1
Q
Shock
A
- Inadequate tissue perfusion
- Progression is neither liner, nor predictable.
- Any insult/injury or disease process can cause the body to go into shock
2
Q
Compensatory Stage of Shock: Clinical Findings
A
- BP: Normal
- HR: >100
- RR: >20
- Skin: Cold/clammy
- Urinary output: Decreased
- LOC: Anxious/confused
- PaCO2: less than 32
3
Q
Progressive Stage of Shock: Clinical Findings
A
- BP: Systolic less than 80
- HR: 150+
- Resp: Rapid, shallow, crackles
- Skin: mottled, petichiae
- UO: 0.5 mg/kg/hr
- LOC: lethargy (*think pt safety)
- PaO2: less than 80
- PaCO2: 45+
- ABG: Metabolic Acidosis
4
Q
Refractory Stage of Shock: Clinical Findings
A
- BP: Requires support
- HR: Erratic, asystole
- Resp: Requires support
- Skin: Jaundice
- UO: Anuric
- LOC: Unconcious
- ABG: Profound Acidosis
5
Q
Early sign of Shock
A
*Decreased pulse pressure
6
Q
Elderly Adult: Your First Thought
A
Give them O2
7
Q
Hypovolemic Shock: Management
A
- 2 large bore IV for fluid replacement
- Fluid should be a crystalloid solution (*NS is safe)
- Monitor ABG and H/H
8
Q
Main Causes of Death for Spinal Cord Injury
A
Pneumonia, PE, and Sepsis
9
Q
Autodestruction
A
Cell death that continues for weeks-months after injury
10
Q
SCI: Spinal Shock
A
- *Temporary
- Loss of ALL reflexes
- Loss of sensation
- Flaccid paralysis below injury
11
Q
SCI: Neurogenic Shock
A
- Loss of vasomotor tone
- HypoTN, warm/dry skin (opposite of hypovolemic shock), decreased CO, loss of SNS, bradycardia
12
Q
SCI: Neurogenic Shock Interventions
A
-SCDs, TEDs, Dopamine (vasopressor)
13
Q
SCI: Hyperflexion
A
-Sudden, forceful, forward acceleration of head (chin to chest)
14
Q
SCI: Hyperextension
A
- Head snapped back.
- Ex: a fall, where the pt hits their chin on the counter on the way down.
- Vertebrae may fracture or subluxate
15
Q
Axial Loading
A
- Vertical force
- Vertebrae shatters from force
- Common in diving accidents
- If pt has a heel fx, check for axial loading as well.
16
Q
Complete Cord Involvement
A
Total loss of sensory and motor fxn below level of injury
17
Q
Incomplete Cord Involvement
A
Mixed loss of voluntary motor fxn and sensation, and leaves some traits in tact
18
Q
Central Cord Syndrome
A
- Most commonly in C spine
- *Motor weakness and sensory loss present in upper and lower extremities, but more pronounced in upper.
19
Q
Brown-Sequard Syndrome
A
- Result of damage to one half of the spinal cord
- *Paralysis, loss of motor fxn, position and vibration sense on SAME side as injury
- *Loss of pain and temp sensation on OPPOSITE side, below injury
20
Q
SCI: Respiratory System Manifestations
A
- Above C3: Near total ventilatory muscle paralysis
- C3-C5: Loss of Phrenic nerve fxn
- C6-T8: Loss of Intercostals
- T7-T12: Loss of abd muscles
21
Q
SCI: Cardiovascular System Manifestations
A
- HR slow (less than 60)
- ANY increase in vagal stimulation can cause arrest
22
Q
Poikilothermism
A
-The inability to regulate ones own body temperature (think of reptiles)
23
Q
Hypovolemic Shock
A
- Caused by decreased blood volume
- External loss due to hemorrhage, surgery, or D/V
- Internal loss due to burn, ascities, dehydration, or the pancreas storing fluid
24
Q
Hypovolemic Shock: Management
A
- Replace fluid (NS) and blood
- heart monitor, and labs: ABGs, H and H, serum lactate, glucose, electrolyte levels
25
Cardiogenic Shock
- Impaired pump fxn
| - Caused by MI, valve failure, and dysrhythmias
26
Cardiogenic Shock: Management
- O2, pain control, labs, dopamine
- Monitor CT, EKG, Echocardiogram
- *only a little fluid
27
Hypovolemic Shock: Vicious Triad
- Acidosis R/T shock and tissue injury
- Hypothermia from fluid loss and exposure (causes increased O2 consumption adn arrythmias)
- Hemodilution
28
Obstructive Shock: Beck's Triad
- HypoTN
- Distended neck veins
- Muffled heart sounds
29
Obstructive Shock: Caused by
- Non-cardiac obstruction to blood flow
| - PE, tension pneumothorax, pericardial tamponade
30
Distributive Shock: Types
Anaphylactic, Neurogenic, and Septic
31
ICP: Components and Percentages
- Brain tissue: 78%
- Blood: 12%
- CSF: 10%
32
Normal ICP Range
10-15 mm Hg
33
Monroe-Kellie Doctrine
The cranial compartment is a fixed compartment; because of limited space, if any one component increases in volume, another must decrease in volume.
34
ICP: Component Displacement
- CSF is easiest to displace
- Blood is 2nd easiest
- Brain is the hardest component to displace and a big problem b/c it herniates.
35
Calculating MAP
- (2D+S)/3 = MAP
- 2 times the diastolic, plus the systolic
- divide that by 3 = MAP
36
Calculating Cerebral Perfusion Pressure (CPP)
MAP - ICP = CPP
37
MAP: Perfusion Parameters
- MAP must be at least 60 to perfuse coronary arteries
- 70+ for brain and kidneys
- If MAP is below 50, the brain is unable to autoregulate
38
Types of Cerebral Edema
- Vasogenic (most common, occurs in white matter)
- Cytotoxic (comes from a local disruption in functional integrity of the cell)
- Interstitial
39
Causes of Increased ICP
- Mass lesion
- Cerebral edema
- Head injury
- Brain inflammation (can be due to bacterial meningitis)
- Metabolic insult
40
Increased ICP: Clinical Manifestations
- Constant or worsening HA
- Changes in LOC
- *Restlessness/Confusion (early sign)
- Weakness in one extremity
41
Increased ICP: Cushing's Triad
- Bradycardia
- HTN
- Bradypnea
- At this point, herniation of brain stem and occlusion of cerebral blood flow occur if interventions are not initiated.
42
Complications of Increased ICP
- Inadequate cerebral perfusion
- Cerebral herniation
- Both cause brain to be hypoxic
43
Increased ICP: Diagnosing
Cerebral angiography is the standard
44
Measuring ICP
- Drill a hole
| - Ventricular monitor is best
45
Indications to Monitor ICP
- *Pt admitted w/ Glasgow Coma Scale of 8 or less
- Abnormal CT or MRI
- Hx of neurological insult
46
Increased ICP: Meds
- Mannitol: Osmotic diuretic (turns your plum into a prune)
| - Corticosteroids: decrease inflammation
47
Increased ICP: Management
- Maintain airway
- Adequate O2
- Monitor neuro assessment for changes
- Document and report any changes
48
Triage Process
-Pts with a threat to life, vision, or limb are seen first
49
Emergency: Primary Survey (ABCD)
- Airway
- Breathing
- Circulation
- Disability
50
Emergency: Secondary Survey (EFGHI)
- Identifies Injuries
- Exposure/Environmental control
- Full set of vitals/Family presence
- Give comfort measures
- Hx and head-to-toe assessment
- Inspect posterior surfaces (need three people, one to hold C-spine)
51
Death in ED
- Follow hospital rituals
- Determine if pt can be donor
- If pt dies w/in 24 hours of arrival, you must call ME (leave lines intact)
52
Mallory Weiss tears
Bleeding from tears in mucosa at junction of stomach and esophagus due to ETOHism, coughing, or vomiting
53
GI Emergency: Upper GI Bleed
-Caused by: PUD, Varicies, Mallory Weiss tears, SRES (Stress-Related Erosive Syndrome)
54
Upper GI Medical Emergencies
- Varicies: pt can bleed to death (constant swallowing)
- Gastric perforation: stomach contents will leak into abd cavity, and cause peritonitis
- GP s/s: severe upper abd pain radiating to shoulder and rebound tenderness
55
GI Emergency: Lower GI Bleed
-Caused by: Diverticula, CA, or Inflammatory bowel disease
56
Heat Exhaustion: S/S
- Prolonged exposure to heat
- General malaise, N/V, profuse diaphoreses, dilated pupils, hypoTN
- *Temp range: 99.6-104
57
Heat Exhaustion: Tx
-Moist sheet, remove restrictive clothing, replace fluids and electrolytes orally if possible, *if not use NS only
58
Heat Stroke: S/S
- Pt stops sweating
- *Temp >104
- Altered LOC
59
Heat Stroke: Types
- Classic: Environmental (non-exertional)
| - Exertional: Occurs in healthy individuals in extreme heat/humidty
60
Heat Stroke: Tx
- Ice bags on armpits and genitalia
- Ice bath
- Wet blanket + fan
- Get IV access early b/c of circulatory collapse
- Give Chlorpromazine to stop shivering
- Aggressive temp reduction until core reaches 102
- Monitor for Rhabdo (CK will be 5x normal)
61
Frostbite: Tx
- Immerse in 102-108 degree bath water
| - Keep sheets off frozen tissue
62
Mild Hypothermia: S/S
-Temp 93.2-96.8, shivering, lethargy, decreased LOC, minor HR changes
63
Moderate Hypothermia: S/S
- Temp 86-93.2
| - Core temp
64
Profound Hypothermia: S/S
-Temp
65
Mild Hypothermia: Tx
Passive or active external rewarming: Warming blankets, heat lamps
66
Moderate-profound Hypothermia: Tx
Active core rewarming: Periorbital, gastric, or colonic lavage w/ warm fluid
67
Hypothermia: Rewarming Risks
- Rewarming should be d/c at 95
- Heart monitor for possible arrhythmias while rewarming
- *Watch for after drop: colder blood in peripherals is returned to core after shunting is reversed and can cause a sudden drop in core temp
68
Submersion Injury
- Pt becomes hypoxic due to submersion
| - Alveolar damage leads to respiratory failure (ARDS)
69
Submersion Injury: Tx
- ABCD
- Correct hypoxia
- Use PEEP to keep alveoli open
- *Heart monitor
- *Pt should be monitored for minimum of 4-6 hrs for delayed pulmonary edema
70
Animal Bites: Who-dun-it?
- Dogs: Tearing bite, will have muscle and tissue damage
| - Cats: Puncture wounds, high risk for infection, septic arthritis, tensynovitis, osteomylitis
71
Animal Bites: Tx
- Dog: Loosely suture to leave access for cleaning
| - Cats: Never close bites
72
Animal/Human Bites: Tx
- Splint wounded joints
| - Rabies prophylaxis
73
Spider Bites
- Black Widow: Neurotoxic, can mimic appendicitis, causes abd pain, anti-venom only given for hypoTN and systemic rxn
- Brown Recluse (Fiddle-back): Cytotoxic, causes tissue necrosis, fever, chills, nausea, joint pain
74
Poisonings: Decontamination
Takes priority over all interventions EXCEPT basic life support
75
Explosion Damage
- Causes Blast, Crush, and Penetrating damage
- Bleeding ears are a sign that a person was close to explosion
- Hollow organs take more damage
76
First Rule of Emergency Preparedness
Keep staff safe!
77
Burns: Superficial Partial Thickness
- Sunburn
- Blanches
- Uncomfortable to touch
- Complete recovery with no intervention
78
Burns: Deep Partial Thickness
- Epidermis and portion of dermis
- Pain
- Sensitive to air currents
- Blistered
- Mottled, red base
- Weeping and edema
- Hair follicles in tact
- Takes 2-4 weeks to heal
79
Burns: Full Thickness
- Full dermal layer
- White, cherry-red, charred, leather-like texture
- No pain
- Require grafting
- No blisters
80
Burns: Inhalation Injury
- Look for: Singed nasal hairs, soot around nose/mouth, burnt/dry oral mucosa
- Transfer to burn unit
81
Burns: Zones of Injury
- Zone of Coagulation: cell death has occurred, requires graft
- Zone of Stasis: Compromised blood supply, tissue may survive
- Zone of Hyperemia: Complete recovery expected
82
Burns
- 25-40% requires fluid resuscitation
| - Assess for other injuries
83
Referral to Burn Unit
- 2nd and 3rd degree burns over more than 10% TBSA
- All 3rd degree burns greater than 5% TBSA
- Suspected inhalation injury
- Any pt with other disease process
- Any pt with burns on hands, feet, face, or genitalia
84
Burns: Resuscitative Phase
- Time starts from time of burn, lasts 24 hours
- Fluid replacement
- Ask how much fluid EMTs gave
- Intubate if necessary
- Labs: CBC, CMP, BUN, ABG, clotting studies, urinalysis
401
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