person to the floor
- Turn the person gently onto one side. This will help the
person breathe
- Clear the area around the person of anything hard or sharp.
This can prevent injury
- Put something soft and flat like a folded jacket under his/her
head
- Remove eyeglasses
- Loosen ties or anything around the neck that may make it
hard to breathe
- Time the seizure
PATIENT EDUCATION DON’Ts
- Do not hold the person down or try to stop his/her
movements
- Do not put anything in the person’s mouth. This can injure
the teeth or jaw. A person having a seizure cannot swallow
his/her tongue
- Do not try to give mouth to mouth breaths like CPR. People
usually start breathing again on their own after seizure
- Do not offer the person a water or food until he or she is fully
alert
Status Epilepticus POST EVAL QUESTIONS (INCOMPLETE)
- Potential complication of all type of seizures - Injury without penetration through the skull
- This is a seizure that lasts longer than 5 minutes or more than o CLOSED OR INTRACRANIAL INJURY
1 seizure within 5 minutes period, without returning to - The loss of memory for events after trauma or disease onset
normal level of consciousness between episodes o POST TRAUMATIC AMNESIA
- Hence, this is medical emergency that may lead to - The classification of TBI that may occur hours or even days
permanent brain damage or death after the initial injury and is due to primarily brain swelling or
CAUSES ongoing bleeding
- Stroke o SECONDARY INJURY
- Low blood glucose levels - This are specific to injuries that affect the brain and may not
- Too much alcohol , withdrawal symptoms involve visible bruises or any apparent structural damage
DIAGNOSTIC o CONCUSSIONS
- EEG - What are the two types of head injuries?
- CT o OPEN AND CLOSED HEAD INJURY
- MRI - Direct penetration through the skull to the brain (gunshot
- LP wounds, knife, or sharp object penetration)
PRINCIPLE OF MANAGEMENT o CAUSE OF OPEN INJURY
- Goal: control seizure as quickly as possible, preventing
recurrence, maintaining patient safety, and identifying the
underlying cause

8 – ASV
 NCMB418 REVIEWER - FINALS

ASSESSMENT OF CRITICALLY ILL CLIENTS W/ SHOCK AND MODS 2. Relative hypovolemia – occurs when the fluid volume moves
Discussed by: Prof. Melinda Gonzales out from the vascular space into extravascular space due to
Shock vasodilation and an increase in vascular capacitance
- Can be defined as a condition in which a widespread o Also known as THIRD SPACING
perfusion to the cells are inadequate to deliver oxygen and o Example: increased cutaneous vasodilation from
nutrients to support the vital organs and cellular functions heat stress, hypoxia, intense physical exercise, or
- Common to all types of shock: systemic vasodilation from sepsis, burn injuries, and
o Hypoperfusion of tissue ascites.
o Hypermetabolism - Cardiogenic Shock
o Activation of the inflammatory o Is a kind of shock during which the heart does not
4 MAIN TYPES OF SHOCK adequately pump enough blood to the body’s
- Hypovolemic shock tissue.
o The most common type of shock o Which may result to decrease in the delivery of
o Caused by an inadequate circulating blood volume oxygen to the organs causing failure to its function
in the intravascular bed and eventually breakdown or cellular destruction
o Results in a decreased venous return, decrease and die.
preload to the heart leading to decreased cardiac o The most common cause of cardiogenic shock is
output. HEART ATTACK
o Causing hypotension that may results to inadequate
tissue perfusion, causing cellular hypoxia, organ
failure, and death.

- Obstructive shock
o Is a condition that prevents blood and oxygen from
getting into the organs due to the obstruction in
the great vessels or major blood vessels connected
to the heart. Examples include the following:
▪ A large blood clot in your pulmonary
2 Categories of Hypovolemic Shock
artery
1. Absolute hypovolemia – occurs as a results of fluid loss from
▪ Fluid around the heart
the intravascular space
▪ High pressures in the chest because of
o Example: hemorrhage, GI loss such as from
lung injury such as tension pneumothorax
vomiting, diarrhea, DI, diuresis, or fistula drainage
▪ Collapse of the lungs
▪ Hypovolemia – Absolute & relative
- Distributive shock
o Also called circulatory shock is a medical emergency
where in the body can’t get enough blood to the
heart, brain, and kidneys.
o This happens because the blood vessels are
extremely dilated (flaccids or relaxed) which brings
down the blood pressure and unable to deliver
enough blood to the organs
o Three types of DS:
▪ Septic shock
▪ Anaphylactic shock
▪ Neurogenic shock
1 – ASV
 NCMB418 REVIEWER - FINALS
ANAPHYLACTIC SHOCK
- Rare but severe allergic reaction that can be deadly if not
treated right away
- Its most often caused by an allergy to food, insect bites, or
certain medications
- A shot of epinephrine is needed immediately
NEUROGENIC SHOCK
- It is a combination of both primary and secondary injuries
that lead to loss of sympathetic tone and thus unopposed
parasympathetic response driven by the vagus nerve
- Consequently, patients suffers from instability in blood
pressure, heart rate, and temperature regulation
SEPTIC SHOCK
- It is an inflammatory response
- The septic process is initiated by the launch of immune
mediators that are part of the inflammatory reaction
- Eventually the immune system is overwhelmed, and the
process actually harms the body
- Systemic Inflammatory Response Syndrome (SIRS) refers to a
hosts response to a variety of clinical insults, both infectious
and non infectious and is part of the acute sepsis process
- The patient in septic shock can exhibit skin lesions that are
the most often located on the lower extremities
- These lesions can be associated with the development of
disseminated intravascular coagulation (DIC) which is
another complication of septic shock; the lesions can also be
associated with causative bacteria
- Hyperglycemia can be first indicators of sepsis in the pt with
diabetes
- Is a distributive shock characterized by tachycardia,
hyperthermia, or hypothermia and hypotension caused by
decreased SVR.
- A decline in SVR is one of the first indications of shock
- The blood volume is adequate but misplaced
- Fluid is lost in the interstitial space
- Renal involvement during sepsis can vary from a minor
proteinuria to acute tubular necrosis (ATN) in septic shock
2 – ASV
Compensatory Mechanism
- Is a self protective process to maintain the whole physiologic
function of the body
- Include baroreceptors reflex which causes an increased heart
rate and vasomotor
- The SNS is stimulated which results in the release of
epinephrine and norepinephrine which causes systemic
vasoconstriction
- This release causes blood to be shunted to the vital organs
- Compose of a number of physiologic events:
o Neural
▪ Pressoreceptors or baroreceptors – they
sense the BP and relay the information to
the brain so that the normal BP can be
maintained
o Hormonal
▪ Catecholamines
▪ ACTH – regulates the BP, blood sugar,
immune system in response to stress
▪ RAAS – regulates the blood volume,
electrolytes balance and systemic
vascular resistance
- Kidney effects:
o Decrease renal blood flow and decrease in
glomerular filtration rate causing a decrease in
urine output
o Initiation of the RAAS renin angiotensin (I and II)
and aldosterone system which may results in
vasoconstriction and sodium and water retention
o The retention of sodium and water is the body’s
attempt to compensate for the decrease in blood
flow by increasing the venous return to the heart
and possibly increasing patient’s BP
o Continued decrease in blood flow to the vital
organs ultimately causes tissue ischemia and
acidosis from anaerobic metabolism
o Anaerobic metabolism leads to depletion of
cellular ATP and the failure of the sodium
potassium pump, which results in further
 NCMB418 REVIEWER - FINALS

hemodynamic compromise and an inability to

maintain BP
- Renal effects and manifestations:
o Decrease MAP due to the GFR cannot maintained
o ARF may develop
o Increased BUN, creatinine level
o Loss of renal hormonal regulation for BP
o UO decreases to < 0.5 ml/kg/hr
- Cardiac effects:
o Increased in cardiac contractions GENERAL AND MANAGEMENT STRATEGIES IN SHOCK
o Increased in heart rate > 150 bpm - Identify the cause of shock
o Increased in cardiac output - Fluid replacement
o Dysrhythmias and ischemia - Medication therapy
o Chest pain or myocardial infarction - Maintain adequate tissue perfusion
o Increased in CK-MB and troponin - Fluid resuscitation:
o Increased in BNP – B type natriuretic peptide o Administer in all types of shock
- Respiratory effects: o Improve cardiac, tissue oxygenation
o Tachypnea – one of the first signs that reflex o Crystalloids – an electrolyte solutions that move
reduced blood flow and oxygen transport freely between intravascular and interstitial spaces
o Crackles are heard over the lungs fields o Colloids – large molecules IV solutions
o Decreased in pulmonary blood flow causes arterial o Blood components – PRBC, FFP, PLATELETS
oxygen level to decrease in carbon dioxide - Medication therapy:
increase o Inotropic drugs – dobutamine (dobutrex),
o Alveolar collapse dopamine, epinephrine, and milrinone
o Pulmonary edema o Vasodilators – nitroglycerine, nitroprusside
o The patient may progress into acute respiratory ▪ Desired action in shock:
distress syndrome (ARDS) • Improve contractility, increase
- Neurologic effects: stroke volume, increase cardiac
o Mental status output
o Subtle changes in behavior or agitation • Reduce preload and afterload.
o Confusion Reduce oxygen demand in the
o Lethargy heart
- Peripheral effects: o Vasopressors agents – norepinephrine (levophed),
o Skin causing cold clammy skin dopamine, phenylephrine, vasopressin
- Hepatic effects: ▪ Desired action in shock:
o Impaired metabolism and phagocytic functions • Increase blood pressure by
o Increased ammonia and lactic acid vasoconstriction
o Gluconeogenesis and glycogenesis are impaired - Monitor tissue perfusion:
o Infection o Monitor level of consciousness, vital signs, urine
o Liver enzyme are increased output, skin and laboratories (base deficits and
o Jaundice lactic acid levels)
- Gastrointestinal effects and manifestations: o Report vital signs
o Causing hypoactive bowel movement o Pulse pressure 30-40 mmHg
o Stress ulcers in stomach – risk for bleeding - Nutritional support
o Bloody diarrhea o More than 3000 calories
o Bacterial toxins translocation o Early in shock: depletion of glycogen stores about 8-
10 hrs
o Parenteral nutrition
o Enteral nutrition

3 – ASV
 NCMB418 REVIEWER - FINALS

o Glutamine: fuel source of lymphocytes and

macrophages
o Antacids, H2 blocker (famotidine, ranitidine) >stress
ulcers
MANAGING HYPOVOLEMIC SHOCK
- Treatment of the underlying cause:
o Fluid resuscitation or blood replacement
SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (SIRS)
o Restore intravascular volume
- Is the body’s response to an infectious or non infectious insult
o Administer fluids that will remain in the
affecting the whole body
intravascular compartment to avoid fluid shifts
from intravascular to intracellular
- Blood transfusion:
o Basis of BT
o Lack of response to fluid resuscitation
o Volume of blood lost
o Need for hemoglobin
o Correct coagulopathy
MULTIORGAN DYSFUNCTION SYNDROME
- Is the progressive dysfunction of more than one organ in
patients who are critically ill or injured
- It is the leading cause of death in ICU
- Causes including, but not limited to:
o Extensive burns
o Trauma
o Cardiorespiratory failure
o Multiple blood transfusion
o Systemic infection – most common
PATIENT’S AT GREATEST RISK FOR DEVELOPING MODS
- Patients with systemic infection particularly a gram-negative
sepsis
- Extensive burns
- End-organ failure
- Pancreatitis
- Hypovolemia
- Cardiogenic shock
- HIV
- Aspiration
- Multiple blood transfusions
- Trauma
NURSING INTERVENTIONS
- Prevention and treatment:
o Aggressive infection control and strategies
o Initiate broad spectrum antibiotics therapy
o Early aggressive surgery to remove necrotic tissue
o Aggressive pulmonary management
o Strict aseptic techniques
- Prognosis
o Mortality is high with MODS
o Potential for recovery depends on:
▪ The severity of illness or injury

4 – ASV
 NCMB418 REVIEWER - FINALS

▪ Underlying organ reserve

▪ The speed of instituting effective
treatment
▪ Adequacy of treatment
▪ The number and severity of subsequent
injuries and complications
o If the treatment is unsuccessful, death usually
occurs between 21 and 28 days after the initial
insult
TERMINOLOGIES
- Distributive shock
o this is also called circulatory shock, the primary
cause of decreasing BP is massive vasodilation and
pooing of blood into the peripheral vessels.
Anaphylactic, Septic and Neurogenic shock are
distributive shock
- MODS
o Multiorgan dysfunction syndrome
- Shock
o inadequate tissue perfusion
- Systemic Inflammatory Response Syndrome (SIRS)
o the body’s response to an infectious or
noninfectious insult affecting the whole body

5 – ASV
 NCMB418 REVIEWER - FINALS

NURSING CARE OF CLIENTS IN EMERGENCY SITUATION – 1 - The fingers of the other hand are placed under the bony part
WEEK 16: AIRWAY, BREATHING, CIRCULATION (ABC) of the lower jaw near the chin and lifted up.
AIRWAY OBSTRUCTION - The chin and the teeth are brought forward almost to
- Is a life-threatening medical emergency. occlusion to support the jaw.
- The airway may be partially or completely occluded. JAW-THRUST MANEUVER
- If the airway is completely obstructed, permanent brain - After one hand is placed on each side of the patient’s jaw, the
damage or death will angles of the victim’s lower jaw are grasped and lifted,
- Occur within 3 to 5 minutes secondary to hypoxia. displacing the mandible forward.
- Partial obstruction of the airway can lead to progressive - This is a safe approach to opening the airway of a victim with
hypoxia, hypercarbia, and respiratory and cardiac arrest. suspected neck injury because it can be accomplished
PATHOPHYSIOLOGY UPPER AIRWAY OBSTRUCTION without extending the neck.
- Aspiration of foreign bodies PULMONARY INJURY
- Anaphylaxis, viral or bacterial infection, trauma, and - Damage to the lung tissue due to inhalation of the chemical
inhalation or chemical burns. by- products of combustion causes significant damage to the
- In adults, aspiration of a bolus of meat is the most common lower airways, resulting in atelectasis, reduced ciliary
cause of airway obstruction. clearance, and loss of surfactant.
- In children, small toys, buttons, coins, and other objects are - Intensive care treatment is required and is mainly supportive,
commonly aspirated in addition to food. aimed at preventing hypoxia, infection, and atelectasis.
CLINICAL MANIFESTATIONS ANAPHYLAXIS
- Choking - Is an acute systemic hypersensitivity reaction that occurs
- Apprehensive appearance within seconds or minutes after exposure to certain foreign
- Inspiratory and expiratory stridor substances, such as;
- Labored breathing o Medications (eg, penicillin, iodinated contrast
- Use of accessory muscles (suprasternal and intercostal material)
retraction) o Agents, such as insect stings (eg, bee, wasp, yellow
- Flaring nostrils jacket, hornet)
- Increasing anxiety, restlessness, and confusion. o Foods (eg, eggs, peanuts).
- Cyanosis o Repeated administration of parenteral or oral
- Loss of consciousness develop as hypoxia worsens. therapeutic agents (eg, repeated exposures to
ASSESSMENT AND DIAGNOSTIC FINDINGS penicillin)
- Assessment - asking the person whether he or she is choking - The antibody immunoglobulin E (ige) is responsible for most
and requires help. of the immediate type of human allergic responses.
- If the person is unconscious - inspection of the oropharynx - The individual becomes sensitive to a particular antigen after
may reveal the offending object. production of ige to that antigen.
- X-rays, Laryngoscopy, Bronchoscopy also may be performed. - A second exposure to the same antigen results in a more
MANAGEMENT severe and more rapid response.
1. Repositioning the patient’s head to prevent the tongue from CLINICAL MANIFESTATIONS
obstructing the pharynx.
2. Alternatively, other maneuvers, such as abdominal thrusts
3. The head-tilt–chin-lift maneuver the jaw-thrust maneuver
4. Insertion of specialized equipment may be needed to open
the airway
5. Remove a foreign body and maintain the airway.
6. In all maneuvers, the cervical spine, must be protected from
injury.
HEAD-TILT–CHIN-LIFT MANEUVER
- The patient is placed supine on a firm, flat surface.
- One hand is placed on the victim’s forehead, and firm
backward pressure is applied with the palm to tilt the head
back.
1 – ASV
 NCMB418 REVIEWER - FINALS

MANAGEMENT WITH AN ANAPHYLACTIC REACTION

1. Establishing a patent airway and ventilation is essential.
2. Epinephrine - intramuscular
3. Antihistamine to block further histamine binding at target
cells
4. Aminophylline by slow intravenous infusion for severe - Ventricular fibrillation
bronchospasm and wheezing refractory o Is caused by direct damage or irritation of the heart.
5. Early endotracheal tube intubation is essential to avoid loss o This may be because of:
of the airway, and oropharyngeal suction may be necessary ▪ Myocardial ischemia or infarction
to remove excessive secretions. ▪ Poisoning
6. Resuscitative measures are used, especially for patients with ▪ Gross electrolyte imbalance
stridor and progressive pulmonary edema. ▪ Hypothermia and near drowning
7. Cricothyroidotomy is used to provide an airway if glottal ▪ Electrocution
edema occurs. ▪ Penetrating trauma
8. Albuterol inhalers or humidified treatments to decrease ▪ Iatrogenic causes (e.g. Cardioversion and
bronchoconstriction; crystalloids, colloids, or vasopressors to cardiac catheterization)
treat prolonged hypotension.
9. Isoproterenol or dopamine for reduced cardiac output;
oxygen to enhance tissue perfusion.
10. Intravenous benzodiazepines for control of seizures, and
corticosteroids for prolonged reaction with persistent
- Pulseless electrical activity
hypotension or bronchospasm.
CARDIAC ARREST o Is that state when the pump (the myocardium) is
unable to function despite a relatively normal
- The heart stops functioning in three main ways:
electrical stimulus (the ECG signal).
1. Failure of the oxygen supply causes asystole (or extreme
bradycardia). There is no electrical activity and no o This can be because of primary damage to the
cardiac muscle including:
pumping.
▪ Extensive myocardial infarction
2. Failure of electrical control causes ventricular fibrillation
(VF) or pulseless ventricular tachycardia (VT). There is no ▪ Ruptured cardiac aneurysm
▪ Papillary muscle rupture
effective electrical activity and no effective pumping.
▪ Tension pneumothorax
3. Failure of the pump mechanism causes pulseless
electrical activity (PEA) (formerly known as ▪ Cardiac tamponade
▪ Pulmonary embolism (pe)
electromechanical dissociation or EMD). There is
electrical activity but no pumping.
CAUSES OF THE THREE ARREST RHYTHMS
- Asystole
o Similar to any other pump, the heart slows and
stops when deprived of its power supply.
o This results from:
▪ Hypoxia CAUSES OF CARDIAC ARREST
▪ A condition leading to hypoxia (e.g. - The commonest cause of adult cardiac arrest is thrombo-
Hypovolemia) emboli (AMI/ PE)
▪ Tachycardia during hypoxia is the result of - Tension pneumothorax presenting in V-Fib
the influence of the autonomic nervous - The ‘four Hs and four Ts’ should be considered in all cardiac
system. arrests.
▪ The hypoxic heart contracts more slowly THE FOUR H’S AND FOUR T’S IN CARDIAC ARREST
(terminal bradycardia) and then arrests in - Hypoxia
asystole. - Hypovolemia
- Hyperkalemia or hypokalemia
- Hypothermia
2 – ASV
 NCMB418 REVIEWER - FINALS

- Tension pneumothorax o Two large-bore intravenous canulae are inserted to

- Tamponade provide a means for fluid and blood replacement
- Toxins o Blood samples are obtained for analysis, typing, and
- Thrombosis (coronary or pulmonary) cross-matching.
TRAUMA - Replacement fluids may include:
- Cardiac arrest 2° to blunt trauma has a poor outcome. o Isotonic electrolyte solutions (lactated Ringer’s,
- Use the normal ABCDE approach with aggressive and prompt normal saline)
treatment of injuries. o Colloid
- These may encompass: o Blood component therapy = packed red blood cells
o Intubation are infused when there is massive blood loss.
o bilateral needle decompression - Control of External Hemorrhage
o bilateral chest drain placement - Pressure points to control bleeding
o fluid bolus (± O negative blood), HEAD INJURY
o with compressions supported by adrenaline. - Skull fractures
- Thoracotomy should be considered where there is a history o The brain is well protected by the skull, CSF, and
of penetrating trauma meninges, and it takes a significant trauma to cause
ASTHMA a skull fracture and cerebral contusion.
- Cardiac arrest because of a severe asthma attack is often a o Skull fractures are usually classified as linear,
terminal event. depressed, or base of skull.
- It is linked to bronchospasm, mucus plugging, tension 1. A linear skull fracture is a simple fracture that
pneumothorax, and arrhythmias. may be seen in the occipital, temporal–
- The ABCDE/ early defibrillation approach should be followed, parietal, or midline areas of the skull.
using the four Hs and four Ts to guide management. ▪ These fractures are caused by a
- Early intubation assists with oxygenation. significant trauma to the skull and
HEMORRHAGE may cause an underlying hematoma.
- Stopping bleeding is essential to the care and survival of 2. A depressed skull fracture is more complicated
patients in an emergency or disaster situation. and may be associated with a scalp laceration.
- Hemorrhage that results in the reduction of circulating blood ▪ The depressed segment may be
volume is a primary cause of shock. evident on examination, and
- Minor bleeding, which is usually venous, generally stops neurosurgical intervention may be
spontaneously unless the patient has a bleeding disorder or required to elevate the segment to
has been taking anticoagulants. prevent further damage to neural
- Assessed for signs and symptoms of shock: tissue.
o Cool, moist skin (resulting from poor peripheral 3. A fracture of the basilar bone of the skull
perfusion) occurs in the floor of the skull.
o Falling blood pressure ▪ Fractures in this bone can cause tears
o Increasing heart rate in the sac compartments that hold
o Delayed capillary refill the brain, resulting in leakage of CSF
o Decreasing urine volume (a late sign). and thus exposing the cranial vault to
- The goals of emergency management: the outside environment and
o To control the bleeding potential infection.
o Maintain an adequately circulating blood volume ▪ Prophylactic antibiotics may be
for tissue oxygenation considered.
o Prevent shock. SIGNS OF A BASILAR SKULL FRACTURE MAY INCLUDE:
MANAGEMENT OF HEMORRHAGE - Eye bruising (‘raccoon eyes’);
- Fluid Replacement - fluid replacement is imperative to - Bruising around the mastoid process (battle’s sign);
maintain circulation - Blood in the ear canals or behind the tympanic membrane
o A loss of circulating blood results in a fluid volume (tm).
deficit and decreased cardiac output. o Patients may complain of:
▪ Visual disturbance
3 – ASV
 NCMB418 REVIEWER - FINALS

▪ Loss of hearing - Around 80% of strokes are due to occlusion of an artery that
▪ Altered facial sensation carries blood to the brain.
▪ Nasal drip caused by leaking CSF - Stroke is a medical emergency, and there should be no time
▪ Facial muscle weakness delays in assessing these patients to specific treatments.
▪ Balance problems - Stroke may be caused by
▪ Loss of sense of smell o Cerebral thrombosis, as a result of atherosclerosis
COMPLICATIONS OF HEAD INJURY or hypertension
- Intracranial hematoma o Cerebral embolism, as a result of atrial fibrillation
o Deteriorating level of consciousness after a head (af), mi, or valve disease.
injury may be due to an intracranial hematoma. o Intracerebral hemorrhage, when a blood vessel
o Accurate observation and monitoring are essential ruptures within the brain
for identifying and the need for surgical o Subarachnoid hemorrhage, when a blood vessel on
intervention may be lifesaving. the surface of the brain bleeds into the
o Patients on anticoagulants or those with bleeding subarachnoid space
disorders are at high risk of developing an o Carotid artery dissection.
intracranial hematoma after a head injury. RISK FACTORS OF STROKE
- Extradural hematoma - Hypertension
o Results from rupture of one of the meningeal - Age >70y
arteries that run between the dura and the skull. - Trauma
o The most common cause is the linear fracture of the - Hyper or hypo coagulable state
temporo– parietal bone, with associated injury to - Smoking
the middle meningeal artery. - AF or MI
o The patient may be unconscious - Diabetes
o Signs and symptoms will be due to rising icp. - Oral contraceptives
o The need for accurate neurological assessment and - Ethnicity
consistent monitoring. SIGNS/SYMPTOMS
- Subdural hematoma - Varying levels of consciousness
o It is a blood clot that forms beneath the dura mater. - Motor weakness (opposite side to cerebrovascular accident
o This type of venous bleed is usually caused by - Incontinence
trauma such as a fall, an assault, or the - Speech deficits
acceleration– deceleration patterns associated with - Facial drooping and/ or loss of tongue control
a road traffic accident. - CN involvement (same side as CVA)
o Two main types of subdural hematoma: IMMEDIATE MANAGEMENT OF NON-HEMORRHAGIC STROKE
▪ Acute – develops within 24h of the initial - For suspected stroke, should be assessed for thrombolysis
trauma and is associated with severe brain treatment.
insult; - If clinically indicated, there must be no delay in administering
▪ Chronic – develops over a period of the treatment
several days after the initial trauma and - admit the patient directly to a specialist acute stroke unit.
often occurs in the elderly or in alcoholics. - Brain imaging should ideally be performed immediately.
- Diffuse axonal injury IMMEDIATE MANAGEMENT OF INTRACEREBRAL HEMORRHAGE
o This is a severe brain injury, often caused by rapid - These patients should be closely monitored for deterioration
deceleration, and it is the commonest cause of in consciousness by specialists in a neurosurgical or stroke
coma and subsequent disability. care unit.
o Patients with diffuse axonal injury are often in a IMMEDIATE NURSING INTERVENTIONS
deep coma immediately after injury, despite an - Assess and resuscitate the patient, as needed.
initially normal ICP and normal CT scan. - Position the patient to avoid aspiration, and establish IV
STROKE access.
- Stroke occurs when the blood supply to part of your brain is - Collect blood samples, and ensure that these are sent to the
interrupted or reduced, preventing brain tissue from getting laboratory.
oxygen and nutrients.
4 – ASV
 NCMB418 REVIEWER - FINALS

- Record CBG levels, and correct them if blood glucose

concentration
- Record an ECG, and request a chest X- ray (CXR).
- An NG tube may be indicated, but a urinary catheter should
not be routinely sited.
- Provide reassurance to the patient throughout any
procedure.
- The outstretched palm and fingers of the client
- Ensure personal hygiene and pressure area care
approximates to 1% of the body surface area.
- Keep the patient’s mouth clean and moist
- If the burned area is small, assess how many times your
BURNS
hand covers the area.
- Is an injury to the skin or other organic tissue primarily caused
by heat or due to radiation, radioactivity, electricity, friction
or contact with chemicals.
- Different types of BURN:
1. Thermal Burn – due to external heat sources that raise
the temperature of the skin and tissues.
2. Radiation Burn – caused by prolonged exposure to
ultraviolet rays of the sun
3. Chemical Burns – tissue damage caused by strong acids,
drain cleaners, paint thinner, gasoline and other FLUID RESUSCITATION: PARKLAND FORMULA
substances. - The Parkland formula, also known as Baxter formula, is a
4. Electrical Burns – happen when an electric current can burn formula developed by Charles R. Baxter
damaged the skin, tissue and major organ. - It is used to estimate the amount of replacement
5. Friction Burns – occurs when the skin is scraped off by fluid required for the first 24 hours in a burn patient so as to
contact with some hard object. ensure the patient is hemodynamically stable.
Quick Assessment of TBSA and Fluid Replacement - This is the most commonly used fluid resuscitation formula
THE RULE OF NINES - Easy to use leading to fewer respiratory problems; although
- Commonly used to estimate the burned surface area in adults there may be pronounced general edema in the first stages
- The body is divided into anatomical regions that represent of its use as large volumes of fluids are required.
9% (or multiples of 9%) of the total body surface.

5 – ASV
 NCMB418 REVIEWER - FINALS

NURSING CARE OF CLIENTS IN EMERGENCY SITUATION – 2

TRIAGE AND SEVERITY INDICES
TRIAGE
- Derived from Old French word “trier” which means “to sort”
- The process of determining the priority of patients’
treatments based on the severity of their condition.
- Sorting injured people into groups are based on their need
for an immediate medical treatment.
- NOTE: Before performing a triage
o Evaluate every situation before acting
o perform quick incident scene survey
o Determine scene hazards
o Use appropriate PPE
o Remain in appropriate zone
- Casualty – a person severely affected by an event or
situation, victim
o Multiple – number of victims is < 100
o Mass – number of victims is > 100 - MCI (Mass
Causality Incident) is an event that exceeds the
health care capabilities of the response
o Direct Victim – an individual who is immediately
affected by the event
o Indirect Victim – may be a family member or friend TRIAGE TAGGING
of the victim or a first responder - Green = minor – minimal “walking wounded”
o Displaced – those who have to evacuate their - Black = expectant (deceased)
home, school or business as a result of the disaster - Red = immediate – client needs immediate treatment within
o Refugees – a group of people who have fled their the hour but has a chance of survival
home or even their country as a result of famine, - Yellow = delayed – client not in immediate danger; treatment
drought, natural disaster, war or civil unrest may be delayed for an hour
DISASTER TRIAGE METHODS
1. M.A.S.S.
- Move, Assess, Sort, Send
- moving, evaluating, classifying and transferring
- Starts the process by clearing the ‘walking wounded’
using verbal instructions
- has four tags: red, yellow, green and black
2. S.A.L.T.
- Sort, Assess, Life-threatening interventions, Treat and
Transport
3. S.T.A.R.T.
EMERGENCY SEVERITY RATING SYSTEMS
- Simple Triage and Rapid Treatment (Jump START for
- Emergency department triage has several functions:
Pediatrics)
o Identification of patients who should not wait to be
- Rapid approach to triaging large numbers of causalities
seen
- Fast, easy to use and to remember
o Prioritization of incoming patients
- Allows the most good for the most patients with the
o Determining the patient’s illness/injury severity or
least amount of resources
acuity
- RPM = 30-2-Can Do
o Assess the degree to which the patient’s condition
is life- or limb-threatening and whether immediate
treatment is needed to alleviate symptoms

1 – ASV
 NCMB418 REVIEWER - FINALS

o Means of scoring an individual’s severity of ▪ Mild headache

condition ▪ Cold symptoms
▪ Minor laceration
▪ Sprain
▪ Strains
- NO CATEGORY or BLACK CATEGORY
o Includes dead or even catastrophically injured
patients who have a minimal chance for survival
despite optimal medical care.
EMERGENCY SEVERITY INDEX (ESI)
❖ A – intubated, pulseless, apneic, unresponsive = unstable
❖ B – high risk situation (confused, lethargic, or disoriented; in
EMERGENCY DEPARTMENT TRIAGE SYSTEM (THREE-TIER severe pain or distress) = threatened = stable in less than 60
SYSTEM) minutes
- EMERGENT (RED) ❖ C – number of resources needed = could be delayed
o Priority 1 ❖ D – danger zone = reclassify based on vital signs
o Injuries are life threatening
o Needs immediate attention and continuous
evaluation
▪ Severe head injury or comatose state
▪ Active seizures
▪ Sustain chemical splashes to the eye
▪ Severe respiratory distress or cardiac
arrest
▪ Chest pain with acute dyspnea or cyanosis
▪ Trauma
▪ Severe chest or abdominal wound
▪ Limb amputation
▪ Severe shock
▪ Excessively high temperature (40.6 °C)
- URGENT (YELLOW)
o Priority 2
o Injuries have complications that are not life
threatening
o Needs to be treated within 1 to 2 hours (evaluation
30-60 minutes thereafter)
▪ Asthma without respiratory distress
▪ Persistent nausea and vomiting
and/or diarrhea QUICK ASSESSMENT COMPONENTS
▪ Hypertension - For Adults (AMPLE)
▪ Other types of severe pain o Allergies
▪ Simple fracture o Medications taken
▪ Abdominal pain o Past medical history
▪ Client with renal stone o Last mealtime
▪ Fever above 38.9 °C o Event/environment
- NON-URGENT (GREEN) - For Pediatric Clients (CIAMPEDS)
o Priority 3 o Chief complaint
o Injuries do not have immediate complications o Immunizations
o Can wait for several hours for medical treatment o Allergies
(evaluation every 1-2 hours) o Medications taken
2 – ASV
 NCMB418 REVIEWER - FINALS

o Past medical history SNAKE BITES

o Event/environment - Children between the ages of 1 and 9 years are the most likely
o Diet and diapers victims.
o Signs and symptoms present (include onset) - The greatest number of bites occur through the daylight
ENVIRONMENTAL EMERGENCIES hours into early evening during summer months.
HEAT STROKE - The most frequent poisonous snakebite occurs from pit
- Is an acute medical emergency caused by failure of the heat- vipers.
regulating mechanisms of the body. - The most common site is the upper extremity.
- It usually occurs during extended heat waves, especially - Venomous snake bites are medical emergencies and nurses
when they are accompanied by high humidity. should be familiar with the types of snakes.
- This is due to exposure to elevated ambient temperature or - Snake venom consists primarily of proteins with a broad
excessive exercise during extreme heat. range of physiologic effects.
SYMPTOMS - Multiple organ systems, especially the neurologic,
- Profound central nervous system (CNS) dysfunction cardiovascular, and respiratory systems, may be affected.
o Confusion MANAGEMENT
o Delirium - Initial first aid at the site of the snake bite includes having the
o Bizarre behavior victim lie down
o Coma - Removing constrictive items such as rings
- Elevated body temperature - Providing warmth
o (40.6°C [105°F] or higher) - Cleansing the wound
o Hot, dry skin - Covering the wound with a light sterile dressing
o Anhidrosis (absence of sweating) - Immobilizing the injured body part below the level of the
o Tachypnea, hypotension, and tachycardia. heart.
MANAGEMENT - Initial evaluation in the ED is performed quickly and includes
- The primary goal is to reduce the high temperature as quickly information about the following:
as possible o Whether the snake was venomous or
- Treatment focuses on stabilizing oxygenation using the abcs nonvenomous; if the snake is dead, it should be
of basic life support. transported to the ED with the patient for
- During cooling, the patient is massaged to promote identification
circulation and maintain cutaneous vasodilation. o Where and when the bite occurred and the
NEAR-DROWNING circumstances of the bite
- Is survival for at least 24 hours after submersion. - Sequence of events, signs and symptoms (fang punctures,
- The most common consequence is hypoxemia. pain, edema, and erythema of the bite and nearby tissues)
- Drowning is one of the leading causes of unintentional death - Severity of poisonous effects
in children younger than 14 years of age. - Vital signs
- Factors associated with drowning and near-drowning - Circumference of the bitten extremity or area at several
include: points; the circumference of the extremity that was bitten is
o alcohol ingestion compared with the circumference of the opposite extremity.
o inability to swim - Laboratory data (complete blood count, urinalysis, and
o diving injuries clotting studies)
o hypothermia - There is no one specific protocol for treatment of snake bites.
o exhaustion. - Generally:
MANAGEMENT 1. Ice
- Immediate cardiopulmonary resuscitation 2. Tourniquets
- Therapeutic goals include: 3. Heparin
o maintaining cerebral perfusion 4. Corticosteroids are not used during the acute stage =
o adequate oxygenation to prevent damage to vital contraindicated in the first 6 to 8 hours after the bite,
organs. because they may depress antibody production and
o prevention of hypoxia and improve ventilation which hinder the action of antivenin (antitoxin manufactured
helps to correct respiratory acidosis. from the snake venom and used to treat snake bites).
3 – ASV
 NCMB418 REVIEWER - FINALS
5. Parenteral fluids may be used to treat hypotension.
6. Vasopressors are used to treat hypotension - use for
short-term
7. Close observation for at least 6 hours = patient is never
left unattended
ADMINISTRATION OF ANTIVENIN (ANTITOXIN)
- An assessment of progressive signs and symptoms which is
most effective if administered within 12 hours after the snake
bite. Children may require more antivenin than adults
because their smaller bodies are more susceptible to toxic
effects of venom.
- A skin test should be performed before the initial dose to
detect allergy to the antivenin
- Before administering antivenin and every 15 minutes
thereafter, the circumference of the affected part
is measured proximally.
- Premedication with diphenhydramine and cimetidine
decreases the allergic response to antivenin.
- Antivenin is administered as an intravenous infusion
whenever possible, although intramuscular administration
can be used.
- The antivenin is diluted in 500 to 1000 mL of normal saline
solution; the fluid volume may be reduced for children.
- The infusion is started slowly, and the rate is increased after
10 minutes if there is no reaction.
- The total dose should be infused during the first 4 to 6 hours
after poisoning.
- The initial dose is repeated until symptoms decrease. After
the symptoms decrease, the circumference of the affected
part should be measured every 30 to 60 minutes for the next
48 hours to detect symptoms of compartment syndrome
(swelling, loss of pulse, increased pain, and paresthesias).
- The most common cause of allergic reaction to the antivenin
is its too-rapid infusion
- 11. Reactions may consist of a feeling of fullness in the face,
urticaria, pruritus, malaise, and apprehension followed by
tachycardia, shortness of breath, hypotension, and shock.
- 12. Intravenous diphenhydramine (Benadryl)
- 13. Vasopressors are used for patients in shock
- 14. Resuscitation equipment must be on standby while
antivenin is infusing.
4 – ASV
POISONING
- is any substance that, when ingested, inhaled, absorbed,
applied to the skin, or produced within the body in relatively
small amounts, injures the body by its chemical action.
- Poisoning constitutes a major health hazard and emergency
situation.
POISONING/OVERDOSE
- May be accidental or deliberate.
- Consider the agent. Some are toxic to the rescuer (e.g.
cyanides, organophosphates).
- The ABCDE approach should be followed to prevent
cardiopulmonary arrest.
GOALS OF EMERGENCY TREATMENT
- Identification of the poison may enable the
- Use of an appropriate antidote to neutralize a specific poison
(e.g. Naloxone for opioids).
- To remove or inactivate the poison before it is absorbed
- To provide supportive care in maintaining vital organ systems
- To implement treatment that hastens the elimination of the
absorbed poison
INGESTED (SWALLOWED) POISONS
- Corrosive poisons include alkaline and acid agents that can
cause tissue destruction after coming in contact with mucous
membranes.
o Alkaline agents = Lye, drain cleaners, toilet bowl
cleaners, bleach, non phosphate detergents, oven
cleaners, and button batteries (batteries used to
power watches, calculators, or cameras)
o Acid products = toilet bowl cleaners, pool cleaners,
metal cleaners, rust removers, battery acid.
MANAGEMENT
- Stabilize cardiovascular and other body functions to prevent
shock
- ECG, vital signs, and neurologic status are monitored closely
- Indwelling urinary catheter is inserted to monitor renal
function.
- Blood specimens to test for concentration of drug or poison.
- Determine what substance was taken; the amount, time
since ingestion
- Measures are instituted to remove the toxin or decrease its
absorption.
- The patient who has ingested a corrosive poison is given
water or milk to drink for dilution
- However, dilution is not attempted if the patient has acute
airway edema or obstruction or if there is clinical evidence of
esophageal, gastric, or intestinal burn or perforation.
- Gastric emptying procedures may be used as prescribed:
o Syrup of ipecac to induce vomiting in the alert
patient
o Gastric lavage for the obtunded patient
 NCMB418 REVIEWER - FINALS
o Gastric aspirate is saved and sent to the laboratory
for testing (toxicology screens)
o Activated charcoal administration if poison is one
that is absorbed by charcoal
o Cathartic, when appropriate
SIGNS AND SYMPTOMS
- Pain or burning sensations
- Evidence of redness or burn in the mouth or throat
- Pain on swallowing or an inability to swallow,
- Vomiting, or drooling
INHALED POISONS: CARBON MONOXIDE POISONING
- May occur as a result of industrial or household incidents or
attempted suicide
- Exerts its toxic effect by binding to circulating hemoglobin
and thereby reducing the oxygen-carrying capacity of the
blood.
- Exposure to carbon monoxide requires immediate treatment
CLINICAL MANIFESTATIONS
- Appears intoxicated (from cerebral hypoxia)
- Headache
- Muscular weakness
- Palpitation
- Dizziness
- Confusion
- Coma
MANAGEMENT
- To reverse cerebral and myocardial hypoxia and to hasten
elimination of carbon monoxide.
- General measures apply:
o Carry the patient to fresh air immediately
o Open all doors and windows.
o Loosen all tight clothing
o Initiate cardiopulmonary resuscitation if required;
administer O2
o Prevent chilling; wrap the patient in blankets
o Keep the patient as quiet as possible
o Do not give alcohol in any form
o 100% oxygen is administered at atmospheric or
hyperbaric pressures to reverse hypoxia and
accelerate the elimination of carbon monoxide
o Oxygen is administered until
carboxyhemoglobin level is less than 5%.
o 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.
SKIN CONTAMINATION POISONING (CHEMICAL BURNS)
- 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.
- 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.
- Identity and characterize chemical agent for future
treatment
- Antimicrobial treatment
- Debridement
- Tetanus prophylaxis
- 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.
FOOD POISONING
- 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.
- Specimen for examination:
o Food
o Gastric contents
o Vomitus
o Serum
o Feces
the
5 – ASV
 NCMB418 REVIEWER - FINALS

- Monitoring
o Respirations
o Blood Pressure
o Sensorium
o CVP (if indicated)
o Muscular activity
o Fluid and electrolyte balance
▪ Severe vomiting produces alkalosis
▪ Severe diarrhea produces acidosis.
- Treatment
o Antiemetic medication
o Mild nausea, take sips of;
▪ Weak tea
▪ Carbonated drinks
▪ Tap water
▪ After nausea and vomiting subside, clear
liquids are usually prescribed 12 to 24
hours
▪ Diet progressed to a low-residue, bland
diet

“Commit everything you do to the LORD. Trust him, and he will help
you.” –Psalms 37:5

- God bless sa finals future RN, isang sem nalang

- RN LAHAT SA 2024!!!!

6 – ASV