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Emergency and critical care Review for Nursing Boards Basic life support (BLS) A means of providing oxygen to the brain, heart and other organs until help arrives Also known as CARDIOPULMONARY RESUSCITATION Basic life support (BLS) An adult is a person above age 8 A child is any person age 1 to 8 years old An infant is anyone under 1 year Basic life support (BLS) The BLS follows the A-B-C principle • A= airway • B= breathing • C= circulation Basic life support (BLS) Causes of cardiac arrest • Respiratory arrest • Direct injury • Drug overdose • Cardiac arrhythmias Basic life support (BLS) ADULT STEPS in CPR: First STEP!!! • ASSESSMENT: determine Unresponsiveness • Assess for 5-10 seconds • Shake the victim’s shoulder and ask: “are you okay” Basic life support (BLS) ADULT STEPS in CPR: Second Step • Survey the area Basic life support (BLS) ADULT STEPS in CPR: Third Step • Call for HELP • Activate emergency medical system • Note: for child and infant this is done LAST Basic life support (BLS) ADULT STEPS in CPR: Fourth step • Place Victim in Supine position on a flat firm surface • Log roll the patient when moving Basic life support (BLS) ADULT STEPS in CPR: Fifth step • OPEN the airway • Head tilt-Chin Lift method • Jaw thrust maneuver if neck injury is suspected Basic life support (BLS) ADULT STEPS in CPR: Sixth step • Assess BREATHING Place ear over the nose and mouth Look for chest movement Perform for 3-5 SECONDS Basic life support (BLS) ADULT STEPS in CPR: Sixth step • Assess BREATHING If breathing: place on side if no neck injury; DO NOT move if with neck injury If NOT BREATHING: deliver INITIALLY 2 rescue breath via mouth to mouth Then deliver 10-12 breaths/minute Basic life support (BLS) ADULT STEPS in CPR: Seventh step • Assess CIRCULATION Check for the carotid pulse on the side close to you for 5-10 SECONDS If with (+) pulse ; continue giving 10-12 breaths/minute Basic life support (BLS) ADULT STEPS in CPR: Seventh step • Assess CIRCULATION If withOUT pulse: START Chest Compression Correct hand placement: LOWER HALF of sternum one hand over the other with fingers interlacing Depress: 1 ½ to 2 INCHES 80-100 compressions/min Basic life support (BLS) ADULT STEPS in CPR: Seventh step • Assess CIRCULATION If withOUT pulse: START Chest Compression ONE-rescuer: 30 chest: 2 breaths *before: 15:2 TWO-rescuer: 5 chest: 1 breath DO FOUR cycles and re-assess for pulse Basic life support (BLS) CHILD 1-8 years old AIRWAY: assess unresponsiveness and keep airway patent by HTCL or JT BREATHING: assess for airflow and chest movement • If breathing: maintain patent airway • If NOT breathing : deliver 2 rescue breaths by mouth to mouth • DELIVER 20 breaths/minute Basic life support (BLS) CHILD 1-8 years old CIRCULATION: assess the carotid pulse • If with pulse: continue to deliver 15-20 breaths/minute • If WITHOUT pulse: start chest compression • Correct hand placement: lower half of sternum using heel of ONE HAND • DELIVER: 1 to 1 ½ inches 80- 100 chest compressions/min 5:1 (do 20 cycles EMS) Basic life support (BLS) INFANT Less than 1 Determine unresponsiveness AIRWAY: Place head of infant in NEUTRAL position BREATHING: assess for rise-fall of chest and airflow • If breathing: maintain patent airway • If NOT breathing: initiate 2 rescue breathing via mouth to mouth and nose • DELIVER 20 breaths/min SLOWLY Basic life support (BLS) INFANT Less than 1 CIRCULATION: assess for pulse: The BRACHIAL pulse is utilized!! • If with pulse: continue to deliver 20 breaths/min • If WITHOUT pulse, start chest compression • Correct hand placement: just below the nipple line in the sternum using 2-3 fingers of one hand!! • DELIVER: ½ to 1 inch depth 100 chest com/min 5:1 ratio (do 20 cycles EMS) AIRWAY Obstruction Incomplete • Crowing sound is heard encourage to cough Complete • Clutching of the neck • Ask: “Are you choking?” • Perform Heimlich’s AIRWAY Obstruction Complete • If patient becomes unconscious: Place supine on flat surface Perform tongue-jaw lift maneuver FINGERSWEEP to remove object Open airway and attempt ventilation Perform Heimlich while supine Reattempt ventilation SEQUENCE: TJL finger-sweep rescue breaths Heimlich’s TJL AIRWAY Obstruction Pediatric considerations: CHILD: NEVER DO Blind Finger sweep AIRWAY Obstruction Pediatric considerations: INFANT: never DO blind fingersweep Give five back blows in the interscapular area and turn the infant with head lower than trunk then deliver chest thrust below the nipple line AIRWAY Obstruction Obstetric considerations: Hand is placed over the middle part of sternum: backward chest thrust If unconscious: place pillow below the RIGHT abdomen to displace uterus Shock An abnormal physiologic state where an imbalance exists between the amount of circulating blood volume and the size of the vascular bed. Pathophysiology of Shock 1. Cellular effects of shock In the absence of oxygen, the cell will undergo Anaerobic metabolism to produce energy source and with it comes numerous by-products like lactic acid The cell will swell due to the influx of Na and H20, mitochondria will be damaged, lysosomal enzymes will be liberated, and then cellular death ensues. Pathophysiology of Shock 2. Organ System Responses When the patient encounters precipitating causes of shock, the circulatory function diminishes there is decreased cardiac output Hypotension and decreased tissue perfusion will result Shock Stages There are three stages of shock Compensatory stage Progressive stage Irreversible stage Shock Stages THE COMPENSATORY STAGE OF SHOCK In this stage, the patient’s blood pressure is within normal limits. Patient’s blood is shunted from the kidney, skin and GIT to the vital organs- brain, liver and muscles Manifestations of cold clammy skin, oliguria and hypoactive bowel sounds can be assessed. Medical management includes IVF and medication Nursing management includes monitoring of tissue perfusion & vital signs, reduction of anxiety, administering IVF/ordered medications and promotion of safety THE PROGRESSIVE STAGE OF SHOCK In this stage, the mechanisms that regulate blood pressure can no longer compensate and the mean arterial pressure falls. The overworked heart becomes dysfunctional. Heart rate becomes very rapid (as high as 150 bpm) Blood flow to the brain becomes impaired, the mental status deteriorates due to decreased cerebral perfusion and hypoxia. Laboratory findings will reveal increased BUN and Creatinine. Urinary output decreases to below 30 mL/hour. Shock Stages THE PROGRESSIVE STAGE OF SHOCK Decreased blood flow to the liver impairing the hepatic functions. Toxic wastes are not metabolized efficiently, resulting to accumulation of ammonia, bilirubin and lactic acids. The reduced blood flow to the GIT causes stress ulcers and increased risk for GI bleeding. Hypotension, sluggish blood flow, metabolic acidosis (due to accumulation of lactic acid), and generalized hypoxemia can interfere with normal blood function. Shock Stages THE IRREVERSIBLE STAGE OF SHOCK This stage represents the end point where there is severe organ damage that patients do not respond anymore to treatment. Survival is almost impossible to maintain. Despite treatment, the BP remains low, anaerobic metabolisms continues and multiple organ failure results. Medical management is the use of life supporting drugs like epinephrine and investigational medications. Assessment of Shock Assessment Findings Skin : Cool, pale, moist in hypovolemic and cardiogenic shock : Warm, dry, pink in septic and neurogenic shock Pulse Tachycardia, due to increased sympathetic stimulation Weak and thready Blood pressure 1. Early stages: may be normal due to compensatory mechanisms 2. Later stages: systolic and diastolic blood pressure drops. Assessment of Shock Assessment Findings Respirations: rapid and shallow, due to tissue anoxia and excessive amounts of CO (from metabolic Acidosis) Level of consciousness: restlessness and apprehension, progressing to coma Urinary output: decreases due to impaired renal perfusion Temperature: decreases in severe shock (except septic shock). Management of Shock Nursing Interventions Management in all types and phases of shock includes the following: Basic life support Fluid replacement Vasoactive medications Nutritional support Management of Shock A. Maintain patent airway and adequate ventilation. B. Promote restoration of blood volume; administer fluid and bloodreplacement as ordered C. Administer drugs as ordered D. Minimize factors contributing to shock. E. Maintain continuous assessment of the client. F. Provide psychological support: reassure client to relieve apprehension, and keep family advised G. Provide Nutritional support Hypovolemic Shock This is the MOST common form of shock characterized by a decreased intravascular volume Risk factors: external Fluid Losses Trauma, Surgery, Vomiting, Diarrhea, Diuresis, DI Risk factors: internal fluid shifts Hemorrhage, Burns, Ascites, Peritonitis, Dehydration Hypovolemic Shock Decreased blood volume decreased venous return to the heart decreased stroke volume decreased cardiac output decreased tissue perfusion Assessment findings: cold clammy skin, tachycardia, mental status changes, tachypnea Hypovolemic Shock MEDICAL MANAGEMENT: • The major medical goals are to restore intravascular volume, to redistribute the fluid volume, and to correct the underlying cause of fluid loss promptly Hypovolemic Shock NURSNG MANAGEMENT: • Primary prevention of shock is the most important intervention of the nurse. • General nursing measures includesafe administration of the ordered fluids and medications, documenting their administration and effects. The nurse must monitor the patient for signs of complications and response to treatment. Oxygen is administered to increase the amount of O2 carried by the available hemoglobin in the blood. Cardiogenic shock This shock occurs when the heart’s ability to contract and to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues Risk factors: Coronary factorMyocardial infarction Risks factors: NON coronary: •Cardiomyopathies •Valvular damage •Cardiac tamponade •Dysrhythmias Cardiogenic shock Precipitating factors will cause decreased cardiac contractility Decreased stroke volume and cardiac output leading to 3 things: Damming up of blood in the pulmonary vein will cause pulmonary congestion Decreased blood pressure will cause decreased systemic perfusion Decreased pressure causes decreased perfusion of the coronary arteries leading to weaker contractility of the heart Cardiogenic shock ASSESSMENT FINDINGS: Angina, hemodynamic instability, dysrhythmias MEDICAL MANAGEMENT: • The goals of medical management are to limit further myocardial damage and preserve and to improve the cardiac function by increasing contractility. NURSING MANAGEMENT: • The nurse prevents cardiogenic shock by early detection of patients at risk. • Safety and comfort measures like proper positioning, side-rails, and reduction of anxiety, frequent skin care and family education. Circulatory shock This is also called distributive shock. It occurs when the blood volume is abnormally displaced in the vasculature. • Septic Shock • Neurogenic Shock • Anaphylactic Shock Circulatory shock Massive arterial and venous dilation allows pooling of blood peripherally maldistribution of blood volume decreased venous return decreased stroke volume decreased cardiac output Decreased blood pressure decreased tissue perfusion. Circulatory shock Risk factors for Septic Shock •Immunosuppression •Extremes of age (<1 and >65) •Malnourishment •Chronic Illness •Invasive procedures Circulatory shock Risk factors for Neurogenic Shock •Spinal cord injury •Spinal anesthesia •Depressant action of medications •Glucose deficiency Circulatory shock Risk factors for Anaphylactic Shock •Penicillin sensitivity •Transfusion reaction •Bee sting allergy •Latex sensitivity SEPTIC SHOCK This is the most common type of circulatory shock and is caused by widespread infection. The HYPERDYNAMIC PHASE • High cardiac output with systemic vasodilatation. • The BP remains within normal limits. • Tachycardia • Hyperthermic and febrile with warm, flushed skin and bounding pulses SEPTIC SHOCK The HYPODYNAMIC or irreversible phase • LOW cardiac output with VASOCONSTRICTION • The blood pressure drops, the skin is cool and pale, with temperature below normal. • Heart rate and respiratory rate remain RAPID! • The patient no longer produces urine. SEPTIC SHOCK MEDICAL MANAGEMENT: • Current treatment involves identifying and eliminating the cause of infection. Fluid replacement must be instituted to correct Hypovolemia, Intravenous antibiotics are prescribed based on culture and sensitivity. SEPTIC SHOCK NURSING MANAGEMENT: • The nurse must adhere strictly to the principles of ASEPTIC technique in her patient care. • Specimen for culture and sensitivity is collected. Symptomatic measures are employed for fever, inflammation and pain. IVF and medications are administered as ordered. Neurogenic Shock This shock results from loss of sympathetic tone resulting to widespread vasodilatation. The patient who suffers from neurogenic shock may have warm, dry skin and BRADYCARDIA! Neurogenic Shock MEDICAL MANAGEMENT: • This involves restoring sympathetic tone, either through the stabilization of a spinal cord injury or in anesthesia, proper positioning. Neurogenic Shock NURSING MANAGEMENT: • The nurse elevates and maintains the head of the bed at least 30 degrees to prevent neurogenic shock when the patient is receiving spinal or epidural anesthesia. Anaphylactic Shock This shock is caused by a severe allergic reaction when a patient who has already produced antibodies to a foreign substance develops a systemic antigen-antibody reaction Anaphylactic Shock MEDICAL MANAGEMENT: • Treatment of anaphylactic shock requires removing the causative antigen, administering medications that restore vascular tone, and providing emergency support of basic life functions. • EPINEPHRINE is the drug of choice given to reverse the vasodilatation Anaphylactic Shock NURSING MANAGEMENT: • It is very important for nurses to assess history of allergies to foods and medications! • Drugs are administered as ordered and the responses to the drugs are evaluated. Triage “trier”- to sort To sort patients in groups based on the severity of their health problem and the immediacy with which these problems must be addressed Triage in the E.R. 1. Berner’s Emergent 2. Urgent 3. Non-urgent Triage in DISASTER! 1. NATO Immediate 2. Delayed 3. Minimal 4. Expectant Triage 1. Emergent • Patients have the highest priority • With life-threatening condition 2. Urgent • Patients with serious health problems • Not life-threatening, MUST be seen in 1 hour 3. Non-urgent • Episodic illness that can be addressed within 24 hours Triage category Conditions Priority Color Immediate 1 RED Delayed 2 YELLOW Stable abdominal wound, eye and CNS injuries Minimal 3 GREEN Minor burns, minor fractures, minor bleeding Expectant 4 BLACK Triage in Disaster Chest wounds, shock, open fractures, 2-3 burns Unresponsive, high spinal cord injury Preparing for terrorism 1. 2. 3. Recognition and Awareness Use of personal protective equipments Decontamination of contaminants Biological Weapons ANTHRAX Drug of choice is Ciprofloxacin or Doxycycline SMALLPOX Supportive Chemical Weapons Organophosphates • Supportive care • Soap and water • Atropine • Pralidoxine Cyanide • Sodium nitrite, Amyl Nitrite, Methylene Blue • Sodium thiosulfate • Hydrocobalamin CYANIDE POISONING Radiation Alpha Particles Cannot penetrate skin Causes local damage Beta Particles Moderately penetrate the skin Can cause skin damage and internal injury if prolonged Gamma Particles Penetrate skin Can cause serious damage X-ray is an example
