emergency + disaster
describe notification and activation of emergency preparedness plan
- radio/ cellular communication between ED and EMS at scene
- media broadcast message via radio, TV
- DMAT team: disaster medical assistance team
- facility incident commander with clear lines of authority and accountability for resources
briefly describe chemical, electrical, radiation, thermal and scald burns
- chemical: acid or alkaline (burns deeper) destroys tissue protein.
- electrical: entry + exit wound following path of least resistance like muscle, bone, blood vessel, nerves
- radiation: more often sunburn, can cause 2nd degree
- thermal: most common type of burn, exposure to dry heat (flame) or moist heat (steam/ fluids)
- scald: hot fluids
medications for shock (inotropes)
- left ventricle must be strong enough to continuously pump blood to whole body
- increases myocardial contractility, increase CO > increased tissue perfusion (digoxin, dobutmine)
components of shock + examples
- Pump: the heart
- Plumbing: vasculature and circulatory
- Fluid: circulating blood volume (lack can lead to hypovolemia). Phases to control blood loss include vascular spasm, platelets plug, coagulation cascade.
therapeutic management of shock
- ABCs: stop fluid loss
- IV fluids; positive inotropic, vasopressors/ dilation, crystalloids (NS or LR)
- check VS/ neuro check
- position supine with HOB ~10 degrees feet 20 degrees, cover to prevent shivering/ loss of heat.
- oral hygiene, suction, ventilation
list local vs. systemic body responses during burn
- local: hemostasis (platelets form thrombus to wall off), inflammation (vasodilate) proliferation, remodeling, possible excess scarring
- systemic: catecholamine release, acidosis, vasoconstriction, renal ischemia, liver alteration, cardiac changes, hypoxia
vasopressors
- stimulate contraction of muscle tissue, constricting blood vessels which improves peripheral resistance.
- can be administered WITH fluid volume resuscitation, used to treat neurogenic, septic and anaphylactic shock.
- increase afterload, assess for chest pain, o2, urine output (high doses can decrease renal perfusion), BP every 15 minutes, IV site for infiltration.
- dopamine (inotropic), epinephrine and norepinephrine
describe stage 1 (initial) of shock
- a drop in MAP <10 Hg
- SNS increases peripheral constriction
- beginning lactic acid build up due to cellular metabolism (still aerobic vascular constriction of DBP known as narrowing pulse pressure)
- CO and MAP are still normal
- increase in HR and respirations early signs
describe causes, nursing care and symptoms of hypovolemic shock
- 759-1000mL of fluid loss whether it is external (blood/plasma) or internal (3rd spacing)
- low BP, low o2, cold clammy pale skin, weak and thready pulse, rapid shallow respirations, hypothermia (evaporation of sweat)
describe symptoms of inhalation burns
- soot in nasal, carbon sputum, adventitious LS, dyspnea, dysphagia
- cilia stop functioning causing bronchial congestion/ infection. pulse ox is not accurate if CO poisoning present
- GI: stress ulcer (curling), paralytic ileus, sepsis
- urinary: hemoglobinuria: carbon in urine, pyuria, hematuria
opioids
- patient must be stable enough to tolerate med without masking symptoms and becoming hypotensive/ apneic
- treats pain asap, must be carefully regulated and pt. monitored frequently
describe stage 2 (compensatory) of shock
- MAP < by 10-15 Hg, hyperkalemia, acidotic, tachycardic, thirst, restlessness, FOF d/t release of epinephrine + norepinephrine
- kidney and hormonal adaptive mechanisms activated triggering actions of renin, aldosterone and ADH (decrease U.O)
- tissue hypoxia in non-vital organs, decrease SBP and increase DBP. Cool extremities
- increase need for glucose so catecholamine stimulates liver to release glycogen
- effects of this stage are reversible
describe causes, symptoms and nursing care for cardiogenic shock
- MI most common, cardiac tamponade, pericarditis, dysrhythmias. HR may increase d/t low CO
- heart is unable to pump forward the amount of blood in one stroke to support life (LV at risk). Anything that hinders flow of blood OUT of the heart
- cyanosis, hypotension, angina, JVD, crackles, pulmonary edema, SOB, oliguria/ anuria
describe rule of 9's, Lund and Browder, and parkland formula
- rule of 9's: extent of burn to determine fluid replacement
- L&B: surface area on age
- parkland formula: fluid resuscitation, 1st 8 hours receive 1/2 amount of fluid for 24 hours, next 16 hours you receive other 1/2.
* 2 large bore IVs needed, crystalloids, restore circulating volume
prophylaxis
- tetanus
- given in open wounds
describe stage 3 (progressive) of shock
- sustained decrease in MAP +20 mmHg
- 35-50% fluid loss (1800-2500mL) to anaerobic metabolism > increase lactic acid > acidosis
- Na+ moves into cell and K+ enters blood stream = decreased serum Na+ and increase K+
- weak pulse, severe thirst, hypotension, pallor-cyanosis, cool-moist skin, anuria, 5-20% decrease in o2 sat.
- can be reversed with some organ damage
describe causes, nursing care and symptoms of distributive (neurogenic, anaphylactic and septic) shock
- flow of blood is not distributed evenly
- anaphylactic (antibody-antigen response is triggered by allergen, increase histamine causing vasodilation in periphery and vasoconstriction in airway). SE: warm, edematous, paresthesia
- neurogenic (imbalance between PNS and SNS of vascular smooth muscle) SE: slow bounding pulse, warm dry skin, lowered temp)
- septic: caused by virus, bacteria or fungi. Infection > early sepsis > SIRS > organ failure > MODS. SIRS: cytokines and mediators associated with inflammatory response. SE: early warm, hyperdynamic, fast respirations, anxious, elevated temp. late: cold clammy, hypodynamic
describe wound care for burns
- topical antimicrobial cream: Silvadene most used (unless allergy to sulfa)
- ABX given pre and post op with autografts
- 3rd solutions contain peroxide for debridement
- wound care twice a day in the morning
describe crystalloids + colloids
- crystalloids: simple solutions of small solutes. 0.9% saline, 5% dextrose, LR (isotonic) lactate helps buffer acidosis.
- colloids: suspension of macromolecules blood (whole), PRBCs, platelets, plasma, albumin, dextran (synthetic)
describe stage 4 (refractory) of shock and its complications.
- tissue becomes anoxic, cellular death widespread
- MAP can be restored by too much damage to maintain life (kidneys shut down completely)
- complications: MODS (MAP <60 d/t poor organ perfusion, watch GCS, renal +resp. compromised and do not respond to meds; pt. needs help achieving homeostasis.
> ARDS, DIC, PE
describe causes, nursing care and symptoms of obstructive shock
- impaired diastolic filling (pneumothorax, cardiac tamponade) decreased cardiac output and blood pressure with reduced tissue perfusion.
- increased right ventricle afterload (P.E) and increased left ventricular afterload (aortic stenosis)