Emergency Nursing.
standard guideline
1.remove the patient form potential source of danger - live electrical current, water, fire.
2.determine whether patient is conscious.
-If not fully conscious, assess ABC in systemic manner.
3. assess pupillary reaction and level of responsiveness to voice or touch.
- if unconscious, head injury, spinal cord injury-ensure proper handling.
4. immediate intervention 필요 - compromised airway, respiratory arrest, profuse bleeding, cardiac arrest
5. call for help as soon as possible.
6. assist with transport
Cardiopulmonary resuscitation
1.determine unresponsiveness ; tap or gently shake patient while shouting " Are you OK? "
2. activate emergency medical service(or 9ll) if outside hospital.
3. place patient supine on a firm, flat surface.
4. open the airway ( tilt the head back.)
5. determine presence or absence of spontaneous breathing.
-귀를 코와 입에 대고 숨소리를 듣는다. look for the chest to rise and fall. feel for the flow of air.
-mouth to mouth breathing (코를 막고, take a deep breath.)
6. determine pulselessness.
- While maintaining head tilt with one hand on the forehead, palpate the carotid or femoral pulse.
- if not palpable - chest compression시작. 1.5-2inch압박,(둘이서 5;1의 비율)
Foreign body airway obstruction.
Heimlich maneuver with conscious.
1. stand behind the patient → Wrap your arms around waist → Make a fist with one hand, placing the thumb side of the fist against the patient's abdomen in the midline, slightly above the navel and well below the xiphoid process. → Grasp the fist with the other hand.
2. press your fist into the patient's abdomen with a quick upward thrust.
Heimilich maneuver with unconscous
1.position supine with face up.
2. Kneel astride the patient's thighs, facing head.
3. 나머지는 conscious와 같음
Head injury
-primary assess ; vomitus, bleeding, foreign objects, breathing, circulation.
-primary interventions 1. open airway using the jaw-thrust technique without head tilt.
2. high flow oxygen(hyperventilation유지)
3. bag valve mask for inadequate respirations.
4. control bleeding ( loose dressing, do not apply pressure.)
5. IV line (keep vein open)
-general interventions
1. keep the neck in a neutral position with the cervical spine immobilized.
2. hyperventilation (to reduce ICP)
3. IV ( normal saline or Ringer's lactate fluid )
4. seizure 예방 -diazepam
5. steroid (reduce brain swelling ), mannitol (reduce cerebral edema), antibiotics.
cervical spine injuries.
-초기사정 ; 사정하는 동안 immediate immobilization of the spine
airway → breathing (cervical 손상시-intercostal paralysis with diaphragmatic breathing.)
→circulation.
-초기중재 ; 1. immobilize the cervical spine →open airway ( bag valve mask준비)
-일반중재 ;1.monitor ABGA serially.
2. nasotracheal intubation준비
3. IV line유지(KOV)
4. indwelling urinary cath.
5. spinal shock관찰 ; hypotension, bradycardia, hypothmia
6. Continue with repeated neurologic exam
Maxillofacial Trauma (facial lacerations and fractures to the facial bones)
-primary assessment ; assess air way obstruction (due to tongue swelling (fractured jaw), bleeding, missing teeth.
ex) nasal fracture, orbital fractures maxillary fractures, mandibular fracture.
- primary interventions 1.air way 유지 ; high flow suction. oral airway or intubation.
if CSF leakage or nasal fracture - nosopharyngeal airway금지.
2. bleeding control ; bulky loose dressing.
-일반사정 1.inferior orbit fracture(blowout fracture) ; paralysis of the upward gaze
2.nasal fracture ; crepitus or a crackling feeling on palpation around the nose.
3.maxilla or mandible fracture ; malocclusion of the teeth.
4.zygoma(cheekbone) fracture ;
a palpable flattening of the cheek and a loss of sensation below the orbit.
5.maxilla fracture ; spasms of the jaw and mobility of the jaw.
6.CSF leakage ; rhinorrhea or otorrhea.
-일반 중재 ; 1.gently applly ice to areas of swelling or ecchymosis.(eye injury시-do not apply ice.
2. if permit, elevate the head of the bed.
3. pain control ; morphine, diazepam.
Soft tissue injury (subcutaneous tissue and muscle 손상)
-초기사정 ; heavy bleeding →shock (skin(pale, mottled cold, diaphoretic), tachycardia(rapid weak pulse),
tachypnea(rapid shallow breathing), hypotension(후기증상)
-초기중재 ; 1. Most external bleeding can be controlled by direct pressure.
2. sterile dressings (if become saturated, reinforce the dressing.(do not remove the dressing)
3. After bleeding has stopped, apply a pressure dressing.
4. Elevating the injured area.(심장부위이상으로 상승)
**fracture가 의심된다면 상승금지(why? pain & discomfort 야기)
5. pressure point - 출혈이 조절이 안될때 출혈부위의 main artery을 압박시킨다.
- apply firm steady pressure with the fingers or the heel of the band.
6.그래도 지혈안되면 tourniquet (최후의 수단.)
-subsequent assessment 1. assess vascular status to the injury
(pallor-poor arterial perfusion, cyanosis-venous congestion.)
(capillary refill time 2초↑-decreased arterial capillary perfusion.)
2. neurologic assess ; sensory function-눈을 감게하고 손상된쪽을 light touch한다.
motor function - 발을 움직여보게한다.
3.determine tetanus immunization status.
4. Any would that is more than 6 hours old is considered at high risk for infection.
-General intervention.
1.shave the area( Eyebrows are never shaved. )
2.irrigate gently and copiously with isotonic sterile saline or sterile water( remove dirt and debris)
3.세척전후로 anesthetize 필요.
4. wound를 즉시 repair하면 fastest healing을 도모.
* 3-4일후 repair하려면 covered with a steriledressing.
5 3겹의 dressing.(1.adaptic, petroleum gauze, xeroform gauze 2.surgical dressing 3.rolled gauze & tape.
6. antimicrobial treatment / tetanus toxoid.
7. 환자교육 ; 통증은 24시간내에 사라진다. 다시발생하면 감염의심. AAP로 조절하라.
첫 48시간 동안 손상부위 상승. fecial laceration시 머리상승시키고 수면.
Injury to Bones and Joints.
-초기사정; assess occult blood loss( pelvic, femoral fracture produce hypovolemic shock.)
중재 ; support ABC / IV line.
-subsequent assessment.
* neurovascular assess, neurologic assess.
*fracture sign ; pain, tenderness, grating or crepitus, swelling, deformity, loss of use,
bleeding에 의한 discoloration, shortening
*dislocation ; loss of joint motion, obvious deformity, sever pain.
*sprain ; pain in the joint area, swelling, limited use or movement, discoloration.
*strain ; pain in a muscle or tendon( not bone or joint), 약간의 swelling
-일반중재 1. IV line with Ringer's lactate.
2. immobilize -splint로고정.
3. elevation ( if compartment syndrome의심시-손상부위 상승금지-why-blood perfusion방지.
4. ice pack or cold compresses
**compartment syndrome ; bleeding and swelling에 의해 pressure야기.
- 6P ; pain, pallor, pulselessness, paresthesias, paralysis, puffiness( late sign)
Shock.
1. hypovolemic S ; significant amount of fluid loss (ex/ hemorrhage, burn, fluid shifts)
-증상 ; hyperthermia
2. Cardiogenic S ; heart fails as a pump (ex/ MI, serious cardiac dysrhythmias, myyocardial depression
cardiac tamponade, vena cava obstruction. tension pneumothorax.
-증상 ; SBP↓(80mmHg↓or 정상의 30mmHg이상하락), oliguria, cold clammy skin, weak thready peripheral pulses, fatigue, hypotension, dyspnea, tachypnea, cyanosis,
dysrhythmia, sinous tachycardia. chest pain.
3. septic S ; bacteria infection.
4. Anaphylactic S ;
-원인 ; immunotherapy, stinging insects, skin testing, mediaction, contrast media infusion, food 운동.
-증상 ; laryngeal edema, bronchospasm, cough, wheezing, lump in throat. hypotension, tachycardia, urticaria(hives), angioedema, pruritus, erythma(flushing), N/V, diarrhea, abd. pain, bloating.
-primary assessment and intervention.
- assess ; ABC -CPR - oxygen - cardiac monitoring - control hemorrhage.
- 일반사정 1. assess LOC
2. monitor arterial BP (초기 보상기전에 의해 약 20정도 상승.→narrowing pulse pressure(초기)
fall of SBP 80mmHg↓, arterial pressure 60mmHg↓ (shock상태)
3. pulse ; 보통 상승. weak thready pulse due to deceased cardiac output &말초의 저항증가)
4. urine output ; 25ml/hr↓ (50ml/hr↑이 목표)
5. capillary perfusion ; capillary refill time 2초 ↑ - indicate vasoconstriction.
6. metabolic acidosis, excessive thirst, hyperthermia.
-일반중재
1. O2 유지(80-100 PaO2) 100% O2 by nonrebreather face mask로 공급 / intubation.
2. fluid (2개의 large bore IV line) - Ringer's lactate(initial), N/S(second choice), 수혈.
3. indwelling urinary cath.
4. pneumatic antishock garment ( military antishock trousers ) ; internal bleeding 조절, blood flow증가.
-to correct internal bleeding and hypovolemia by the application of counter pressure around the legs and abdomen. (artificial peripheral resistance로 인해 coronary perfusion을 돕는다.
5. supine position with leg elevated. (두뇌손상시 금기.)
6. ECG mornitoring.
Abdominal injuries.
assess ; - history -If stabbed, how long was the blade?/찌른사람이 남자냐?여자냐?
-Men usually hold a knife underhand and stab upward.
-Women usually will stab downward with an overhand motion.
-hemorrhage / tenderness, rebound tenderness, guarding, rigidity, spasm.
*pain( Kehr's sign-pain radiating to the left shoulder (blood beneath the left diaphragm.
‥ radiating to the right shoulder ( laceration of liver)
*increasing abd, distension.
-peritoneal irritation ; silent abdomen.
*Cullen's sign ; slight bluish discoloration around the navel ( hemoperitoneum의미)
-loss of dullness of liver or spleen - presence of free air or presence of blood.
-chest injury관찰.
-rectal exam for all & pelvic exam for female
General intervention.
1.goal ; control bleeding, maintain blood volume. prevent infection.
2. keep quiet and on the stretcher(massive hemorrhage방지)
3. cut the clothing away from the wound and count. (if comatose, immobilize the cervical spine.)
4. apply compression to external bleeding wound and occlusion of chest wound.
5. two large bore IV line( one line- central venous location ) infuse Ringer's lactate.
6. NG tube ( empty the stomach,/ relieve gastric distention,/ facilitate abd assessment.)
7. cover protruding abdominal viscera. ( 억지로 집어넣지 말고, sterile saline dressing한다.)
8. open wound with dry dressings.
9. NPO. indwelling cath.
10. tetanus toxoid, broad spectrum antibiotics.
11. peritoneal lavage.(umilicus 2-3cm 아래, needle 삽입 후 aspirate, no blood -500-1000cc solution삽입)
/if blood, feces, bile - immediate laparotomy
Multiple Injuries.
primary assessment ; 1. cervical spine injury 확인.
&intervention - open airway using the jaw thrust technique without head tilt.
2. suction to clear the trachea and bronchial tree (remove broken teeth, mucus)
3.oropharyngeal airway (occlusion by the tongue방지, avoid flexing the head )
4. endotracheal intubation ( if upper airway trauma or edema→cricothyroidotomy.)
일반중재.
1. auscultate the lungs ( assess for tracheal deviation-if tension pneumothroax →trachea이동.)
2. ask the conscious patient if difficulty in breathing or chest pain with breathing.
3. oxygen by 100% nonrebreather mask or bag valve mask.
4. assess cardiac function and treat cardiac arrest - CPR.
if unstable chest wall(flail chest), thoracotomy and manual compression of heart.
5. apply pressure over bleeding point. (surgical intervention→internal bleeding)
6.palpate the carotid pulse → femoral(70mmHg) and radial pulses (80mmHg)
systolic pressure 적어도 60mmHg이상유지.
7. 2 large IV line (one ; above diaphragm and one below) -CVP. transfusion.
8. assess LOC, pupil size reactivity, motor power and reflexes.
9. monitor ECG
10. indwelling urethral catheter./ splint fracture / peritoneal lavage /
11. draw blood for lab study ( type and cross-matching, Hg, Hct, CBC, BUN glucose, PT )
12 NG tube./ Tetanus immunization /
Heat Exhaustion
정의 ; inadequacy of the collapse of peripheral circulation due to volume and ecectrolyte depletion.
증상 ; headache, fatigue, dizziness, muscle cramping, nausea, skin-pale, ashen, moist
BT40'c. hypotension, orthostatic changes, tachycardia, tachypnea.
lab- hemoconcentration and hyponatremia(if sodium depletion), hypernatremia(if water depletion)
중재 ; 1. move the patient to a cool environment and remove all the clothing.
2 supine with the feet slightly elevated.
3. do not give fluids by mouth if nausea & vomiting.
4. IV line with Ringer's lactate or normal saline(lab본후에)
5. ECG for cardiac rhythm and V/S
6. fans and cool sponge baghs as cooling methods.
7. 교육 ; avoid immediate reexposure/ adequate fluid intake/ wearing loose clothing /
reducing activity in hot weather.
* Athletes should monitor fluid losses, replace fluids, and use a gradual approach to
physical conditioning, allowing sufficient time for acclimatization.
Heatstroke
정의 ; medical emergency. hyperpyrexia 40,6'C and neurologic symptoms by shutdown or failure of the
heat-regulating mechanisms of the body.
primary assess ; assess airway breathing and circulation, LOC
일반사정 ; 1. 동반한 사람에게 history taking-환경, 상태, 활동, 투약,
2. neurologic assess ; irritability, confusion, combativeness, coma
-tremors, seizures, fixed and dilated pupils decerebrate or decorticate (p) 3. V/S ; BT 40.6↑, hypotension, rapid pulse, rapid respiration,
flushed and hot skin(초기)→ moist →dry.
중재 1.cooling measure (39'C목표) -spray tepid water while electric fans
- ice packs to neck, groin, axillae, scalp
-soak sheet or towel in ice water and place on patient.
-immerse in cold water (controversial-말초혈관수축- heat loss↓)
-hypothermia blanket.
*여전히 안떨어지면 initiate core cooling -iced saline lavage of stomach, cool fluid 복막투석
- 찬물 방광세척,
2. Oxygen100% nonrebreather mask or intubate
3. monitor ECG, CVP, BP pulse, respiratory rate neurologic assess(30분마다)
4. fluid replace / foley cath.
5. 투약 ; diuretic(mannitol), anticonvulsant, potassium, sodium bicarbonate,
diazepam -intense shivering / clotting factor( platelets, FFP)
antipyretic은 heatstroke에 비효과적, 부작용만 야기(coagulopathy and hepatic damage)
6. complication - heat failure, cardiovascular collapse, hepatic failure, renal failure, DIC.
Frostbite 동상.
Type ; frostnip ; white skin, numb, painfree
superficial F ; SC tissue damage, white waxy skin, feel stiff, absent sensation.
Deep F ; white or yellow white or mottled blue white skin, feel frozen and hard, 완전감각손실
중재 ; 1.frostnip may be treated by placing a warm hand over the chilled area.
2.pad the extremity → Handle gently → remove all constricting clothing(watch, rings)
3. Rewarming 1.37-40'C목표 -large tepid water (주기적으로 따뜻한 물 첨가.) dry heat 금지.
2. 20-30분지속, (The area is warm to the touch and pink or flushed할 때 완성.)
3. do not rub or massage
4. 투약 ; narcotic for pain, antibiotic for open wound, tetanus prophylaxis,
5. infection 방지 ; rewarming후 1시간-며칠동안 large blisters가 생긴다.(sterile gauze dressing한다.
6. 손상부위상승(부종방지) 터트리지마라.
7. whirlpool bath (aid circulation,/ debride dead tissue,/ infection방지목적)
8. Escharotomy (further tissue damage방지, normal circulation, joint motion유지)
Fasciotomy - incision in fascia to release pressure on the muscles nerves, blood vessels
to treat compartment syndrome.
9. encourage hourly active motion. (금연 - 니코틴은 vasocontriction효과.)
Ingested poisons
primary assess and intervention ; maintain airway, ventilation, oxygenation
일반사정 ; 1. identify the poison ; determine-언제 어디서, 왜, 얼마나,
call the poison control center (unknown toxic agent or antidote위해)
2. toxicology screening (blood, urine)
3. monitor neurologic status.
중재 1. large bore IV access.
2. side with head down position ( aspiration of gastric contents 방지)
3. foley cath.
4. 흡수최소화 - activated charcoal with a cathartic (po) mixed tap water.
- induction of emesis (after poison ingestion 30분내에 효과적)
*성인-syrup of ipecac 30cc with 2-3 glass water. (12m↓; 15cc, 10oz water
*caustic substances hydrocarbon, iodides, silver nitrates, strychnine,
petroleum distillates일때 금지
5. gastric lavage ; inspect oral cavity for loose teeth→tube size nost and the xiphoid process
→lubricate with water soluble lubricant
→left later position with head 15' degree down ward →oral rout
Carbon Monoxide poisoning.
primary assess ; airway, breathing ( respiratory depression, laryngeal edema..)
intervention ; 100% oxygen by tight fitting mask
subsequent assess ; determine LOC,(cerebral hypoxia → confusion. coma
-headache, muscular weakness, palpitation, dizziness.
-respiratory distress ; rales or wheezes
-arterial blood sample for carboxyhemoglobin (normal=less than 12%)
-CNS damage ; psychoses, spastic paralysis, visual disturbance, deterioration.
일반중재 1, 100% O2 / ECG monitoring.
Insect Stings
assess 1.anaphylactic reactions ; erythema, edema, pain at site of injury, generalized pruritus, urticaria, angioedema.→심해지면 unconsciousness, laryngeal edema, cardiovascular collapse
-rapiratory status ; dyspnea, wheezing, stridor.
중재 1, apply ice packs ( relieve pain)
2. elevate extremity with large edematous local reaction.
3. administer oral antihistamine / tetanus prophylaxis.
4. clean with soap and water or antiseptic solution.
5. 환자교육 ; -always have epinephrine on hand ( EpiPen)
* take epinephrine immediately if stung.
* remove stinger with one quick scrape of fingernail.(do not squeeze venom sac.)
* report to nearest health care facility for observation.
- avoid exposure * 곤충에 물릴수 있는 장소를 피하고, 맨발로 다니지 말고, 노란색 자켓을 입지 말고, 향수나 냄새좋은 비누나 밝은색을 피한다. 창문을 닫아두고, garbage는 rapid acting insecticide를 뿌린다.
Snakebites
일반 ; The majority of snakes in the US are not poisonous.
poisonous varieties ; pit vipers( rattlesnakes, copperheads ) and coral snakes. 물리면-envenomation
assess ; local reaction ; burning, pain, swelling, numbness →몇시간지나면 -hemorrhagic blisters
systemic reaction ; nausea, sweating, weakness, lightheadedness, initial euphoria, drowsiness.
severe envenoamtion ; neurotoxicity, respiratory paralysis, shock coma, death.
intervention 1. calm and rest in a recumbent position / immobilization.
2.O2. IV line with N/S or Ringer's lactate
3. antivenin 투약. (allergic reaction가능- antivenin = horse serum based )