Emergency Medicine Review
Jun. 20th, 2010 10:00 pm![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
liveonearthExcellent basic rundown of EMT procedures when working a scene:
http://people.vanderbilt.edu/~akshay.shah/ems/notes/notes2.html
notice, all ye from NCNM, that on this page a normal oriented person is A&O x4
ONLY at NCNM is normal x3. =-/
» EYE PAIN AND INJURIES «
Ocular injuries are TRUE EMERGENCIES
Foreign object in the eye:
1) Inspect for location (cornea or conjunctiva)
2) Flush from inner acanthi outward with fresh water
3) Draw upper lid down over the lower lid and as the upper lid returns to its normal position, the under surfaces will be drawn over the lashes of lower lid and the foreign body will be removed
4) Expose the underside of the upper lid by grasping the lashes of the upper lid and rolling them over a match stick or Q-tip
5) Pull down the lower lid and remove the particle with a gauze corner
6) DO NOT PROBE – if embedded place a bandage over both eyes and transfer
7) Perform fluorescein and slit lamp examination to confirm diagnosis
8) Consider x-ray or CT scan for intraocular metal foreign body
9) Orbital injuries require hospitalization and possible surgery; remember they are true emergencies
DO NOT REMOVE IMPALED OBJECTS
• bandage both eyes
• protect eye/object with cup or cone
• stabilize head
• reassure patient
Chemical burns: flush for 20 minutes
• lavage with copious amounts of isotonic saline solution, Ringer’s or water
• remove any remaining particles
Acute Closed Angle Glaucoma:
• red eye
• decrease pupil reaction
• colored halo around bright objects
• headache
• nausea
• may cause blindness
• severe pain
• fixed, irregular, mid-dilated pupil
• sudden onset
• shallow anterior chamber
• elevated intraocular pressure
• photophobia
• Tx: Glycerin, 1 g/kg body weight orally, in cold 50% solution mixed with chilled lemon juice
Retinal detachment
• “curtain” blocking the vision
• light flashes
• dark spots in front of eyes
• transport gently
• do not bump patient (Bryonia)
may be preceded by vitreous humor detachment: floaters and flashes, have it assessed just in case
fix is surgical, prevention is antidiabetic
Corneal abrasion
• Use flourescene dye to detect injury
• very painful
• 3 – 6 hours after injury
Light burns
• welding flash, snow blindness, UV light burn
• PAIN; Actinic keratitis
• Perform fluorescene and slit lamp examination to confirm diagnosis
• consider x-ray or CT scan for intraocular metal foreign body
• rest eyes, remain in dark room, will heal within two to five days
Heat burns
• apply sterile wet dressing
General Eye Treatment:
• Wash only if chemic burn or detergent injury
• do not put salves or medicines into the injured eye
• do not remove blood from eye
• do not force eye lids open unless chemical burns
• limit use of uninjured eye
• keep patient quiet and don’t let them walk around
• bandage both eyes and transport
Red or painful eye – priority of questions/concerns:
1) Trauma
2) Chemical exposure
3) Foreign body, dust, metal chips
4) Light burns
5) Visual acuity
6) Discharge
Red or painful eye – with conjunctival discharge
purulent Bacterial or Chlamydial conjunctivitis
not purulent Gram and Giemsa stains and culture
Allergic, Viral or Nonspecific conjunctivitis
Red or painful eye – decreased visual acuity – constricted pupil Uveitis
Pain with no history of trauma, light, foreign body or chemical exposure and…abnormal fluorescein examination of cornea
1) keratitis
2) corneal ulcer
3) corneal abrasion
Differential Diagnosis List for decreased visual acuity and pain:
1) Keratitis
2) Corneal Ulcer
3) Corneal abrasion
4) Uveitis
5) Acute Angle-Closure Glaucoma (normal fluorescein)
Orbital Cellulitis and Cavernous Sinus Thrombosis
*Must Be Differentiated*
usually caused by Staph in adults, Haemophilus influenza in children
Cavernous Sinus Thrombosis
Signs and Symptoms:
chills
headache
lethargy
nausea
pain
decreased vision
fever
vomiting
unilateral or bilateral exophthalmos
absent papillary reflexes
impaired EOM
decreased corneal sensation
What to do with this patient?:
Hospitalize the patient immediately
Send blood to the laboratory for culture
Ophthalmolgic, neurological, medical consultation
Obtain CT scan of the head and orbit
Anterior Uveitis and Iritis
Symptoms:
Photophobia
Unilateral gradual onset of eye pain
Red eye without discharge
Blurred vision
Excessive tearing
Signs:
Perilimbal injection
» GI BLEEDING «
» Esophageal varices – Mallory Weiss Syndrome – Peptic Ulcers – Hemorrhoids – Neoplasm «
Mallory Weiss Syndrome – tears in mucosa of espophago-gastric junction secondary to prolonged or forceful vomiting.
Alcohol consumption
Bulimia
Active, profuse hematemesis or hematochezia may indicate
Major, acute gastrointestinal tract bleeding
Severe liver disease
Advanced age
Coagulopathy
Cardiopulmonary disease
If frank blood is not present:
1) obtain vital signs
2) examine for shock
If supine hypotension or postural hypotension is NOT present
1) Obtain history
2) Perform brief examination
3) Obtain venous access and blood for type and screen, hematocrit, and PT/PTT
4) Nasogastric lavage
a. Upper GI Bleed, may include any of the following:
i. hematemesis
ii. blood in nasogastric aspirate
iii. melenic stool
iv. Hyperactive bowel sounds
v. DDX: Gastric ulcer, gastritis, peptic ulcer, esophageal varices
b. Lower GI Bleed
i. No hematemesis
ii. bile and no blood in nasogastric aspirate
iii. maroon stools
iv. hematochezia, esp. with normal hyperactive bowel sounds
v. DDX: Neoplasm, hemorrhoids, angioma, diverticulitis
What tests do you want to run if active profuse hematemesis or hematochezia is occurring?
o blood type and crossmatch
o PT/PTT
o CBC
o serum electrolytes
o liver function tests
o BUN
o creatinine
o glucose
Immediate treatment if hypotensive with hematemesis or hematochezia:
o 2 L crystalloid solution, wait for blood
o Administer oxygen - 5-10 L/min by nasal cannula or mask
o Abdominal/Rectal exam – gross and occult blood in stool
o Insert urinary catheter if PT is in shock
o Insert nasogastric tube – perform aspiration and lavage
o Hospitalize in ICU
GI DDX:
Gastroenteritis
Gastritis
Colitis
Diverticulosis
Appendicitis
Peptic Ulcer Disease
Bowel Obstruction
Crohn Disease
Pancreatitis
Esophagogastric varices
Hemorrhoids
Cholecystitis
Acute hepatitis
» BURNS «
Leading cause of accidental death in the U.S.
Any burn of the upper body is more serious than a burn of the lower body of same degree with the hands, feet and external genitalia the most critical
Degree of Burns, and Severity:
First Degree
o moderate if 50% - 75% of adult
Second Degree
o minor – less than 15% in adult, 10% in child
o moderate – 15% - 30% in adult, 10% - 20% in child
o critical – greater than 30% in adult, greater than 20% in child
Third Degree (full thickness)
o minor – less than 2% body surface
o moderate – less than 10% body surface
o critical – more than 10%, any involvement of face, hands, feet or genital area OR if burns are caused by chemicals or electricity
Critical Burns
• Burns that are complicated by respiratory tract injuries or other major injury or fracture
• third degree burns involving the face, hands, feet or genitals
• third degree burns > than 10% of adult body or 2-3% of child body surface
• A moderate burn in an 80 y.o. or debilitated person
• second degree burns that cover > 30% of an adult’s body or > 20% of a child’s body surface
• First degree burn that cover more than 75% of the body surface
• most chemical burns
• most electrical burns
• burns in patients with serious underlying medical condition
Moderate Burns
• third degree burns, cover 2-10 % of adult body sfc; excluding face, eyes, ears, hands, feet, genitals
• second degree burns that cover 15-30% of adult body surface
• first degree burns that cover 50-75% of an adult’s body surface
• An uncomplicated burn that covers 10-20% of a child’s body surface in the second degree
Treatment and Care of Burns:
• monitor airway
• remove from heat source
• vital signs
• get history
• remove clothing and jewelry
• Immerse in cool water – up to 30 min – no ice!
• keep warm, prevent and treat for shock
• examine for respiratory/cardiac complications
Treatment for Inhalation injuries:
• Insert airway
• Remove from fire
• 02 high flow
• Transport immediately
Chemical Burns
• TREAT AGGRESSIVELY
• Flush with water
• Remove clothing/jewelry
Electrical Burns
• separate patient from source
• ABC’s – breathing, pulse
• CPR prn
• Tx for shock
• Tx burns as heat burns
• cover burns with dressing
• assess for other injuries
• Transport
» HEAD AND NECK INJURIES «
Check the following:
• Vital Signs
• Level of consciousness
• Condition of pupils
• Patient’s ability to move
• Patient’s pattern of speech
• History
Rising Blood Pressure pressure inside skull
Falling Blood Pressure blood loss and shock
High or Rising Pulse hemorrhage or neurological shock
Falling Pulse pressure inside skull
Rising Temperature brain injury
Slow Respirations depressed respiratory system
Ataxic Respirations serious, medulla damage
Always aggressively manage airway and assume C-spine injury with any head injury
DO NOT stop bleeding or CSF draining from nose or ears when skull fracture is suspected, for this will result in intracranial pressure
What is the most life threatening problem with head injuries?
• respiratory distress due to ataxic breathing or apnea
COMA
Causes:
• hypoglycemia
• drug overdose
• carbon monoxide poisoning
Treatment:
• 02 with 100% non-rebreather mask
• IV 50% dextrose IV
• Secure an airway
• ABC’s
Emergency Care of Head Injuries
• Establish an airway
• control scalp hemorrhage
• apply gentle direct pressure
• Avoid moving HEAD or NECK
• For open skull fracture, loosely apply sterile dressing
• Stabilize head, keep supine
• Suspect c-spine injury
• Neurological exam
• Monitor Vital Signs
o Intracranial pressure
increased (↑) BP with decreased (↓) pulse and respiration
• MUST RULE OUT CERVICAL SPINE INJURY WITH X-RAY
o even if PT can move
o look for…paresthesias, neck discomfort, numbness, tingling, loss of function, loss of bladder or bowel control, impaired breathing, priapism
Treatment of Cervical Injuries:
• splint neck/back in original position of injury
• advise to not move their heads
• Immobilize before movement
• spine board
• Monitor respiratory status
• Monitor for shock
» ABDOMINAL INJURY «
Solid Organ injury
• liver and spleen
• rapid and significant blood loss
• exsanguinations
Hollow Organ injury
• Colon and small intestine
• sepsis, wound infection, abscess formation, peritonitis
Retroperitoneal Organ injury
• Kidneys, ureters, pancreas, duodenum
• massive hemorrhage
Pelvic Organ injury
• urinary bladder and urethra
• sepsis, wound infection, abscess
TREATMENT:
• apply saline gauze or dry sterile dressing
• cut away clothing to assess wound
• suspect shock with any abdominal injury
• control bleeding – dress wounds
• position on back, legs elevated or flexed
• monitor vital signs
• administer oxygen for shock (high flow)
• stabilize impaled objects
• transport
» ABDOMINAL PAIN «
REFERRED PAIN
Ailments and their pain referrels:
• cardiac pain neck, jaw, shoulder, pectoral muscle, down the arms
• biliary pain right shoulder
• renal colic genitalia and flank areas
• uterine and rectal pain low back
• leaking aortic aneurysm lower back or buttock
Ailments and their type of pain:
Abrupt, excruciating pain
o Biliary colic
o Ureteral colic
o Myocardial infarction
o Perforated ulcer
o Ruptured aneurysm
Rapid onset of severe constant pain
o Acute pancreatitis
o Mesenteric thrombosis
o Strangulated bowel
o Ectopic pregnancy
Gradual, steady pain
o Acute cholecystitis
o Acute cholangiitis
o Acute hepatitis
o Appendicitis
o Acute salpingitis
Intermittent, colicky pain, crescendo with free intervals
o Early pancreatitis
o Small bowel obstruction
o Inflammatory bowel diseases
Most common SIGNS AND SYMPTOMS and most likely associated ailments:
Nausea, vomiting, anorexia
o Appendicitis
o Biliary tract disease
o Gastritis
o High intestinal obstruction
o Pancreatitis
Diarrhea
o Inflammatory process (IBD, gastroenteritis)
Constipation
o Dehydration
o Obstruction
o Iatrogenic causes
Change in stool color
o Biliary tract obstruction (clay colored stools)
o Lower intestinal bleeding (black, tarry stools)
Chills and fever
o Appendicitis
o Bacterial Infection
o Cholecystitis
o Pyelonephritis
Colicky Pain – Intense, writhing pain of a roller-coaster quality coming in intense waves. We might also call this crescendo-decrescendo. Causes include:
• small or large bowel obstruction (sigmoid volvulus, adhesions or neoplasms)
• Bile duct obstruction (gallstones, pancreatitis or ulcer disease)
• Obstruction of the ureters (kidney disease)
Peritoneal Pain – Constant, severe and generalized abdominal discomfort caused by inflammation of the peritoneal wall. REBOUND TENDERNESS.
• Appendicitis
• diverticulitis
• ectopic pregnancy
• abdominal infection
• anything causing hemorrhage to the peritoneum
Abdominal pain with nausea and vomiting:
• Bowel obstruction
• Gastroenteritis
• Gallstones
• Kidney stones
• Myocardial Infarction
• Elevated intracranial pressure
Signs and Symptoms of ectopic pregnancy:
• Pallor
• Weakness
• Hypotension
• Syncopy
• Shoulder pain
• vaginal bleeding
» DIABETIC EMERGENCIES «
DIABETIC COMA
TWO TYPES:
1) Hyperglycemic hyperosmolar ketoacidosis (ketotic coma, DKA) (rare)
• decrease insulin, high blood sugar
• coma caused by acidosis and dehydration
• More common
• SLOW ONSET (2-3 d.)
• lethargy increases, eventually trouble waking them up
• Causes: too-small insulin dose, failure to take, forgot to take insulin, infection, stress, increased dietary intake, decreased metabolic rate, MI…
• Symptoms: air hunger, rapid deep breathing, warm dry skin, dry lips, fever, sunken eyes, dim vision, sweet fruity breath, rapid weak pulse, N/V, intense thirst, dehydration, frequent urination, fatigue, stupor, frothy urine, Kussmaul’s respiration, confusion, decreased consciousness…
• Treatment: Monitor Vitals, Maintain Airway, Give oxygen, give fluids, give insulin, Tx for shock, IV insulin, hospitalize
2) Hyperglycemic hyperosmolar nonketotic coma (never seen it have you??)
• no ketones, no acetone (sweet) breath
• Symptoms: flaccid, quiet breathing, extreme dehydration, weakness, frequent urination, flushed dry skin, postural hypotension
• Precipitating factors: advancing age, preexisting cardiac or renal disease, inadequate insulin secretion or action, increased insulin requirements, medications
• Treatment: Does not change, same as above – fluid, insulin, potassium, phosphate
INSULIN SHOCK (HYPOGLYCEMIA) (common, esp with pts on hypoglycemics or insulin, poorly managed, multiple meds)
Blood sugar below 40 – occur 5 – 20 min after injection of insulin
Gave self insulin then missed meal
or More activity on that day than normal, went rafting, etc
• High Insulin, Low Sugar
• Insufficient sugar for brain due to too much insulin
• SUDDEN ONSET (MINUTES)(can occur at night: can't rouse the diabetic in the morning, give sugar)
• Causes: skipping a meal, high insulin, excess exercise, vomiting/diarrhea, severe emotional excitement or exertion, exposure to cold, liver disease, malnutrition, cancer, sepsis, beta-blockers, salicylates in children or infants
• Symptoms: shock, extreme weakness, pale moist cool skin, diplopia, apathy, irritability, unconsciousness, drooling, tremors, convulsions, low thirst, paresthesias in fingers/feet, faintness, sweating
• Treatment: SUGAR on the tongue
When in doubt, give sugar. It cannot hurt the patient in a diabetic coma (too much sugar, not enough insulin) and may end up saving the life of a patient in insulin shock (low sugar, high insulin)
» HEAT AND COLD EMERGENCIES «
HYPERTHERMIA
Usually associated with rigorous exercise, marathon, elderly, or early in the summer
HEAT EXHAUSTION VERSUS HEAT STROKE
HEAT STROKE
A mild??? state of shock brought on by the pooling of blood in vessels; blood flows away from major organs and the body loses large amounts of salt and water via sweat. Two types: salt depletion and water depletion. Also known as “sunstroke”, this is when the body’s heat regulating mechanisms break down and therefore fails to cool the body. Body overheats to 105 – 110 degrees F. The body can no longer “compensate” or “adapt”.
Symptoms
Weak rapid pulse (↑)
Rapid shallow breathing (↑)
Pale, moist, clammy skin
Ashen gray color
Headache, dizziness, nausea
Weakness, faintness, sweating
Anorexia, collapse, dilated pupils, unconsciousness
Heat cramps, difficulty walking Dry, hot, red skin (no sweat)
Constricted pupils
Very high body temperature
Strong, rapid pulse
Coma/near coma
Tremors, mental confusion
Deep rapid breathing shallow and weak
Headache, dry mouth
N/V (if hyponatremic needs electrolytes but can't keep them down: start gradual w/ salty/sugary beverage)
weakness, dizziness
Low BP
Treatment
Rapid cooling, avoid heat sources, drench clothing, submerge, don't waste time
Monitor for reheating, keep rechecking temp just as you would using a tepid bath to lower a high fever
Shock position: Lie down, elevate feet, lower head
Loosen clothing
Saltwater (1 tsp./Qt.) – ½ glass q15 min with glucose too!!! not just salt
IV saline if unconscious
Airway – O2 – Remove from direct sunlight and heat, undress, wet down with cold water and fan briskly.
Complications
Loss of consciousness
Convulsions, muscular twitching, sudden collapse, unconsciousness, decreased urinary output
Brain swelling, heart failure, liver and kidney failure, hypertension, coma,
☺☻DEATH! ☻☺
HYPOTHERMIA
Can occur at environment temperatures of 50 – 60 degrees Fahrenheit, most occur at 40 – 50
Body loses thermal balance at 95 degrees Fahrenheit and coma occurs at core temperature of 79.
Compounding factors: wind chill, moisture, exhaustion, drugs, disease, trauma, age extremes
Signs and Symptoms:
• cyanosis
• pallor
• facial bloating
• slow, slurred speech
• apathy
• drowsiness
• poor judgment
• dizziness
• amnesia
• unconsciousness
• sluggish pupils
• shivering uncontrollably
• dehydration
• muscular rigidity (later stages)
• staggering gait
• mental confusion
• disorientation
• decreased heart and respiratory rate
• weak, irregular pulse
• low blood pressure
91 degrees F is cut-off for ability to turn around symptoms;
SEVERE HYPOTHERMIA BELOW THIS TEMPERATURE
Treatment: depends on how long they have been cold
if cold for long time, say found in snow drift, package cold (do not rewarm)
transport to ALS for rewarming, GENTLY!, this pt is fragile and could go into V-tach if beat around
if not cold for so long rewarm:
• warm up with tepid water – 85–90 degrees F – less than body temperature
• Trunk first than individual extremities one at a time
• Raise body temperature one (1) degree per hour
• If conscious warm fluids internally, hydrate well, toxins from stagnant blood in extremities can cause arrhythmias etc when that blood is returned to central circulation so monitor well!
» MUSCULOSKELETAL INJURIES «
Not going to see a lot of Get to hospital/ER
Sprains – ligamentous tear beyond end range of joint, most commonly in the ankle and knee
• classified by first, second and third degree as gradient of damage, from minimal swelling and joint stable increased swelling and ecchymosis total disruption of ligaments leaving nerves and vasculature compromised
Fractures – MUST BE IMMOBILIZED – will decrease pain, limit surrounding soft tissue injury and prevent progression of closed fracture to an open fracture
• Be aware of potential for blood loss even from closed fracture which is more so a risk a the pelvis or femur (hips) than upper extremities or distal lower extremities.
Assessment: Pain – Pulse – Paresthesia – Paralysis – Pallor
Care of fractures:
1) Remove clothing, jewelry
2) Apply traction
3) DO NOT STRAIGHTEN FRACTURE OF JOINTS – splint in position it is in after trauma
4) DO NOT PUSH BONES BACK in open fracture – cover with sterile dressing and transport
5) Immobilize the joints above and below fracture
6) Splint firmly but DO NOT IMPAIR PULSES – make sure to check distal pulse after splint is applied, as well as sensation and motor function
7) Use traction splint for fractures above the knee, inflatable splints below the knee and the other leg for hip fractures
8) Apply cold to decrease inflammation
9) Apply compression to reduce edema
10) Elevate extremity if possible
POISON
Call poison control for specific instructions
Questions to ask:
• What was ingested? Check specific contents of bottle. Any mixing of chemicals?
• Has there been vomiting?
• Any antidote given?
• Why and how did it take place? Accident? Recreational use? Suicide?
• Psychiatric history
Symptoms for ingestion poisoning:
• nausea
• diarrhea
• vomiting
• dilated pupils
• constricted pupils
• severe abdominal pain
• abdominal cramps
• decreased respiration
• excess salivation
• sweating
• excessive tearing
• odor, breath
• signs of shock
• stains, mouth, hands
Treatment:
• Check the scene
• Retain empty containers
• maintain airway
• Induce vomiting with syrup of Ipecac if within 30-60 minutes
• Follow syrup with activated charcoal in water
• Rule Out MI – Do not induce vomiting if suspicion not cleared
• Monitor vitals, may need life support
Instructions for Ipecac use:
• 1 Tbsp (15 mL) for child over 1 year of age, followed by 2-3 glasses of water
• 2 Tbsp (30 mL) for adult (start with less than repeat), followed by 2-3 glasses of water
• Keep sitting, repeat in 20 minutes if no vomiting occurs
• Give activated charcoal after vomiting has ceased – 2-4 Tablespoons
OXYGEN THERAPY
Device Flow Rate L/min. % Oxygen
Nasal cannula 4-6 25-40
Plastic face mask 10 50-60
Venturi mask 4 24
2 25
2 35
2 40
Partial Rebreather mask 6-8 35-60
Non-rebreather mask 10-15 90
SHOCK
• Hypovolemic- cause by fluid loss hemorrhagic (blood loss due to bleeding) and non-hemorrhagic (metabolic loss such as burns, dehydration, vomiting and excessive urination)
• Cardiogenic- Heart fails to pump enough blood. Heart is damaged or injured- very hard to reverse. Examples are coronary artery disease, ventricular failure, etc..
• Peripheral vascular - blood vessels dilate or constrict, causing pooling of blood in the periphery and decrease perfusion at the core. May be cause by neurogenic shock (spinal or head injury), septic shock (following severe infection) and psychogenic shock (fainting).
Sx and Signs of Shock:
1. Most common early signs: restlessness, mental confusion,
disorientation.
2 paleness of skin, coolness, chalk like color
3. tachycardia, weak and thready pulse
4. thirst, with dry mouth
5. early shock may have NORMAL V/S
6. late signs: low or unobtainable B/P
rapid, thready pulse
bluish or purplish discoloration of skin
dilated pupils, dull lusterless eves
faintness or unconsciousness
irregular, gasping respiration’s
Note: it is important to remember that low B/P is a late and usually serious sign of shock
(not just vasovagal response, low BP indicates decompensation)
Remember – a restless hypoxic patient who is in need of oxygen and lower extremity elevation can be in shock and have near normal B/P
QUICK BLOOD PRESSURE ASSESMENT
If no B/P cuff is avail you can assess:
If radial pulse is palp – B/P is 80 systolic
If a brachial pulse is palp – B/P is 70 systolic
If a femoral pulse is palp – B/P is 60 systolic
If a carotid pulse is palp – B/P is 50 systolic
If you can’t hear a B/P then palpate it
4 STAGES OF SHOCK
• I- COMPENSATED- Blood pressure drops and the body compensates by vasoconstricting to send blood to vital organs.
• II- DECOMPENSATED- the body attempts to compensate with vasoconstriction, but there is not enough supply to support the vital organs. Intervention is necessary and must be immediate.
• III- DISSEMINATED INTRAVASCULAR COAGULATION- Blood begins to coagulate in the microcirculation and clogs capillaries. This occludes the vessels and decrease perfusion. Water and sodium leak into the cells and potassium leaks out, cause inth cell to swell. This stage is difficult to treat but can be reversed.
• IV- IRREVERSIBLE - Multiple Organ Failure Cellular damage will occur and all systems are involved. Must prevent this stage from occurring.
Management of Shock: This is an unstable condition
1. Establish an airway – breathing should be constantly monitored as pt can change any moment.
2 assist breathing as needed.
3. Stop bleeding if present. Use gentle but firm DIRECT PRESSURE with
Sterile gauze if possible. Must maintain pressure ESP if an arterial bleed.
4. Elevate lower extremities and maintain a head low position unless contraindicated.
5. Immobilize fractures; this lessens damage to soft tissues from splintered bone ends.
6. Avoid any rough or excessive handling
7. Transport safely.
8. Keep the temperature normal. Avoid intense cooling, which causes
shivering. Prevent loss of heat. Best to be kept slightly cool than too warm.
9. Monitor state of consciousness, and V/S q 5 min
10. No food or drink.
ANAPHYLAXIS
Onset 1-15 min or 1.5-2 hours
Signs and symptoms
early: flush, dizzy, itching of lips, throat, tongue, sudden pruritic rash over entire body
if conscious give antihistamine, big dose, immediately upon recognizing a systemic reaction
palpation, paresthesia, pruritis, throbbing in ears, cough, sneezing, dyspnea
systemic vasodilation causes loss of BP, dizziness, pulse increases to compensate
later: throat swells shut, if unconscious get airway inserted before this happens
IM epi adminstration in time will prevent airway occlusion (quad, glut, delt)
don't give epi unless airway is threatened
don't give repeat epi unless pt condition deteriorates again
dose is 0.3-0.5 ml depending on body mass, most epi pens contain just one dose of about 0.3
expired epi may still work if it is still clear: if you have no other option, use it
if it is discolored (yellow) it is no good
may have to re-administer epi within 2-20 minutes if fast acting reaction
monitor unconscious patient carefully
epi can be dangerous to pts with cardiovascular compromise so don't give if not thoroughly indicated
convulsions, death unlikely to occur if airway is properly managed
if you have no epi and pt is unconscious and still getting enough air to survive
and if you HAVE benadryl, lots of it, then here's a trick to try
desperate measures: make paste of benadryl and swab it on mucous membranes of mouth and insert anally
coat as much mucus membrane as possible
this may stop the massive degranulation that is causing the anaphylaxis
and save a life
Treatment: (this is Wilson's version, I totally disagree with his version, my notes are above)
Immediately admin. Epinephrine 1:1000 dilution SC give 0.3 to 0.5 ml
In an injected antigen – place a tourniquet above the site and inject 0.1 0.2 ml above the site and at the site.
If no serious side effects of epinephrine, give a second dose if needed in 15– 20 min.
Give O2 in large amounts (10 –15 L/min.) monitor vital signs. A long acting epinephrine can be given as a second injection. Susphrine 0.3 ml SC
If in shock may need IV fluids and keep legs elevated.
Patients unresponsive to epinephrine should be given glucagon
If you have to give O2 and epinephrine be sure to call 911
RESPIRATORY DISTRESS/ ASTHMA
Signs of life-threatening respiratory distress in adults includes:
• Alterations in mental status
• Severe cyanosis
• Absent breath sounds
• Audible stridor
• One-or two-word dyspnea
• Tachycardia
• Pallor and diaphoresis
• Presence of retractions and/or the use of acces¬sory muscles to assist
with breathing
Acute Asthma -Four stages of an acute asthma attack:
Asthma attacks are a true medical emergency.
• Mild: mild dyspnea, diffuse wheezes, adequate air exchange. FEV1 50-80% of normal
• Moderate: respiratory distress at rest, hyperpnea, marked wheezes, air exchange is normal to decreased. FEV1 is 50% of normal
• Severe: marked respiratory distress, marked wheezes or absent breath sounds, check for pulsus paradoxus (drop of systolic blood pressure with inspiration)>10 mm. Sternocleidomastoid retraction.
FEV1 is 25% of normal
• Respiratory failure
severe respiratory distress, lethargy, confusion, prominent pulsus paradoxus, sternocleidomastoid retraction
FEV1 is 10% of normal
Acute Pulmonary Edema
Two general groups of causes: First is cardiac related, such as heavy smoking, MI, CHF, hypertension, etc.. The other is due to near drowning, aspiration pneumonia, smoke inhalation or inhalation of toxins. Oh and yeah folks at high altitudes can get this too, and anyone with metabolic acidosis that goes too far.
Signs and Symptoms
• Dyspnea, rapid shallow labored breathing, crackling or wheezing sounds, cyanosis, blood tinged sputum, distended jugular vein, rapid pulse, cool/clammy skin, restlessness, anxiety, feeling of impending doom, pedal edema
Treatment
High flow O2
keep patients head and shoulders elevated
keep patient calm (and yourself)
transport (call 911)
Hyperventilation/ Panic Attack
Signs and Symptoms
• anxiety
• dyspnea
• dizziness
• blurring of vision
• dryness of mouth
• numbness and /or tingling of hands or feet or around mouth
• lump in throat
• pounding of heart
• caropedal spasm (drawing up of hands at wrist and knuckles with flexed fingers
• fainting
• rapid pulse and respitation
**Remember that the initial presentation of pulmonary embolism and hyperventilation are similar so hyperventilation should be considered only after all other causes have been ruled out.
Treatment
calm patient if possible and have them breath into a O2 mask without being hooked up to O2 source or breath into a paper bag
Homeopathics: Aconite, Chamomile, *Ars, Arg-N, Aur, Bell, *Spong
rescue remedy
http://people.vanderbilt.edu/~akshay.shah/ems/notes/notes2.html
notice, all ye from NCNM, that on this page a normal oriented person is A&O x4
ONLY at NCNM is normal x3. =-/
» EYE PAIN AND INJURIES «
Ocular injuries are TRUE EMERGENCIES
Foreign object in the eye:
1) Inspect for location (cornea or conjunctiva)
2) Flush from inner acanthi outward with fresh water
3) Draw upper lid down over the lower lid and as the upper lid returns to its normal position, the under surfaces will be drawn over the lashes of lower lid and the foreign body will be removed
4) Expose the underside of the upper lid by grasping the lashes of the upper lid and rolling them over a match stick or Q-tip
5) Pull down the lower lid and remove the particle with a gauze corner
6) DO NOT PROBE – if embedded place a bandage over both eyes and transfer
7) Perform fluorescein and slit lamp examination to confirm diagnosis
8) Consider x-ray or CT scan for intraocular metal foreign body
9) Orbital injuries require hospitalization and possible surgery; remember they are true emergencies
DO NOT REMOVE IMPALED OBJECTS
• bandage both eyes
• protect eye/object with cup or cone
• stabilize head
• reassure patient
Chemical burns: flush for 20 minutes
• lavage with copious amounts of isotonic saline solution, Ringer’s or water
• remove any remaining particles
Acute Closed Angle Glaucoma:
• red eye
• decrease pupil reaction
• colored halo around bright objects
• headache
• nausea
• may cause blindness
• severe pain
• fixed, irregular, mid-dilated pupil
• sudden onset
• shallow anterior chamber
• elevated intraocular pressure
• photophobia
• Tx: Glycerin, 1 g/kg body weight orally, in cold 50% solution mixed with chilled lemon juice
Retinal detachment
• “curtain” blocking the vision
• light flashes
• dark spots in front of eyes
• transport gently
• do not bump patient (Bryonia)
may be preceded by vitreous humor detachment: floaters and flashes, have it assessed just in case
fix is surgical, prevention is antidiabetic
Corneal abrasion
• Use flourescene dye to detect injury
• very painful
• 3 – 6 hours after injury
Light burns
• welding flash, snow blindness, UV light burn
• PAIN; Actinic keratitis
• Perform fluorescene and slit lamp examination to confirm diagnosis
• consider x-ray or CT scan for intraocular metal foreign body
• rest eyes, remain in dark room, will heal within two to five days
Heat burns
• apply sterile wet dressing
General Eye Treatment:
• Wash only if chemic burn or detergent injury
• do not put salves or medicines into the injured eye
• do not remove blood from eye
• do not force eye lids open unless chemical burns
• limit use of uninjured eye
• keep patient quiet and don’t let them walk around
• bandage both eyes and transport
Red or painful eye – priority of questions/concerns:
1) Trauma
2) Chemical exposure
3) Foreign body, dust, metal chips
4) Light burns
5) Visual acuity
6) Discharge
Red or painful eye – with conjunctival discharge
purulent Bacterial or Chlamydial conjunctivitis
not purulent Gram and Giemsa stains and culture
Allergic, Viral or Nonspecific conjunctivitis
Red or painful eye – decreased visual acuity – constricted pupil Uveitis
Pain with no history of trauma, light, foreign body or chemical exposure and…abnormal fluorescein examination of cornea
1) keratitis
2) corneal ulcer
3) corneal abrasion
Differential Diagnosis List for decreased visual acuity and pain:
1) Keratitis
2) Corneal Ulcer
3) Corneal abrasion
4) Uveitis
5) Acute Angle-Closure Glaucoma (normal fluorescein)
Orbital Cellulitis and Cavernous Sinus Thrombosis
*Must Be Differentiated*
usually caused by Staph in adults, Haemophilus influenza in children
Cavernous Sinus Thrombosis
Signs and Symptoms:
chills
headache
lethargy
nausea
pain
decreased vision
fever
vomiting
unilateral or bilateral exophthalmos
absent papillary reflexes
impaired EOM
decreased corneal sensation
What to do with this patient?:
Hospitalize the patient immediately
Send blood to the laboratory for culture
Ophthalmolgic, neurological, medical consultation
Obtain CT scan of the head and orbit
Anterior Uveitis and Iritis
Symptoms:
Photophobia
Unilateral gradual onset of eye pain
Red eye without discharge
Blurred vision
Excessive tearing
Signs:
Perilimbal injection
» GI BLEEDING «
» Esophageal varices – Mallory Weiss Syndrome – Peptic Ulcers – Hemorrhoids – Neoplasm «
Mallory Weiss Syndrome – tears in mucosa of espophago-gastric junction secondary to prolonged or forceful vomiting.
Alcohol consumption
Bulimia
Active, profuse hematemesis or hematochezia may indicate
Major, acute gastrointestinal tract bleeding
Severe liver disease
Advanced age
Coagulopathy
Cardiopulmonary disease
If frank blood is not present:
1) obtain vital signs
2) examine for shock
If supine hypotension or postural hypotension is NOT present
1) Obtain history
2) Perform brief examination
3) Obtain venous access and blood for type and screen, hematocrit, and PT/PTT
4) Nasogastric lavage
a. Upper GI Bleed, may include any of the following:
i. hematemesis
ii. blood in nasogastric aspirate
iii. melenic stool
iv. Hyperactive bowel sounds
v. DDX: Gastric ulcer, gastritis, peptic ulcer, esophageal varices
b. Lower GI Bleed
i. No hematemesis
ii. bile and no blood in nasogastric aspirate
iii. maroon stools
iv. hematochezia, esp. with normal hyperactive bowel sounds
v. DDX: Neoplasm, hemorrhoids, angioma, diverticulitis
What tests do you want to run if active profuse hematemesis or hematochezia is occurring?
o blood type and crossmatch
o PT/PTT
o CBC
o serum electrolytes
o liver function tests
o BUN
o creatinine
o glucose
Immediate treatment if hypotensive with hematemesis or hematochezia:
o 2 L crystalloid solution, wait for blood
o Administer oxygen - 5-10 L/min by nasal cannula or mask
o Abdominal/Rectal exam – gross and occult blood in stool
o Insert urinary catheter if PT is in shock
o Insert nasogastric tube – perform aspiration and lavage
o Hospitalize in ICU
GI DDX:
Gastroenteritis
Gastritis
Colitis
Diverticulosis
Appendicitis
Peptic Ulcer Disease
Bowel Obstruction
Crohn Disease
Pancreatitis
Esophagogastric varices
Hemorrhoids
Cholecystitis
Acute hepatitis
» BURNS «
Leading cause of accidental death in the U.S.
Any burn of the upper body is more serious than a burn of the lower body of same degree with the hands, feet and external genitalia the most critical
Degree of Burns, and Severity:
First Degree
o moderate if 50% - 75% of adult
Second Degree
o minor – less than 15% in adult, 10% in child
o moderate – 15% - 30% in adult, 10% - 20% in child
o critical – greater than 30% in adult, greater than 20% in child
Third Degree (full thickness)
o minor – less than 2% body surface
o moderate – less than 10% body surface
o critical – more than 10%, any involvement of face, hands, feet or genital area OR if burns are caused by chemicals or electricity
Critical Burns
• Burns that are complicated by respiratory tract injuries or other major injury or fracture
• third degree burns involving the face, hands, feet or genitals
• third degree burns > than 10% of adult body or 2-3% of child body surface
• A moderate burn in an 80 y.o. or debilitated person
• second degree burns that cover > 30% of an adult’s body or > 20% of a child’s body surface
• First degree burn that cover more than 75% of the body surface
• most chemical burns
• most electrical burns
• burns in patients with serious underlying medical condition
Moderate Burns
• third degree burns, cover 2-10 % of adult body sfc; excluding face, eyes, ears, hands, feet, genitals
• second degree burns that cover 15-30% of adult body surface
• first degree burns that cover 50-75% of an adult’s body surface
• An uncomplicated burn that covers 10-20% of a child’s body surface in the second degree
Treatment and Care of Burns:
• monitor airway
• remove from heat source
• vital signs
• get history
• remove clothing and jewelry
• Immerse in cool water – up to 30 min – no ice!
• keep warm, prevent and treat for shock
• examine for respiratory/cardiac complications
Treatment for Inhalation injuries:
• Insert airway
• Remove from fire
• 02 high flow
• Transport immediately
Chemical Burns
• TREAT AGGRESSIVELY
• Flush with water
• Remove clothing/jewelry
Electrical Burns
• separate patient from source
• ABC’s – breathing, pulse
• CPR prn
• Tx for shock
• Tx burns as heat burns
• cover burns with dressing
• assess for other injuries
• Transport
» HEAD AND NECK INJURIES «
Check the following:
• Vital Signs
• Level of consciousness
• Condition of pupils
• Patient’s ability to move
• Patient’s pattern of speech
• History
Rising Blood Pressure pressure inside skull
Falling Blood Pressure blood loss and shock
High or Rising Pulse hemorrhage or neurological shock
Falling Pulse pressure inside skull
Rising Temperature brain injury
Slow Respirations depressed respiratory system
Ataxic Respirations serious, medulla damage
Always aggressively manage airway and assume C-spine injury with any head injury
DO NOT stop bleeding or CSF draining from nose or ears when skull fracture is suspected, for this will result in intracranial pressure
What is the most life threatening problem with head injuries?
• respiratory distress due to ataxic breathing or apnea
COMA
Causes:
• hypoglycemia
• drug overdose
• carbon monoxide poisoning
Treatment:
• 02 with 100% non-rebreather mask
• IV 50% dextrose IV
• Secure an airway
• ABC’s
Emergency Care of Head Injuries
• Establish an airway
• control scalp hemorrhage
• apply gentle direct pressure
• Avoid moving HEAD or NECK
• For open skull fracture, loosely apply sterile dressing
• Stabilize head, keep supine
• Suspect c-spine injury
• Neurological exam
• Monitor Vital Signs
o Intracranial pressure
increased (↑) BP with decreased (↓) pulse and respiration
• MUST RULE OUT CERVICAL SPINE INJURY WITH X-RAY
o even if PT can move
o look for…paresthesias, neck discomfort, numbness, tingling, loss of function, loss of bladder or bowel control, impaired breathing, priapism
Treatment of Cervical Injuries:
• splint neck/back in original position of injury
• advise to not move their heads
• Immobilize before movement
• spine board
• Monitor respiratory status
• Monitor for shock
» ABDOMINAL INJURY «
Solid Organ injury
• liver and spleen
• rapid and significant blood loss
• exsanguinations
Hollow Organ injury
• Colon and small intestine
• sepsis, wound infection, abscess formation, peritonitis
Retroperitoneal Organ injury
• Kidneys, ureters, pancreas, duodenum
• massive hemorrhage
Pelvic Organ injury
• urinary bladder and urethra
• sepsis, wound infection, abscess
TREATMENT:
• apply saline gauze or dry sterile dressing
• cut away clothing to assess wound
• suspect shock with any abdominal injury
• control bleeding – dress wounds
• position on back, legs elevated or flexed
• monitor vital signs
• administer oxygen for shock (high flow)
• stabilize impaled objects
• transport
» ABDOMINAL PAIN «
REFERRED PAIN
Ailments and their pain referrels:
• cardiac pain neck, jaw, shoulder, pectoral muscle, down the arms
• biliary pain right shoulder
• renal colic genitalia and flank areas
• uterine and rectal pain low back
• leaking aortic aneurysm lower back or buttock
Ailments and their type of pain:
Abrupt, excruciating pain
o Biliary colic
o Ureteral colic
o Myocardial infarction
o Perforated ulcer
o Ruptured aneurysm
Rapid onset of severe constant pain
o Acute pancreatitis
o Mesenteric thrombosis
o Strangulated bowel
o Ectopic pregnancy
Gradual, steady pain
o Acute cholecystitis
o Acute cholangiitis
o Acute hepatitis
o Appendicitis
o Acute salpingitis
Intermittent, colicky pain, crescendo with free intervals
o Early pancreatitis
o Small bowel obstruction
o Inflammatory bowel diseases
Most common SIGNS AND SYMPTOMS and most likely associated ailments:
Nausea, vomiting, anorexia
o Appendicitis
o Biliary tract disease
o Gastritis
o High intestinal obstruction
o Pancreatitis
Diarrhea
o Inflammatory process (IBD, gastroenteritis)
Constipation
o Dehydration
o Obstruction
o Iatrogenic causes
Change in stool color
o Biliary tract obstruction (clay colored stools)
o Lower intestinal bleeding (black, tarry stools)
Chills and fever
o Appendicitis
o Bacterial Infection
o Cholecystitis
o Pyelonephritis
Colicky Pain – Intense, writhing pain of a roller-coaster quality coming in intense waves. We might also call this crescendo-decrescendo. Causes include:
• small or large bowel obstruction (sigmoid volvulus, adhesions or neoplasms)
• Bile duct obstruction (gallstones, pancreatitis or ulcer disease)
• Obstruction of the ureters (kidney disease)
Peritoneal Pain – Constant, severe and generalized abdominal discomfort caused by inflammation of the peritoneal wall. REBOUND TENDERNESS.
• Appendicitis
• diverticulitis
• ectopic pregnancy
• abdominal infection
• anything causing hemorrhage to the peritoneum
Abdominal pain with nausea and vomiting:
• Bowel obstruction
• Gastroenteritis
• Gallstones
• Kidney stones
• Myocardial Infarction
• Elevated intracranial pressure
Signs and Symptoms of ectopic pregnancy:
• Pallor
• Weakness
• Hypotension
• Syncopy
• Shoulder pain
• vaginal bleeding
» DIABETIC EMERGENCIES «
DIABETIC COMA
TWO TYPES:
1) Hyperglycemic hyperosmolar ketoacidosis (ketotic coma, DKA) (rare)
• decrease insulin, high blood sugar
• coma caused by acidosis and dehydration
• More common
• SLOW ONSET (2-3 d.)
• lethargy increases, eventually trouble waking them up
• Causes: too-small insulin dose, failure to take, forgot to take insulin, infection, stress, increased dietary intake, decreased metabolic rate, MI…
• Symptoms: air hunger, rapid deep breathing, warm dry skin, dry lips, fever, sunken eyes, dim vision, sweet fruity breath, rapid weak pulse, N/V, intense thirst, dehydration, frequent urination, fatigue, stupor, frothy urine, Kussmaul’s respiration, confusion, decreased consciousness…
• Treatment: Monitor Vitals, Maintain Airway, Give oxygen, give fluids, give insulin, Tx for shock, IV insulin, hospitalize
2) Hyperglycemic hyperosmolar nonketotic coma (never seen it have you??)
• no ketones, no acetone (sweet) breath
• Symptoms: flaccid, quiet breathing, extreme dehydration, weakness, frequent urination, flushed dry skin, postural hypotension
• Precipitating factors: advancing age, preexisting cardiac or renal disease, inadequate insulin secretion or action, increased insulin requirements, medications
• Treatment: Does not change, same as above – fluid, insulin, potassium, phosphate
INSULIN SHOCK (HYPOGLYCEMIA) (common, esp with pts on hypoglycemics or insulin, poorly managed, multiple meds)
Blood sugar below 40 – occur 5 – 20 min after injection of insulin
Gave self insulin then missed meal
or More activity on that day than normal, went rafting, etc
• High Insulin, Low Sugar
• Insufficient sugar for brain due to too much insulin
• SUDDEN ONSET (MINUTES)(can occur at night: can't rouse the diabetic in the morning, give sugar)
• Causes: skipping a meal, high insulin, excess exercise, vomiting/diarrhea, severe emotional excitement or exertion, exposure to cold, liver disease, malnutrition, cancer, sepsis, beta-blockers, salicylates in children or infants
• Symptoms: shock, extreme weakness, pale moist cool skin, diplopia, apathy, irritability, unconsciousness, drooling, tremors, convulsions, low thirst, paresthesias in fingers/feet, faintness, sweating
• Treatment: SUGAR on the tongue
When in doubt, give sugar. It cannot hurt the patient in a diabetic coma (too much sugar, not enough insulin) and may end up saving the life of a patient in insulin shock (low sugar, high insulin)
» HEAT AND COLD EMERGENCIES «
HYPERTHERMIA
Usually associated with rigorous exercise, marathon, elderly, or early in the summer
HEAT EXHAUSTION VERSUS HEAT STROKE
HEAT STROKE
A mild??? state of shock brought on by the pooling of blood in vessels; blood flows away from major organs and the body loses large amounts of salt and water via sweat. Two types: salt depletion and water depletion. Also known as “sunstroke”, this is when the body’s heat regulating mechanisms break down and therefore fails to cool the body. Body overheats to 105 – 110 degrees F. The body can no longer “compensate” or “adapt”.
Symptoms
Weak rapid pulse (↑)
Rapid shallow breathing (↑)
Pale, moist, clammy skin
Ashen gray color
Headache, dizziness, nausea
Weakness, faintness, sweating
Anorexia, collapse, dilated pupils, unconsciousness
Heat cramps, difficulty walking Dry, hot, red skin (no sweat)
Constricted pupils
Very high body temperature
Strong, rapid pulse
Coma/near coma
Tremors, mental confusion
Deep rapid breathing shallow and weak
Headache, dry mouth
N/V (if hyponatremic needs electrolytes but can't keep them down: start gradual w/ salty/sugary beverage)
weakness, dizziness
Low BP
Treatment
Rapid cooling, avoid heat sources, drench clothing, submerge, don't waste time
Monitor for reheating, keep rechecking temp just as you would using a tepid bath to lower a high fever
Shock position: Lie down, elevate feet, lower head
Loosen clothing
Saltwater (1 tsp./Qt.) – ½ glass q15 min with glucose too!!! not just salt
IV saline if unconscious
Airway – O2 – Remove from direct sunlight and heat, undress, wet down with cold water and fan briskly.
Complications
Loss of consciousness
Convulsions, muscular twitching, sudden collapse, unconsciousness, decreased urinary output
Brain swelling, heart failure, liver and kidney failure, hypertension, coma,
☺☻DEATH! ☻☺
HYPOTHERMIA
Can occur at environment temperatures of 50 – 60 degrees Fahrenheit, most occur at 40 – 50
Body loses thermal balance at 95 degrees Fahrenheit and coma occurs at core temperature of 79.
Compounding factors: wind chill, moisture, exhaustion, drugs, disease, trauma, age extremes
Signs and Symptoms:
• cyanosis
• pallor
• facial bloating
• slow, slurred speech
• apathy
• drowsiness
• poor judgment
• dizziness
• amnesia
• unconsciousness
• sluggish pupils
• shivering uncontrollably
• dehydration
• muscular rigidity (later stages)
• staggering gait
• mental confusion
• disorientation
• decreased heart and respiratory rate
• weak, irregular pulse
• low blood pressure
91 degrees F is cut-off for ability to turn around symptoms;
SEVERE HYPOTHERMIA BELOW THIS TEMPERATURE
Treatment: depends on how long they have been cold
if cold for long time, say found in snow drift, package cold (do not rewarm)
transport to ALS for rewarming, GENTLY!, this pt is fragile and could go into V-tach if beat around
if not cold for so long rewarm:
• warm up with tepid water – 85–90 degrees F – less than body temperature
• Trunk first than individual extremities one at a time
• Raise body temperature one (1) degree per hour
• If conscious warm fluids internally, hydrate well, toxins from stagnant blood in extremities can cause arrhythmias etc when that blood is returned to central circulation so monitor well!
» MUSCULOSKELETAL INJURIES «
Not going to see a lot of Get to hospital/ER
Sprains – ligamentous tear beyond end range of joint, most commonly in the ankle and knee
• classified by first, second and third degree as gradient of damage, from minimal swelling and joint stable increased swelling and ecchymosis total disruption of ligaments leaving nerves and vasculature compromised
Fractures – MUST BE IMMOBILIZED – will decrease pain, limit surrounding soft tissue injury and prevent progression of closed fracture to an open fracture
• Be aware of potential for blood loss even from closed fracture which is more so a risk a the pelvis or femur (hips) than upper extremities or distal lower extremities.
Assessment: Pain – Pulse – Paresthesia – Paralysis – Pallor
Care of fractures:
1) Remove clothing, jewelry
2) Apply traction
3) DO NOT STRAIGHTEN FRACTURE OF JOINTS – splint in position it is in after trauma
4) DO NOT PUSH BONES BACK in open fracture – cover with sterile dressing and transport
5) Immobilize the joints above and below fracture
6) Splint firmly but DO NOT IMPAIR PULSES – make sure to check distal pulse after splint is applied, as well as sensation and motor function
7) Use traction splint for fractures above the knee, inflatable splints below the knee and the other leg for hip fractures
8) Apply cold to decrease inflammation
9) Apply compression to reduce edema
10) Elevate extremity if possible
POISON
Call poison control for specific instructions
Questions to ask:
• What was ingested? Check specific contents of bottle. Any mixing of chemicals?
• Has there been vomiting?
• Any antidote given?
• Why and how did it take place? Accident? Recreational use? Suicide?
• Psychiatric history
Symptoms for ingestion poisoning:
• nausea
• diarrhea
• vomiting
• dilated pupils
• constricted pupils
• severe abdominal pain
• abdominal cramps
• decreased respiration
• excess salivation
• sweating
• excessive tearing
• odor, breath
• signs of shock
• stains, mouth, hands
Treatment:
• Check the scene
• Retain empty containers
• maintain airway
• Induce vomiting with syrup of Ipecac if within 30-60 minutes
• Follow syrup with activated charcoal in water
• Rule Out MI – Do not induce vomiting if suspicion not cleared
• Monitor vitals, may need life support
Instructions for Ipecac use:
• 1 Tbsp (15 mL) for child over 1 year of age, followed by 2-3 glasses of water
• 2 Tbsp (30 mL) for adult (start with less than repeat), followed by 2-3 glasses of water
• Keep sitting, repeat in 20 minutes if no vomiting occurs
• Give activated charcoal after vomiting has ceased – 2-4 Tablespoons
OXYGEN THERAPY
Device Flow Rate L/min. % Oxygen
Nasal cannula 4-6 25-40
Plastic face mask 10 50-60
Venturi mask 4 24
2 25
2 35
2 40
Partial Rebreather mask 6-8 35-60
Non-rebreather mask 10-15 90
SHOCK
• Hypovolemic- cause by fluid loss hemorrhagic (blood loss due to bleeding) and non-hemorrhagic (metabolic loss such as burns, dehydration, vomiting and excessive urination)
• Cardiogenic- Heart fails to pump enough blood. Heart is damaged or injured- very hard to reverse. Examples are coronary artery disease, ventricular failure, etc..
• Peripheral vascular - blood vessels dilate or constrict, causing pooling of blood in the periphery and decrease perfusion at the core. May be cause by neurogenic shock (spinal or head injury), septic shock (following severe infection) and psychogenic shock (fainting).
Sx and Signs of Shock:
1. Most common early signs: restlessness, mental confusion,
disorientation.
2 paleness of skin, coolness, chalk like color
3. tachycardia, weak and thready pulse
4. thirst, with dry mouth
5. early shock may have NORMAL V/S
6. late signs: low or unobtainable B/P
rapid, thready pulse
bluish or purplish discoloration of skin
dilated pupils, dull lusterless eves
faintness or unconsciousness
irregular, gasping respiration’s
Note: it is important to remember that low B/P is a late and usually serious sign of shock
(not just vasovagal response, low BP indicates decompensation)
Remember – a restless hypoxic patient who is in need of oxygen and lower extremity elevation can be in shock and have near normal B/P
QUICK BLOOD PRESSURE ASSESMENT
If no B/P cuff is avail you can assess:
If radial pulse is palp – B/P is 80 systolic
If a brachial pulse is palp – B/P is 70 systolic
If a femoral pulse is palp – B/P is 60 systolic
If a carotid pulse is palp – B/P is 50 systolic
If you can’t hear a B/P then palpate it
4 STAGES OF SHOCK
• I- COMPENSATED- Blood pressure drops and the body compensates by vasoconstricting to send blood to vital organs.
• II- DECOMPENSATED- the body attempts to compensate with vasoconstriction, but there is not enough supply to support the vital organs. Intervention is necessary and must be immediate.
• III- DISSEMINATED INTRAVASCULAR COAGULATION- Blood begins to coagulate in the microcirculation and clogs capillaries. This occludes the vessels and decrease perfusion. Water and sodium leak into the cells and potassium leaks out, cause inth cell to swell. This stage is difficult to treat but can be reversed.
• IV- IRREVERSIBLE - Multiple Organ Failure Cellular damage will occur and all systems are involved. Must prevent this stage from occurring.
Management of Shock: This is an unstable condition
1. Establish an airway – breathing should be constantly monitored as pt can change any moment.
2 assist breathing as needed.
3. Stop bleeding if present. Use gentle but firm DIRECT PRESSURE with
Sterile gauze if possible. Must maintain pressure ESP if an arterial bleed.
4. Elevate lower extremities and maintain a head low position unless contraindicated.
5. Immobilize fractures; this lessens damage to soft tissues from splintered bone ends.
6. Avoid any rough or excessive handling
7. Transport safely.
8. Keep the temperature normal. Avoid intense cooling, which causes
shivering. Prevent loss of heat. Best to be kept slightly cool than too warm.
9. Monitor state of consciousness, and V/S q 5 min
10. No food or drink.
ANAPHYLAXIS
Onset 1-15 min or 1.5-2 hours
Signs and symptoms
early: flush, dizzy, itching of lips, throat, tongue, sudden pruritic rash over entire body
if conscious give antihistamine, big dose, immediately upon recognizing a systemic reaction
palpation, paresthesia, pruritis, throbbing in ears, cough, sneezing, dyspnea
systemic vasodilation causes loss of BP, dizziness, pulse increases to compensate
later: throat swells shut, if unconscious get airway inserted before this happens
IM epi adminstration in time will prevent airway occlusion (quad, glut, delt)
don't give epi unless airway is threatened
don't give repeat epi unless pt condition deteriorates again
dose is 0.3-0.5 ml depending on body mass, most epi pens contain just one dose of about 0.3
expired epi may still work if it is still clear: if you have no other option, use it
if it is discolored (yellow) it is no good
may have to re-administer epi within 2-20 minutes if fast acting reaction
monitor unconscious patient carefully
epi can be dangerous to pts with cardiovascular compromise so don't give if not thoroughly indicated
convulsions, death unlikely to occur if airway is properly managed
if you have no epi and pt is unconscious and still getting enough air to survive
and if you HAVE benadryl, lots of it, then here's a trick to try
desperate measures: make paste of benadryl and swab it on mucous membranes of mouth and insert anally
coat as much mucus membrane as possible
this may stop the massive degranulation that is causing the anaphylaxis
and save a life
Treatment: (this is Wilson's version, I totally disagree with his version, my notes are above)
Immediately admin. Epinephrine 1:1000 dilution SC give 0.3 to 0.5 ml
In an injected antigen – place a tourniquet above the site and inject 0.1 0.2 ml above the site and at the site.
If no serious side effects of epinephrine, give a second dose if needed in 15– 20 min.
Give O2 in large amounts (10 –15 L/min.) monitor vital signs. A long acting epinephrine can be given as a second injection. Susphrine 0.3 ml SC
If in shock may need IV fluids and keep legs elevated.
Patients unresponsive to epinephrine should be given glucagon
If you have to give O2 and epinephrine be sure to call 911
RESPIRATORY DISTRESS/ ASTHMA
Signs of life-threatening respiratory distress in adults includes:
• Alterations in mental status
• Severe cyanosis
• Absent breath sounds
• Audible stridor
• One-or two-word dyspnea
• Tachycardia
• Pallor and diaphoresis
• Presence of retractions and/or the use of acces¬sory muscles to assist
with breathing
Acute Asthma -Four stages of an acute asthma attack:
Asthma attacks are a true medical emergency.
• Mild: mild dyspnea, diffuse wheezes, adequate air exchange. FEV1 50-80% of normal
• Moderate: respiratory distress at rest, hyperpnea, marked wheezes, air exchange is normal to decreased. FEV1 is 50% of normal
• Severe: marked respiratory distress, marked wheezes or absent breath sounds, check for pulsus paradoxus (drop of systolic blood pressure with inspiration)>10 mm. Sternocleidomastoid retraction.
FEV1 is 25% of normal
• Respiratory failure
severe respiratory distress, lethargy, confusion, prominent pulsus paradoxus, sternocleidomastoid retraction
FEV1 is 10% of normal
Acute Pulmonary Edema
Two general groups of causes: First is cardiac related, such as heavy smoking, MI, CHF, hypertension, etc.. The other is due to near drowning, aspiration pneumonia, smoke inhalation or inhalation of toxins. Oh and yeah folks at high altitudes can get this too, and anyone with metabolic acidosis that goes too far.
Signs and Symptoms
• Dyspnea, rapid shallow labored breathing, crackling or wheezing sounds, cyanosis, blood tinged sputum, distended jugular vein, rapid pulse, cool/clammy skin, restlessness, anxiety, feeling of impending doom, pedal edema
Treatment
High flow O2
keep patients head and shoulders elevated
keep patient calm (and yourself)
transport (call 911)
Hyperventilation/ Panic Attack
Signs and Symptoms
• anxiety
• dyspnea
• dizziness
• blurring of vision
• dryness of mouth
• numbness and /or tingling of hands or feet or around mouth
• lump in throat
• pounding of heart
• caropedal spasm (drawing up of hands at wrist and knuckles with flexed fingers
• fainting
• rapid pulse and respitation
**Remember that the initial presentation of pulmonary embolism and hyperventilation are similar so hyperventilation should be considered only after all other causes have been ruled out.
Treatment
calm patient if possible and have them breath into a O2 mask without being hooked up to O2 source or breath into a paper bag
Homeopathics: Aconite, Chamomile, *Ars, Arg-N, Aur, Bell, *Spong
rescue remedy
