Final Flashcards
(216 cards)
1
Q
Basically what is happening in shock
A
Cells are not being oxygenated, so we have hypoxia going on
2
Q
What is cardiogenic shock? What usually causes these?
A
Where the heart fails to pump.
Usually caused by an acute MI or severe HF
3
Q
What is hypovolemic shock? What typically causes this?
A
Where there is inadequate circulating volume
Typically caused by hemorrhage or severe dehydration
4
Q
What are the 3 types of distributive shock?
A
- Septic
- Neurogenic
- Anaphylactic
5
Q
What is distributive shock?
A
A type of hypovolemic shock, where we have hypovolemia caused the body’s inability to perform vasoconstriction, leading to massive vasodilation.
(something going on system wide that is depleting our blood pressure, where the fluid that was once in the pipes has gone out of the pipes)
6
Q
What is obstructive shock? What causes this?
A
Where there is mechanical obstruction to blood flow into or out of the heart.
These obstructions don’t allow for things to get oxygenated.
(these things are obstructing blood flow, leading to hypoxia, because things aren’t getting blood flow due to the obstruction)
7
Q
What 2 things are decreasing in cardiogenic shock
A
- Decrease in CO
- Decrease in MAP
8
Q
How do we calculate MAP
A
SBP + 2(DBP) / 3
9
Q
What is the classic sign of cardiogenic shock? Why?
A
Crackles in the lungs
Decrease MAP leads to a decrease in perfusion of the coronary arteries, this leads to a decrease in perfusion of the heart leading to ischemia of the heart, this ischemia damages the left ventricle, so now the left ventricle can’t pump blood out leading to a backup of blood into the lungs
10
Q
Besides crackles in the lungs, what other s/s might we see for cardiogenic shock? 7
A
- Chest pain
- Dyspnea
- Low MAP
- SBP less than 90 for 30 minutes or longer
- Decrease in urine output (kidneys stop putting out urine because it they know that we need to try and retain fluid to increase pressure)
- Look at labs to see if we see other organ systems failing (like BUN/Creatinine)
- Look for s/s of failure in other organs
11
Q
What MAP score are we really worried about our pt getting to
A
60 (this means danger! Pt is probably having shock)
12
Q
What are the compensatory mechanisms of not just cardiogenic shock, but shock in general? 8
A
Your fight or flight system will kick in, so you’ll have:
- Increase in HR
- Increase in RR
- Increase in glycolysis for energy
- Decrease in urine to conserve volume
- Decrease blood flow to lesser organs like kidneys, GI tract, liver, etc)
- Decrease peristalsis
- Cool skin
- Diaphoresis
13
Q
What is the difference between absolute hypovolemia and relative hypovolemia (probably don’t need to know the difference)
A
Absolute is when you bodily fluids are being lost externally, like through a trauma, GI bleed, surgery, vomiting, diarrhea, excessive diuresis,
whereas relative hypovolemia is when fluid volume is in a deficit, but it is not leaving your body, instead it is third spacing outside of the vascular space, like from ascites, burns, bowel obstruction, fracture of long bones, ruptured spleen, hemothorax, sepsis.
14
Q
What is happening in distributive shock
A
Massive vasodilation and leaking of fluids (just picture things leaking out)
15
Q
How does sepsis lead to septic shock
A
The pathogen triggers a massive immune response, and this massive immune response overwhelms the body, leading to an impairment of the microvasculature, causing cellular dysfunction, resulting in increased capillary permeability and vasodilation
16
Q
What is happening in anaphylactic shock that causes shock
A
Similar to sepsis, there is an immune response from immunoglobulin IgE, which causes massive amounts of histamine and kinins to be released, flooding the circulatory system, leading to systemic vasodilation and increased capillary permeability.
17
Q
What is happening in neurogenic shock to cause shock
A
Spinal cord is severed above T6, now impulses can’t reach the lower half of the body to cause vasoconstriction to maintain BP, so we have vasodilation, blood pooling in the lower half and not returning to the heart, leading to a decrease in CO.
18
Q
Neurogenic shock, what is unique about HR? Why?
A
Instead of increasing, it actually decreases, which is really unique. (usually when our pt is losing volume, their HR will increase). All other shocks we see tachycardia, but with neurogenic we see bradycardia.
This is due to the unopposed parasympathetic innervation to the heart causing bradycardia without compensation, which would be reflex tachycardia. (basically nervous system isn’t able to cause vasoconstriction to the heart to cause tachycardia due to the severed spinal cord)
19
Q
What 3 things usually cause obstructive shock
A
- PE
- Tension pneumothorax (collapse of a lung or lung area)
- Cardiac tamponade (pressure exerted on the heart that compresses the heart wall and restricts heart actions)
20
Q
Would we see s/s of shocks in the initial stage?
A
No - we usually do not see s/s of shock when it first begins
21
Q
What is actually happening in the initial stage that we can’t see
A
Metabolism changes at the cellular level from aerobic to anaerobic, causing lactic acid to build up. (because the body isn’t getting the right amount of oxygen)
22
Q
What stage would we start to see s/s of shock, what are these? a lot of s/s
A
The second stage, the compensatory stage, where we see suttle signs of change
- Increase in HR (to compensate), not very high, maybe up to 90-99.
- Decrease in BP
- Breathing faster
- SOB
- Decreased/no urine output
- Decrease GI motility
- Cool and clammy (if hypovolemic)
- Hot and flushed (if sepsis or anaphylaxis)
- Crackles
- Distant lung sounds
- Tachypneic
(we will see s/s of our fight/flight system kick in, and we will see the body to try divert blood to essential organs, like brain and heart, we will see s/s of decreased perfusion in the other organs) (except with neurogenic shock, because the spinal cord is severed, we don’t see these compensatory mechanisms kick in)
23
Q
How could we tell if a pt is having a decrease in urine output if they have a foley?
A
Have them connected to a urometer, so we can keep track of their output per hour.
24
Q
If we stop shock at the compensatory stage, how will the pt recover?
A
Typically pts will recover fine if shock is stopped at this stage, going to the next stages are very life threatening (we need to find the s/s of shock at this stage and treat, to prevent any devastating effects to our pt)
25
What happens at the progressive stage
The compensatory mechanisms start to fail, so we see major dysfunction of organs.
26
See table 66.5 in med surg book on pg 1574 for list of s/s of shock in the different stages
27
Is it hard to save someone in the progressive stage
YES! It is very difficult to save anyone at this stage
28
Will we see urinary output right after surgery?
No, normal response is to have a decrease in urine output right after surgery - About 24 hours, you should start putting out fluid after surgery
29
What labs will we look at
- pH less than 7.35 (they're going to be acidotic, because this is an issue with hypoxia)
- Lactate higher than 2 (lactate increases because of impaired tissue oxygenation)
- Base excess/base deficit (caused by a buildup of lactic acid, where our base, bicarb, is outside its normal range of 2 to -2.
- SvO2 lower than 60% (indicates an issue with oxygen supply and demand)
30
What diagnostics can we do if we suspect shock 4
- 12 lead ECG, with continuous monitoring
- Chest x-ray
- Pulse ox
- PAC (pulmonary artery catheter)
31
If we see a lactate higher than 2, what type of shock is this very indicative of
Septic shock, but it can rise in any type of shock
32
What is our tx for shock
1. Give them as much oxygen as possible (want our oxygen at 90% or better)
2. Give 2-3L fluid (crystalloids preferred - like NS, or colloids to expand the volume)
3. Give meds like norepinephrine, dopamine, and/or inotrope (dobutamine)
33
When someone might have shock, should we put in IVs? How many? Where? How big?
Yes, we should put in 2 large bore IVs, preferably in big veins.
34
Why do we want our oxygen to be at 90% or better
Something to do with the oxygen dissociation curve
35
See pg 1578 know what dobutamine, norepinephrine, dopamine, epinephrine (know what these do)
36
What are our vasopressor drugs? What does it mean when we say vasopressors?
- Norepinephrine, epinephrine (in high doses), dopamine, phenylephrine.
They cause peripheral vasoconstriction
37
What is an inotrope? What drug is an inotrope? Why would we give it?
A positive inotrope drug causes your heart to pump harder.
Dobutamine is an example.
It sounds counterintuitive to cause our heart to work harder when we're in shock, but giving an inotrope like dobutamine can increase the perfusion to the coronary arteries, which is what we want
38
What do noepinephrine and epinephrine do
Give noepinepehrine for septic shock, if BPs don't respond give epinephrine
39
When do we give dobutamine
For cardiogenic shock
40
Why might we give a vasodilator, like nitro, for someone in shock?
Mostly given for someone in cardiogenic shock, and it is used to help stop the widespread vasoconstriction compensatory response, which is causing an increase in workload on the heart and impairing perfusion to other organs
(also, it can help dilate the coronary arteries, so the heart can be perfused)
41
What is our MAP goal when using drugs
We want to get our MAP at 65 or greater
42
When should we start enteral nutrition if a person is in shock
Within 24 hours (important to start within 24 hours because the body is working hard during shock and burning a lot of calories, so we want to help the body fight off shock by keeping it fed)
43
If someone is in shock, which is our preferred feeding method between parenteral and enteral?
We prefer enteral, so we can put food directly into the gut to keep the gut going and active, but if enteral is contraindicated or not meeting 80% of the patients caloric needs, then we will use parenteral
44
What labs are we looking at to see if someone is getting enough nutrition 5
- Protein (6.2-8.2)
- Albumin (3.4-5.4)
- BUN 7-20
- Glucose 70-110)
- Electrolytes
45
What are our 2 goals for cardiogenic shock
1. Restore blood flow to the myocardium
2. Reduce workload of the heart
46
What is our tx for cardiogenic shock 4
1. Oxygen
2. Fluids
3. Drugs, usually dobutamine is our first drug of choice,
4. Intra aortic balloon pump (helps heart pump more blood to the coronary arteries)
47
If dobutamine doesn't work for cardiogenic shock, what other 4 drugs might we give and why?
- Nitro, to help dilate the coronary arteries
- Diuretics, to help reduce the preload
- Vasodilators (like sodium nitroprusside) to help reduce the after load
- Beta blockers (decrease HR and contraction)
48
What device can we use to perfuse the coronary arteries
Intra aortic balloon pump
49
What is the difference between positive and negative inotropic drugs?
Positive causes your heart muscle to contract harder, which raises your CO and increases the amount of blood your heart can pump out.
Whereas negative causes the opposite effect, which is causing your heart to not beat as fast, might be useful if you have high BP, chest pain, abnormal heart rhythm or dx of hypertrophic cardiomyopathy.
(positive is almost always used for cardiogenic shock)
50
What are our positive inotropic drugs 6
- Epi
- Norepi
- Dopamine
- Dobutamine (most often the first given)
- Milrinone
- Digoxin
51
What are our 3 negative inotropic drugs
- Verapamil
- Clonidine
- Atenolol
52
How do we treat obstructive shock
Mechanical decompression (get rid of the obstruction like from a pericardial tamponade, tension pneumothorax or hemophneumothorax)
53
What are our txs for hypovolemic shock? 5
- Give fluids, perpheribly warm.
- Stop fluid loss.
- Might need to give blood if they are losing blood.
- Provide O2.
- Get 2 large bore IVs going
54
What is our indicator for determining if we have adequate volume
If we have urinary output (if you can pee, you have adequate volume)
55
Should we give an epi pen before or after we call 911
Give right after or while you're on the phone with 911
56
Why is epi the drug of choice for anaphylactic shock
It cause bronchodilation in low doses and vasoconstriction in high doses as well as stopping the effects of histamine
57
We know that anaphylactic shock causes bronchoconstriction, but what else does it do to the body?
Causes major vasodilation, which causes hypotension due to the leakage of fluid
58
What is our tx for anaphylactic shock
- Remove the inciting antigen (like the stinger)
- Call 911
- Give Epi (can be given IM or IV)
- Have pt remain upright and leaning forward if upper airway swells
- Give O2
- Might need to give fluid (like crystalloids) due to hypovolemia that usually occurs
- IV corticosteroids may be given if hypotension lasts longer than 1-2 hours
59
What are our steps for treating someone with sepsis (in order) based on the surviving sepsis campaign? 5
When should all of these steps be completed?
1. Measure lactate level
2. Obtain blood cultures before giving abx
3. Administer broad spectrum abx
4. Begin rapid admin of 30mL/kg crystalloid for hypotension or if lactate is at or above 4 mmol/L
5. Apply vasopressors if hypotensive during or after fluid resuscitation to maintain a MAP at or above 65 (vasopressors would be norepinephrine, epinephrine, dopamine)
All of these steps should be completed within 1 hour upon recognition of sepsis/septic shock.
60
What is SIRS?
System inflammatory response syndrome - where the inflammatory response goes crazy due to a variety of things, and we see inflammation in organs remote from the initial issue (like these organs weren't involved in the initial issue, but now with they have inflammation and they're involved - for example, say you cut your finger, but for someone now we have an inflammatory response that goes system wide)
61
What events can trigger SIRS (a lot)
- Mechanical tissue trauma:
burns, crush injuries, surgical
procedures
* Abscess formation:
intraabdominal, extremities
* Ischemic or necrotic tissue:
pancreatitis, vascular disease,
MI
* Microbial invasion: bacteria,
viruses, fungi, parasites.
* Endotoxin release: gram-negative bacteria and gram-positive bacteria
* Global perfusion deficits:
postcardiac resuscitation,
shock states
* Regional perfusion deficits:
distal perfusion deficits
(look at all of these things that can cause SIRS... Name one pt who doesn't have one of the above? Which means all pts are at risk for SIRS)
62
What does SIRS usually lead to
MODS (multiple organ dysfunction syndrome)
63
How can we diagnosis someone with SIRS 4 (know this one for sure - going to be on the test)
If they have two or more of the following:
- Core temp greater than 38C (100.9F) or less
than 36C(96.8F)
- Heart rate: tachycardia of greater than 90
beats per min
- Respiratory rate (mean): greater than 20
breath/min or PaCO2 less than 32 mm Hg
- WBCs greater than 12,000/mm3 or less
than 4,000/mm3 or greater than 10%
immature forms
64
What is MODS
When 2 or more organ systems fail, where homeostasis cannot be maintained w/o intervention
65
Why is an inflammatory response, like in SIRS, bad? (a lot)
SIRS causes the following in order:
1. Release of mediators
2. Endothelium is damaged
3. Hypermetabolism taking place
4. Vascular permeability increases, allowing mediators and protein to leak out of the vascular system
5. These leaked out WBCs digest foreign debris
6. Coagulation cascade is activated (used to form clots, but we are going to use up our clotting factors here)
7. Hypotension occurs
8. There is decreased perfusion now to organs
9. Microemboli form
10. Blood is either redistributed or shunted to essential organs, which causes harm to these organs now not being purfused
66
Can any system fail with MODS or are there certain systems that are more likely to fail?
ANY system can fail with MODS - this is why our assessment skills are so critical.
67
If one system fails, is it more or less likely that we'll see another system fail
It is more likely that we'll see more systems begin to fail
68
What system do we often see the first s/s of SIRS and MODS? How can SIRS cause this system to fail? What are those s/s? 5 What does this lead to?
The respiratory system if often the first to show possible SIRS/MODS
SIRS causes the inflammatory response, where these mediators cause capillary permeability, which allows fluid to shift into the alveoli causing all of the s/s below.
S/S:
- Crackles due to alveolar edema
- Decrease in surfactant
- Increase in shunt (blood not being oxygenated )
- Ventilation/perfusion mismatch
- Diffused whiteout on x-ray
Leads to ARDS
69
What are the s/s of the cardiovascular system being impacted by SIRS/MODS (a lot)
1. CO increases in the early stages (as a compensatory mechanism, due to the baroreceptor reflex when it notices a drop in BP)
2. Myocardial depression occurs (CO decreases)
3. Massive vasodilation
4. We see a decrease in BP and SVR
5. Baroreceptors still try to work hard to increase CO by increasing HR, so we see tachycardia
6. Increasing capillary permeability causes albumin and fluid to shift out
7. Might see decrease in cap refill, skin mottling, dysrhythmias
70
What happens to the hematologic system in SIRS/MODS
We see DIC, where we have microvascular clotting and bleeding at the same time (since clotting factors are being used up)
71
Would we see metabolic acidosis or metabolic alkalosis in SIRS/MODS
Metabolic acidosis, due to the impaired tissue perfusion and hypoxia resulting.
72
What are s/s of a failing neurological system 3
- Restlessness (very first sign of hypoxia)
- LOC changes
- Non-responsiveness/loss of consciousness (last sign of a failing neuro system)
73
What 2 systems do we often see s/s of SIRS/MODS first in
Respiratory
Neuro
74
What are s/s of renal system failure
S/S of acute kidney injury (AKI)
- Decrease in urine output because the renin-angiotensin system is activated, which is causing vasoconstriction throughout the body and causing out to retain sodium and water in hops to maintain blood pressure.
- BUN/creatinine
75
What is another worry in regards to the kidneys if we are treating a pt with septic shock
That they're going to be on abx, but often these abx are nephrotoxic, so this can damage the kidneys even further if SIRS/MODS develops.
76
What are s/s of GI system failure 5
- Paralytic ileus
- Abd distention/pain
- Increase risk for ulcers
- Decreased motility
- Translocation of bacteria from gut into blood
- Decreased perfusion to the GI system can cause ulcers and GI bleeding
77
What are s/s of a hypermetabolic state (hypermetabolic state occurs when there is failure) 6
- Hypo/hyperglycemia
- Insulin resistance
- Catabolic state (burning a lot of calories)
- Running on anaerobic
- Liver dysfunction
- Lactic acidosis
78
What txs are we doing for this case study with a girl with sepsis
- Broad spectrum abx hang within 1 hour
- Put on O2
- Start fluid
79
What are we really worried about preventing for pts with SIRS and MODS if they don't have sepsis? Why?
Infection (if they have SIRS/MODS from something other than an infection, then they are at a really high risk of getting an infection) These people have a decrease in tissue perfusion and oxygenation, which allows the chance for infection to occur
80
How can we prevent infection from occurring in someone that has SIRS/MODS 5
- Strict asepsis
- Assess need for invasive lines
- Debridement of necrotic or burned tissue (microorganisms like to grow in necrotic tissue)
- Aggressive pulmonary management
- Early mobilization
81
If someone is intubated, how can we help prevent infection
Provide oral care every 2 hours
82
How can we help provide maintenance of tissue oxygenation for someone with SIRS/MODS (a lot)
Help decrease O2 demand by:
- Sedation
- Mechanical ventilation
- Analgesia
- Rest
- Treat fever/chills/pain
Help increase O2 supply using:
- Positive end-expiratory pressure (PEEP)
- increasing preload using fluids
- Increase myocardial contraction to enhance CO
- Reduce afterload to increase CO
83
How can we support someone nutritionally if they have SIRS/MODS (the body uses 1.5 to 2.0 times more energy during SIRS/MODS)
- Monitor plasma transferrin and prealbumin levels to assess hepatic protein synthesis
- Provide early nutrition, enteral is preferred
- Keep blood sugar at or below 180
84
What can petechiae and jaundiced skin indicate
DIC
85
What labs can indicate DIC 4
- Fibrin
- Prothrombin (10-13 sec)
- Platelets (150,000 - 450,000)
- Bilirubin (0.1-1.2)
86
A patient with a history of alcoholism is admitted to the ICU
with hemorrhage from esophageal varices. Admission VS are
BP 84/58 mm Hg, HR 105, and RR 32 breaths/min. The nurse
recognizes the onset of systemic inflammatory response
syndrome (SIRS) upon finding:
1. pulmonary edema.
2. cardiac dysrhythmias.
3. hypoactive bowel sounds.
4. decreasing blood pressure.
4 for SIRS
87
You are working in an ED when a pickup arrives with a male
patient lying on a long piece of plywood in the back of a truck.
His friends tell you he fell off a ladder and landed on his
shoulders or neck when he hit the ground. You get a team,
place a c-collar and get him into a trauma bay.
* What’s next?
- Place oxygen on using nonrebreather
- Assess ABCs
- Vital signs
- Start assessing other things, starting with neuro
88
What things should we consider for triage 6
- Physiological and anatomical criteria
- Mechanism of injury
- Age (very important)
- Pregnancy >20 weeks (go to OB, usually, we communicate with OB)
- Bleeding disorders
- Transportation time (ie pt states "my speech was slurry when I left the house", we want to know where they live so we know how long their drive was so we can determine onset time of symptoms)
89
What is the "hear report"?
Short patient report to the hospital from the medics (like what I hear over the radio)
90
What is the The Golden Hour for Trauma Victims
It's where the first hour after a trauma is the most important window to increase chances of survival
91
What is the trimodal distribution 3
Where death can occur at 3 different points after a trauma
1. Within minutes, before arrival to the hospital
2. Minutes to hours after arriving to the hospital
3. Days to weeks (from complications like SIRS/MODS?SEPSIS)
92
What are the different levels of trauma centers
I Trauma Center
24 hour coverage with most specialties
Teaching and research
Substance abuse screening and intervention
II Community trauma center
24 hour coverage by MD’s, surgeons
Education for nursing and allied health professionals
(Salem, Riverbend)
III
24 hour ER MD; availability of general surgeon
Coverage, provides back-up for rural hospitals
IV/V - Critical Access Hospital
ACLS, stabilization and transfer
Pediatric Trauma Centers
(Lebanon)
93
What is the purpose of EMTALA that we should remember? *
We are obligated to provide a medical screening exam (MSE) for any pt that walks through our door, regardless of whether they can pay for it or not.
94
What is the emergency severity index (ESI)? Who assigns an ESI?
- ESI is a 5 level triage scale developed by ED physicians and RNs
- Provides a reliable, valid tool for determination of acuity
- Describes parameters for the rapid identification of those who need immediate care
- Discriminates between patient that need to be seen emergently vs urgently
- Improves patient flow based on rapid sorting with projected resources and operational needs
Triage nurse or charge nurse in ambulance bay assigns a pt an ESI number
95
What 4 questions do we ask to determine someone's ESI
Is this patient dying?
Is this a patient who shouldn’t wait?
How many resources are needed?
What are the vital signs?
96
When assigning ESI scores, we look at how many resources a person might take up, what are examples of these resources and what are examples of things that aren't resources and don't factor into their ESI score?
97
Picture with examples of the different ESI levels
98
Picture of a chart showing visually how a pt is assigned an ESI score
99
What is the primary survey
Your primary and secondary assessments on a trauma pt
Primary:
A = airway
B = breathing
C = circulation
D = disability
E = exposure/environment
Secondary:
F = full set of vital signs/family
G = Get resuscitation adjuncts (Gadgets)
H = History/Head to toe
I = Inspect posterior surfaces
At any point during the primary survey when you identify life-threatening conditions you start interventions immediately.
100
Should we do a jaw thrust or head-tilt-chin-lift?
Jaw thrust! Remember that head-tilt-chin-lift is not good for c-spine injuries
101
What types of airways do we do for people who are unconscious or conscious?
oropharyngeal airway (unconscious) or nasal pharyngeal airway (conscious)
102
What do we do if we are assessing the airway and we see cyanosis 3
- Jaw thrust to open airway
- Airway adjuncts like oropharyngeal or nasal pharyngeal
- Suction
103
What should every critically injured or ill pt have on them? Why?
Supplemental oxygen with a 15L nonrebreather
Because EVERY critically injured or ill pt has an increased metabolic and oxygen demand
104
What can we use APVU for?
To determine a pt's level of consciousness
A = alert?
P = responsiveness to pain?
V = responsiveness to voice?
U = unresponsive?
105
What is the key takeaway with exposure
We have to remove all of their clothing, but we want to try and cover them back up to avoid hypothermia
106
What acronym can help you remember what things to assess for in terms of history/head to toe
Use SAMPLE
Symptoms assoc. with injury or illness
Allergies and tetanus status
Medication history
Past health history
Last meal/oral intake
Events leading up to the incident
Head-to-toe
107
What kinds of things should we do when someone dies
- Don't remove any of the cords/wires/tape/lines attached to the pt. You can disconnect them from the machine, but you want to keep everything in place in case there is an autopsy
108
What should we remember about blunt trauma
-No interruption of the skin
-Can be difficult to diagnose because you can’t see it (usually gets really bad before you can see it)
- Critically think about the mechanism of injury, possible anatomical structures involved and patient presentation/assessment
-What’s lurking beneath?
109
What if someone is impaled in one eye
Cover both eyes, because our eyes track together (you don't want the known impaled eye to track, because the impaled eye will also move)
110
What is shearing
When structures slid in the opposite directions or at different speeds
111
How should we document gun shot wounds?
Don't document as "entry" or "exit" - don't assume that they're gun shots. Document as "wound 1", "wound 2", etc.
112
What is interesting about a bullet
Bullets can actually lodge into arteries and travel through arteries to become an "arterial bullet embolism"
113
Should we every place anything that could be considered evidence into a plastic bag? *
NO! Use a paper bag.
114
When can flail chest occur
When there is a fracture of 2 or more ribs in two or more places
115
How can we tx flail chest 2
- Intubate
- Use PEEP to help keep the lung inflated
116
It is important to think about whether an organ is hollow or solid, as hollow organs are more vulnerable to blunt forces.... But what about the bladder?
The bladder can be hollow, but it can become solid, like with urine, which causes it to move up into the abdominal wall (so remember to check for the bladder in different locations)
117
Why are distracting injuries difficult for nurses
Because the pt is also focused on this distracting injury, which may not be the most significant injury that they have. These types of injuries can be distracting:
long bone fracture
suspected visceral injury
large laceration, degloving, or crush injury
large burns
any other injury that produces acute functional impairment
118
Is someone is bleeding out like from hypovolemia shock, is it important to give more fluids or more blood
More blood! Because if we give more fluids, then these fluids will just dilute the blood and will not be helpful
119
What is the definition of exsanguination
When a pt has lost 40% (2L) of their blood at a rate exceeding 250mL/min (this is life threatening!)
120
How fast can we lose 50% of our blood volume
Within MINUTES
121
Do we see symptoms when a person loses 15% of their blood
Not usually, maybe a few
122
At what percentage of blood loss does a pt start showing s/s of the loss? 4
Usually at 30%
- Mild tachycardia
- Tachypnea
- Anxiety
- Hypotension
123
What can exsanguination lead to
Hypovolemic shock
124
Can we have significant blood loss from fractures?
Yes! For example:
- Pelvis = 1-3 liters
- Femur = 1500mLs
- Tibia or fibula = 500-1000mLs
- Ulna or radius = 250-500mLs
- Rib = 125mLs
125
What things are we doing to try and keep a trauma pt alive 2
- Get 2 large bore IVs going, usually 16g
- Administer fluids, usually NS
126
If our pt has hypotension from hypovolemia, will we be using vasopressors? Why?
No vasopressors aren't usually used until volume has been restored.
Vasopressors are given to help increase our BP, but if our BP is low due to hypovolemia, then we can try and fix the BP by giving fluids instead of vasopressors
127
What type of procedure is a last resort for resuscitation
A thoracotomy - where a provider opens a pt's chest to see if they can find/fix the problem
128
What is the blood vicious cycle (aka the trauma triad death) *
“Severe bleeding in trauma diminishes oxygen delivery, and may lead to hypothermia. This in turn can halt the coagulation cascade, preventing blood from clotting. In the absence of blood-bound oxygen and nutrients (hypoperfusion), the body's cells burn glucose anaerobically for energy, causing the release of lactic acid, ketone bodies, and other acidic compounds into the blood stream, which lower the blood's pH, leading to metabolic acidosis. Such an increase in acidity damages the tissues and organs of the body and can reduce myocardial performance, further reducing the oxygen delivery”
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What is damage control surgery
Where we do a surgery to fix the issue, but it's not permanent or long term, once the pt is healthy enough to have the real surgery, then they will go back in for the real surgery
130
What are some things to remember about a tourniquet
- Write down the time it was applied (even if it was applied by the medics)
- It should hurt the pt (probably not working if it doesn't hurt) *
- You shouldn't be able to palpate any distal pulses) *
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What is that pediatric measuring tape called
Broselow pediatric emergency tape (gives you doses by weight based on a child's height)
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Should we treat kids like "little adults"
No - treat them like kids. We need to talk to them like kids... Don't say "I'm gonna take your temperature" "I'm going to see what your temperature is"
133
Can a nonenglish speaking pt use one of their family members as an interpreter
Only if they have first been offered an interpreter by us. If they refuse, we need to document this.
134
What is a normal body temp
96.4-99.8
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Picture of heat loss
Radiation
Conduction
Convection
Evaporation
Breathing
136
Predisposing factors that can affect a persons temp (a lot)
- Climate
High ambient temp = less evaporation
High relative humidity= less evaporation
- Exercise and Activity
Can lose 1+ L of sweat/hr
Loss of electrolytes (Na, Cl, H20)
- Age
- - Elderly
Poor thermoregulation
Medications
Lack of mobility (cannot leave environment, might not be able to dress self)
- - Newborns
Poor thermoregulation
Cannot remove own clothing
- Pre Existing Illness
Heart disease
Dehydration
Obesity
Fever
Fatigue
Diabetes
Drugs/medications
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What should we ask someone if they come in with a temperature issue?
Source
Environment
Loss of Consciousness? Was anyone there to witness it?
Effects
How long exposed
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When do we tend to get heat cramps
While resting after the work
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What is our tx for heat cramps 5
- Fluid replacement of sodium and water
- Elevate the feet
- Massage
- Avoid strenuous activity for 12 hours
- Drink some gatorade
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What are the s/s of heat cramps 5
- Nausea
- Tachycardia
- Pallor
- Weak
- Lots of sweating
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What are the s/s of heat exhaustion 7
- Still able to sweat - profusely
- Ashen skin
- Hypotension
- Tachycardia
- Elevated body temp
- Dilated pupils
- Mild confusion
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What is our tx for heat exhaustion 5
- Put in a cool place
- Loosen clothing
- Oral fluids
- Replace electrolytes
- Place wet sheet over them
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What causes heat exhaustion
Prolonged* exposure to heat
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Which type of heat issue is the most critical and is considered a medical emergency
Heat stroke
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What is wrong with heat stroke
Our hypothalamic system is no longer able to regulate our temp
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What are the s/s of heat stroke 8
- Core temp greater than 105.8
- Sweat glands stop functioning, so you don't sweat
- Altered mental status
- Circulatory collapse
- Hot
- Dry
- Ashen skin
- Cerebral edema/hemorrhage from direct thermal injury to the brain and decreased cerebral blood flow
147
How can we treat heat stroke 6
- Rapidly try to reduce temp
- Give O2
- Give fluids/electrolytes
- Remove clothing*
- Closely monitor their core temp*
- Treat shivering (bc shivering causes core temp to rise)*
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What is our goal with heat stroke
To reduce the temp by at least 0.2 degrees C/min to approx 39 C*
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Why would the body shiver during a heat stroke
The body is in shock, so it's shivering to warm you, even though you're already warm.
150
What is interesting about alcohol and smoking when it comes to cold related issues
- Alcohol causes peripheral vasodilation, which increases your sensation of warmth and depresses shivering
- Smoking increases cold injury due to vasoconstriction from nicotine
151
Picture of the different kinds of frostbite depending on what layers of the skin are affected
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How can we treat frostbite
Management:
Handle carefully; NEVER* squeeze, massage, or scrub the injured tissue as it is easily damaged.
Remove jewelry/clothing
Immerse the affected area in warm water (pain with rewarming)
- Blisters will form in a few hours
- Rewarming is EXTREMELY* painful
- Analgesic and tetanus (we give tetanus because blisters can form)
153
When is a person considered to have hypothermia
If their core temp is less than 95F/35C
154
What are two key takeaways with hypothermia
- Want to remove all of their wet clothing (wet clothing increases evaporative heat loss by 5x)*
- Want to warm the pt to at least 89.6F/32C before pronouncing them dead*
155
How can we treat someone with hypothermia
- Rewarm them*
- Handle them very carefully*
- Have them on the teley, because hypothermia often causes dysrhythmias in the heart
156
When can we stop actively rewarming our pt?
When they reach 89.6-93.2F / 32-34C
157
What are the three types of rewarming techniques (know these three and examples of each)
Passive rewarming* - move them to a warm, dry place, remove wet clothing*, radiant lights, warm blankets
Active external rewarming* - bair hugger, warm water immersion
Active internal rewarming* - heated humidified 02, warmed IV fluids, extracorporeal circulation with cardiopulmonary bypass, rapid fluid infuser, hemodialysis
158
What are we really worried about with a human bite
Infection*
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How can we treat a human bite?
- Leave puncture wound open, unless it's a bite on the face (consider plastics)*
- Give tetanus shot*
- Give abx*
- Irrigate with copious fluids*
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What group of people are most often bit by snakes
Drunk men
161
What is important to remember about a boxer's fracture?
Look for broken skin on their hand where they punched someone in the mouth, chances are the person they punched had their teeth go into their hand, so their hand is at risk for infection from the bite*
162
When will a pt get a tetanus shot
With any penetrating, puncture or laceration wound, the pt will get the shot, unless they had their tetanus shot within the last 5 years and it's documented.
163
What is the main takeaway with poisoning
Call poison control, and they will walk you through on how to treat any poisoning*
164
What are the two key takeaways with decontamination*
- Decontamination takes priority over ALL interventions (can't help anyone if you end up getting decontaminated yourself, so take caution)
- Don't let a person who needs to be decontaminated into your facility, ask them to wait outside to be decontaminated, then you can exam them in a hazmat suit
165
What are the different kinds of burns
Thermal- flame, flash, contact with hot object
Chemical- acids, alkalis, organic compounds
Electrical- intense from electric current
Inhalation- breathing noxious chemicals or hot air
Radiation and extreme cold
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What is the criteria to have a burn pt be sent to a burn center
If they have any of these:
- Partial thickness burns >10% total body surface area
- Burns that involve the face, hands, feet, genitalia, perineum or major joints
- Full thickness burns in any age group
- Electrical burns, including lightning injury
- Chemical burns
- Inhalation burns
- Burn injury in patients with preexisting medical conditions that could complicate things
- Burns with concomitant trauma
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Picture between diff between superficial, partial, and full thickness burns
168
What are the 3 different zones of injury related to burns
1. Zone of coagulation - where there is the greatest damage.
2. Zone of stasis - where there is some damage.
3. Zone of hyperemia - outer zone, blanches with pressure and will heal.
169
When will a superficial burn heal? Will it scar? What can cause superficial burns? Describe what it looks like? *
- Heals in 3-7 days
- No scarring
- Caused by sun or brief exposure to hot liquids
- Minimal damage to the epidermis
- Dry, no blisters, pain, red, blanches easily
- Sensitive wound
- Erythema (red)
(don't need to go to the ED for these)
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What is our tx for superficial burns*
- Tetanus
- Analgesia (pain is most acute during exposure of the wound)
- Wound cleansing (not scrubbing) use irrigation. (tap water is fine)
- Dressing; to promote rapid healing, manage exudate, control bacterial colonization, allows movement, is non-adherent, avoids compromise of the circulation
171
Info about superficial partial thickness burns
Heals 10-14 days
Hot liquids, brief contact with hot object, flash flame
Erythema, brisk cap refill, blisters, moistness, moderate edema
Painful
No scarring
(most often seen on kids with hot liquids)
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Info on deep partial thickness burns
Heals 21 days+; may leave some scarring/needing grafts
Flame, hot liquids, radiation, tar, etc
Epidermis and reticular layer of the dermis
Erythematous or pale, sluggish or absent cap refill
Moist or dry, no blisters
Significant edema and altered sensation
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Info on full thickness burns
Will not heal without excision and grafting
Entire epidermis, dermis, and subcutaneous layer have been destroyed
May involve subcutaneous fat, muscle, and/or bone
Dry, leathery, pale,waxy white, brown, tan, black, charred
No blanching, no cap refill
No pain in the center; but may be sensitive to pressure
Heals with contraction and granulation tissue formation
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Info on deep full-thickness/subdermal burn
Epidermis, dermis, subcutaneous layer and muscle, tendon or bone
May be from electricity, prolonged contact with flame, hot object/material
Charred, dry appearance
Requires skin grafting, flap or amputation
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What are the 3 phases of burn management *
Emergent- resuscitative
Acute- wound healing
Rehabilitative- restorative
(these phases can overlap)
176
How can we calculate the total body surface area (TBSA) of the burn
Rule of Nines*
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What things do we want to determine when analyzing the severity of a pt's burns
- Depth of the burn
- Extent of the burn (using the rule of nines)
- Is it circumferential? (is it a person's entire leg)
- Does the pt have other risk factors (like other traumas, heart, lung, kidney issues, etc)
178
Picture of rule of nines
179
Another picture of rule of nines
180
What are our big concerns in the emergent/resuscitative phase for burn pts (this phase can last up to 72 hours) 6
- Airway (if we see any burning/damage to the mouth - they are getting intubated if still able)
- Hypovolemic shock (we lose a lot of fluid with burns) - so we want to do fluid resuscitation*
- Sodium and potassium shifts
- Hypothermia
- Wound care (but this is not the priority - want to focus on more important things like airway and hypovolemic shock)
- Pain management
181
What do we do when a burn pt arrives to the ED 6
- Remove the burned clothing (unless the clothing is melted into their skin, don't rip this off, think of spandex)
- Remove source of burning (like if they still have powder or liquid on them that is burning, as long as it is still safe to do so)
- Remove jewlery, bc it will become swollen
- For superficial/partial thickness burns cover with clean, cool, tap water towel
- For mid dermal/partial thickness burns cover with a dry burn sheet
- Get your 2 IVs going (preferably not in the burned areas, but if we have to put them there, then we have to do it)
182
What is the Parkland formula
Used for fluid resuscitation for the first 24 hours
183
How can we determine if we are getting adequate fluid resuscitation? What if we aren't meeting this goal? * (this is very important)
We can look at our urine, our pt should be having 0.5mL/kg/hr of output.
If we are not getting 0.5mL/kg/hr out of our pt then we need to give more fluid than what our equation told us.
Example - If our pt weighs 68kg, then they should be putting out 34mL/hr (if they are putting out less than this, then give more fluids)
184
What two types of shocks are we worried about for burns
- Hypovolemic shock*
- Burn shock?*
185
What are complications that can happen during the emergent phase for a burn pt
- Dysrhythmias
- Hypovolemic shock
- Burn shock
- Deep circumferential burns and edema (becomes a tourniquet, think about around your chest, now you can't breath, need an escharotomy)
- Compartment syndrome (needs a fasciotomy)
- VTEs (due to blood thickening/sludging)
- Resp distress
- Acute tubular necrosis
186
What is interesting about inhalation burns/injuries
You may be worried about their airway swelling up, so you get a chest x-ray, but this will usually appear normal. What you want to get is a bronchoscopy so you can see inside their airway to determine the damage.
187
What are s/s that there may be inhalation burns
- Facial burns
- Singed facial/nasal hair
- Agitation
- Inability to swallow
- Hoarseness
- Rales
- Rhonchi
- Diminished breath sounds
188
What type of poisoning can cause metabolic asphyxiation? What is this?
Carbon monoxide poisoning
Because our body has difficulty telling the difference between oxygen and carbon monoxide, and the carbon monoxide has a greater affinity to hemoglobin than oxygen, so instead of oxygen binding to your hemoglobin, you have carbon monoxide binding
189
Can we use our pulse ox to determine an adequate O2 saturation?
No! Because the pulse ox cannot determine between oxygen and carbon monoxide molecules*
190
What are s/s of carbon monoxide poisoning 6
- 50% of cases have a cherry red discoloration of their skin
- Headache
- Confusion
- N/V
- Dizziness
- Dyspnea
191
What is our tx for carbon monoxide
100% O2 nonrebreather
192
Why do we call electrical burns the "iceberg effect"
Because we can't usually see the extent of the damage on the outside
193
What is our biggest worry with electrical burns
That they could have been electrocuted and thrown/fallen, also muscles can contract from the electricity and break your bones *
194
What can electrical burns do to the heart
Can cause necrosis and dysrhythmias
195
What is reverse triage? Why it is important with electrical burns?
Reverse triage is when you help the person least likely to be saved, in this case a, a person with electrical burns are going to look dead, but all they probably need is to be shocked and they'll be fine, so shock them.
196
Do we want to bandage burns along the border?
No give it some room in case it spreads (don't want the tape taking off some of their skin if it spreads)
197
What wounds can acids cause
Eschar wounds from coagulation necrosis
198
What wounds can alkalis cause (sodium hydroxide, ammonia)
Penetrate deeper causing protein liquefaction. Continued tissue damage in deeper structures
199
What wounds can organic compounds cause (petroleum, phenols) 3
- Contact burns and systemic toxicity
- Absorb systematically causing renal and hepatic damage
- If inhaled can cause direct parenchymal lung injury
200
How should we treat chemical burns 3
- Remove chemical from the skin by brushing off*
- Remove clothing with the chemical on it*
- Flush with water, lots and lots of water*
201
What is interesting about burns and pain
Full thickness and deeper burns typically don't have pain, instead it might feel like a dull ache, whereas superficial partial thickness are the most painful
202
What is considered a mass casualty incident (MSI) * 2
- An event that overwhelms the community's ability to respond with existing resources
- Requires assistance from everyday citizens and resources from other communities
203
What amount of time should you spend on triage*
15 seconds
204
In an MCI, can we have on scene bystanders or those with minor wounds assist?*
Yes
205
What is something we should remember when showing up for an emergency
That "this is not my emergency"
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What are our different categories during MCIs
Green: Minor injury
Yellow: Non-life threatening injury
Red: Life-threatening injury
Black: Dead (cannot be saved) (Agonal breathing is when someone who is not getting enough oxygen is gasping for air, and jaw lift doesn't help)
207
Picture of how to triage
208
Important to know*
Triage of each Client should be completed in 15 seconds
Tag each patient by color
Red patients are seen first
Incorporate collaborative effort between all responders
209
What is the goal of triage
To do the greatest good for the greatest number of people *
210
If a question ask who we should see first, we want to see red first (can't help black since they're dead)
211
What are our 4 disease pathogens that can be used for bioterrorism? And what is the tx? *
- Anthrax, plague, tularemia (antibiotic treatment)
- Smallpox (vaccine before or after exposure)
- Botulism (antitoxin)
- Hemorrhagic fever (no known treatment)
212
What is also important about anthrax *
It can take a couple of days for the bacteria to grow before we see symptoms
213
Visual of the pathogens
214
What lab values would we see if someone is starting to head towards shock*
We would see signs of acidosis in their labs (low pH)
215
What would we consider a large bore IV*
18g
216
Never put "entry" or "exit" if they have suspected bullet wounds - just list "wound 1"
