Page 1 of 12

BASIC APPROACH TO EMERGENCY CARE Emergency care Episodic and crisis-oriented care provided to patients with serious or potentially lifethreatening injuries or illnesses. EMERGENCY ASSESSMENT A systematic approach to the assessment of an emergency patient. Types 1. Primary Assessment a. ABC b. Disability- assess LOC and pupils A- is he alert? V- does he respond to voice? P- does he respond to painful stimulus? U- unresponsive to painful stimulus? c. Glasgow coma scale Eye Opening Response Spontaneous--open with blinking at baseline Opens to verbal command, speech, or shout Opens to pain, not applied to face None Oriented Verbal Response Confused conversation, but able to answer questions Inappropriate responses, words discernible Incomprehensible speech None Obeys commands for movement Motor Response Purposeful movement to painful stimulus Withdraws from pain Abnormal (spastic) flexion, decorticate posture Extensor (rigid) response, decerebrate posture None 4 points 3 points 2 points 1 point 5 points 4 points 3 points 2 points 1 point 6 points 5 points 4 points 3 points 2 points 1 point

Page 2 of 12

2. Secondary Assessment Brief, thorough, systematic assessment designed to identify all injuries. a. Expose/environmental control May remove clothing to identify all injuries Warm blankets, over head warmers b. Full set of VS- obtain BP in both arms if chest trauma is suspected c. Five interventions Pulse oximetry Indwelling catheter Gastric tube Laboratory- CBC with platelet, PT, PTT d. Facilitate familys presence Assess familys needs e. Give comfort measures History A. 1. 2. 3. 4. 5. B.

Mechanism of injury Injuries sustained or suspected Vital Signs Treatment Noi, Poi, Doi, Toi If conscious Ask the patient directly C. Ask past medical history from the patient or a family member Heat to Toe Assessment 1. Head and Face a. Inspect for lacerations, abrasions, contusions, impaled objects, ecchymosis or edema b. Palpate for crepitus or crackling sounds 2. Chest a. Inspect for breathing pattern, flail chest or disruptions in chest wall integrity b. Auscultate breath sounds or adventitious sounds c. Palpate crepitus 3. Abdomen/Flanks a. Lesions, eviscerations or distention

Page 3 of 12

b. Bowel sounds c. Palpate for rigidity, masses, guarding or areas of tenderness 4. Pelvis/Perineum a. Lesions b. Blood at meatus, priapism c. Palpate for pelvic instability and anal sphincter tone 5. Extremities a. Color, temperature, signs of injury, bleeding, sensation b. Palpate pulses

TRIAGE From French verb meaning- to sort- to set prioritize Level Level 1 Category Resuscitation Description >Requires immediate nursing and physician assessment >Delay will result to life or limb threatening >Examples: >Requires assessment within 15 minutes of arrival >head injuries, severe trauma, chest pain, bleeding with unstable VS, abdominal pain in patients older than 50, fever in 3 months infants, pain scale of 7, sexual assault, neonates 7 days young >Requires assessment within 30 minutes of arrival >alert head injury with vomiting, mild to moderate asthma, abuse or neglect, Gi bleeding with stable VS, seizure history but alert on arrival >1 hour > alert head injury without vomiting, minor trauma, vomiting and diarrhea in patient older than age 2 without evidence of dehydration, earache, minor allergic reaction >Assessment within 2 hours > sore throat, minor symptoms, chronic abdominal pain

Emergent

Urgent

Less Urgent

Nonurgent

Page 4 of 12

PSYCHOLOGICAL CONSIDERATIONS TRAUMA- insults both physiologic and psychological homeostasis therefore requires healing. Approach to the Patient 1. Understand and accept the basic anxieties of the traumatized patient. Be aware of the patients fear of death, mutilation and isolation a. Personalize the situation as much as possible. Speak or react in warm manner. b. Explain on laymans term c. Accept the rights of the patient and family to have and display their own feelings d. Maintain a calm and reassuring manner 2. Understand and support the patients feelings concerning loss of control. 3. Treat the unconscious as if conscious. a. Call by name. b. Explain procedure c. Do not make negative comments about patients condition. d. Orient to PPT as soon as he is conscious. e. Bring the patient back to reality in calm and reassuring way. f. Encourage the family to orient patient to reality. 4. As a nurse, be prepared to handle all aspects of acute trauma; know what to expect and what to do. Approach to the Family 1. Inform the family where the patient is. Give as much information as possible about the treatment. 2. May consider a family member to be present during resuscitation. 3. Recognize anxiety and allow them to talk. Acknowledge remorse, anger and criticism. 4. Allow the family to relive the events, actions and feelings preceding admission to the ED. 5. Deal with reality as gently and quickly as possible. Avoid encouraging and supporting denial. 6. Assist the family to cope with death. a. Take family to a private place. b. Talk to the family altogethter so they can mourn together. c. Inform of the treatment rendered and everything possible was done. d. Avoid using passed on. Show respect by touching or offering coffee. e. Allow the family to talk about the deceased. f. Encourage family to support each other and to express emotions freely.

Page 5 of 12

g. Avoid giving sedation- may mask grieving process, which is necessary to achieve emotional equilibrium and prevent prolonged depression. h. Be cognizant of cultural and religious beliefs and needs.

INJURIES TO THE HEAD, SPINE AND FACE Head Injuries Include fractures to skull and face, direct injuries to brain (from bullet), indirect injuries to brain like concussion, contusion, intracranial hemorrhage. a. Concussion- temporary loss of consciousness b. Contusion- bruising of brain tissue c. Intracranial hemorrhage- bleeding into a space or a potential space between skull and brain. Maybe classified as epidural, subdural, subarachnoid hematomas depending on the site of bleeding. Assume cervical spine fracture for any patient with significant head injury Primary Assessment 1. Airway- assess for vomitus, bleeding, foreign objects.- Ensure cervical spine immobilization. 2. Breathing- assess for abnormally slow or shallow respirations. An elevated carbon dioxide partial pressure can worsen cerebral edema. 3. Circulation- assess pulse and bleeding. 4. Disability- assess neurologic status Primary Interventions 1. Open airway a. Use jaw-thrust maneuver b. Oral suction equipment c. Do not stimulate gag reflex- may increase ICP 2. Administer high-flow oxygen: death usually results from cerebral anoxia. 3. Control bleeding a. Do not apply pressure to the injury site. b. Apply a bulky, loose dressing. c. Do not attempt to stop the blood flow or CSF from nose or ears. d. Initiate 2 IV lines

Page 6 of 12

Subsequent Assessment 1. History a. Mechanism of injury b. Duration of loss of consciousness c. Memory of the event d. Position found 2. LOC a. Changes are the most sensitive indicator of a change in the patients condition. b. CGS 3. VS a. Hypertension and bradycardia are late signs of increased ICP b. May have associated cardiac dysrhythmias noted by irregular or rapid pulse. c. Elevated temperature- associated with head injury 4. Unequal or unresponsive pupils 5. Rhinorrhea or otorrhea= leakage of CSF 6. Periorbital ecchymosis= anterior basal fracture 7. Periauricular ecchymoses- bluish discoloration behind the ears= basal skull fracture NGT is contraindicated Use orogastric tube only General Interventions 1. 2. 3. 4. 5. Neck in neutral position Immobilize cervical spine IV line of NSS or LR- restricted fluid volume Maintain normothermia. Pharma a. Anticonvulsants b. Mannitol c. Antibiotics d. Antipyretics

Cervical Spine Injuries Suspect this injury if a person has head, neck or back injury, fractures to upper leg and to the pelvis Primary Assessment

Page 7 of 12

1. Immobilize while assessing the patient. a. Airway b. Breathing- intercostal paralysis with diaphragmatic breathing indicates cervical spinal cord injury c. Circulation d. Disability- assess LOC Primary Interventions 1. 2. 3. 4. Immobilize cervical spine Open airway- jaw thrust May intubate nasally BVM for shallow respirations

Subsequent Assessment 1. Position when found- indicates type of injury incurred 2. Hypotension + bradycardia + warm dry skin= spinal shock 3. Neck/back pain or burning sensation to the skin 4. History of unconsciousness 5. Sensory loss and motor paralysis below level of injury 6. Loss of bowel and bladder control= urinary retention and distention 7. Loss of sweating below level of cord lesion 8. Priapism 9. Hypothermia- inability to constrict peripheral blood vessels and conserve body heat 10. Loss of rectal tone General Interventions 1. 2. 3. 4. 5. 6. 7. NGT Kept warm IV access Indwelling catheter- prevents bladder distention Monitor VS Continue monitor Neurologic exams Manage seizures

Maxillofacial Trauma Primary Assessment 1. Immobilization of the spine while assessing

Page 8 of 12

2. Airway obstruction may result from tongue swelling, fractured jaw, bleeding, broken missing teeth 3. Breathing- impaired due to obstructed airway 4. Circulation- control bleeding 5. Disability Primary Interventions 1. Establish and maintain airway a. High flow oxygen b. Oral airway or intubation c. Nasopharyngeal airway if no nasal fractures or rhinorrhea 2. Control bleeding a. No direct pressure over the injured site b. Apply bulky or loose dressing Subsequent Assessment 1. 2. 3. 4. 5. 6. 7. 8. 9. Examine mouth for broken or missing teeth Assess potential eye injury, double vision or eye pain Examine eye for dysconjugate gaze- incoordination of eye movements Paralysis of upward gaze= inferior orbit fracture or blowout fracture Crepitus around the nose indicates nasal fracture Malocclusion of teeth= maxilla or mandibular fracture Zygoma fracture= flattening of the cheek and loss of sensation below the orbit Trismus- spasms of the jaw Maxilla fracture- trismus + mobility of the jaw

General Interventions 1. Ice over areas of swelling or ecchymosis except direct eye injury 2. If not contraindicated, HBR 3. If with rhinorrhea, no nasal blowing, coughing or sneezing- prevents transmitting infection to the brain or eyes

Page 9 of 12

SOFT TISSUE INJURIES Involves skin, SQ and muscles Classification 1. Closed wound- injury to soft tissue without skin break a. Contusion- bleeding beneath the skin into soft tissue b. Hematoma- pocket of blood and fluid beneath the skin 2. Open wound- soft tissue injury with skin breakdown a. Abrasion- superficial loss of skin from rubbing or scraping of skin over a rough surface b. Laceration- tear in the skin c. Puncture- does not cause external bleeding but have significant internal bleeding and damage Penetrating- entrance only Perforating- entrance and exit only d. Avulsion- tearing off or loss of a flap of skin. e. Amputation- tearing or cutting off a finger, toe, arm or leg Primary Assessment 1. Ensure ABC before initiating treatment 2. When bleeding, assess for shock a. Skin- pale, mottled, cold and diaphoretic b. Tachy-Tachy-Hypo c. Restlessness, anxiety 3. Assess for arterial or venous bleeding a. Arterial bleeding- bright red and spurts form injured site b. Venous bleeding- darker red, flows steadily from wound Primary Interventions Goal: CONTROL BLEEDING 1. Direct Pressure a. Cover injury with sterile dressings. b. Direct pressure over injured site c. Continue until bleeding stops or pressure dressing is done d. If dressing becomes saturated, ENFORCE dressing. DO NOT REMOVE. e. Check pulse distal to the dressing.

Page 10 of 12

2. Elevation a. Elevation + direct pressure= controls bleeding b. Elevate above heart c. Do not raise limb positive for fracture or if it causes pain 3. Pressure Points Subsequent Assessment 1. Expose wound, remove clothing but not the impaled objects. 2. Assess concomitant injuries, vascular status distal to injury site. 3. Compare the injured and uninjured extremity. a. Color of the injured extremity Pallor- poor arterial perfusion Cyanosis- venous congestion b. Capillary refill c. Pulses distal to the injury- should be full and strong 4. Perform neurologic assessment a. Sensory function- eyes closed, light touch distal to the injury b. Motor function- ask to move extremity 5. Determine tetanus immunization status 6. History of injury. Wound more than 6 hours is at high risk for infection. 7. Determine allergies to local anesthesia, antibiotics and epinephrine. General Interventions 1. Wound Preparation a. Shave area surrounding the wound but NOT EYEBROWS. b. Irrigate with isotonic fluid or sterile water. May use catheter tip syringe to create hydraulic action Irrigate 50 mL/inch of wound/hour of age of wound If grossly contaminated, clean with surgical scrub sponge then irrigate. c. Local anesthetic through ID or regional nerve block d. Remove devitalized tissue and foreign matter 2. Wound Closure a. Closure by primary intent Done with suturing, skin tapes, staples or tissue adhesives Wound is repaired without delay after injury b. Closure by secondary intent Done by cleaning and covering with sterile dressing.

Page 11 of 12

Wound is allowed to granulate on its own without surgical closure. c. Closure with secondary intent with delayed closure Wound is cleaned and dressed Closed 3-4 days after 3. Wound Dressing a. Dressing in 3 Layers 1. First layer or Contact layer Use non-absorbent hydrophilic dressing that allows exudates to pass through the second layer without wetting the first layer Examples: Adaptic, petroleum gauze, Xeroform gauze. 2. Second layer or Absorbent layer Surgical dressing pads or 4x4 gauze dressing 3. Third layer or Outer wrap Holds dressing in place May use rolled gauze or tape or bandage. 4. Pharmacologic Interventions a. Anti-infectives b. Analgesic c. Tetanus prophylaxis 5. Patient Education a. Pain should subside in 24 hours b. If pain reappears= wound infection is suspected. c. Elevate wound- limits accumulation of fluid in the wounds interstitial spaces Elevate for first 48 hours Semi Fowlers for facial laceration Report fever, bleeding, pain, foul odor, purulent drainage, swelling, redness of wound.

Page 12 of 12