NCM 218 - EMERGENCY NURSING CONCEPT

AMIE S. PEREZ-AGUJETAS, RN
Clinical Instructor

Emergency
● A sudden, urgent, usually unforeseen occurrence requiring immediate action
(Dorland's medical dictionary)
○ Ex. Myocardial infarction
○ Ex. Sudden cardiac arrest or chest pain which eventually leads to cardiac
arrest
● A medical or surgical condition requiring immediate or timely to prevent permanent
disability or death
○ Ex. Occupational hazards
● The care given to patients with urgent and critical needs
○ Ex. difficulty in breathing; chest pain
● A condition is still considered an emergency situation until it is stable or no longer
threatens the client’s integrity or well being
○ prioritize in stabilizing the patient prior to transferring to ex. ICU, other
hospitals
https://www.youtube.com/watch?v=QvB4dyx-rVk

Types of Emergencies
● Danger to Life
○ Emergencies that can cause an immediate danger to the life of people
involved
● Danger to Health
○ Not immediately threatening to life
○ Might have serious implications for the continued health and well-being of a
person
● Danger to Property
○ Emergencies that do not threaten any people, but do threaten peoples’
property
● Danger to Environment
○ Emergencies that do not immediately endanger life, health, or property, but do
affect the natural environment and creatures living within it

Emergencies are divided into 2 groups:

● Medical Emergencies
○ All acute psychological crises that are NOT directly caused by traumatic
impact to the body
○ Related to internal medicine; do not require surgical intervention
○ Ex. MI, stroke, anaphylaxis reaction, asthma, respiratory disease

● Traumatic Emergencies
○ Physiological crises that are directly caused by an impact to the body and
generally require surgical intervention.
○ Example: appendectomy , gallbladder removal
Emergency Nursing
● A nursing specialty in which nurses care for patients in the emergency or critical
phase of their illness or injury
● Skilled in dealing with people in the phase when a diagnosis has not yet been made
and the cause of the problem is not known.
● Patients may range from birth to geriatric

The Four Universal Goals of Emergency Nursing

● Care provider - direct care on patients
● Educator - educate the patient, watcher, parents, etc.
● Manager - coordinators of the health team
● Advocate - protecting patient’s rights: privacy, care & education

Goals of Emergency Nursing

1. Establish a partnership with the patient/relatives
2. Achieve a level of independence in the patient appropriate to the illness or injury
3. To enable the individual to avoid ill-health or injury through self-care, health
education, and environmental safety
4. To ensure the maximum effectiveness of nursing and medically prescribed treatment
is observed.

Scope and Practice of Emergency Nursing

1. Assessment, analysis, nursing diagnosis, planning, implementation of interventions,
outcome identification, and evaluation of human responses of individuals in all age
groups
2. Care that is complicated by the limited access to medical history and the episodic
nature of the health care (make use of secondary assessment, i.e. diagnostic testing)
3. Triage and prioritization (not first come, first serve; to be able to serve more patients)
4. Emergency operations preparedness (i.e. what to do during earthquakes; part of
disaster nursing)

Emergency Room Team

● Emergency Response Team
○ Delegates tasks (i.e. bagging, CPR, giving medication, documentation, etc)
● Triage Team
○ Located in the front of the ER
○ Assesses the patient to see who needs immediate care
○ Segregates patients (i.e. Emergency, surgical, paediatric, OB)
■ Example: chest pain & pregnant → check if not MI. mother may be
experiencing GERD
● ER Resident Doctors
● ER Nurses
● Nursing Assistant/Aide

Other Personnel in ER
● Admitting Staff
● Post Graduate Interns
 ● Medical/Respiratory/Nursing Students
● Respiratory Therapist
● Medical Technologist/Radiological Technician

EMERGENCY NURSE
● Specialized education, training, experience, and expertise in assessing and
identifying patients’ health care problems in crisis situations.
● Focused on giving timely care to their patients
● FUNCTIONS
○ Establishes priorities
○ Monitor and consciously assess pts who are acutely ill and injured
○ Supports and attends to families
○ Supervises allied health personnel
○ Educates pts and families within a time-limited, high pressured care
environment.
Youtube links:
https://www.youtube.com/watch?v=msUI-fSoJLQ
https://www.youtube.com/watch?v=Gr18bvqWSW8&feature=youtu.be

GENERAL PRINCIPLES OF EMERGENCY MANAGEMENT

● Remain calm and think before acting
● Identify oneself as a nurse to victim and bystander
- Tell them that you are a nurse.
● Do a rapid assessment for priority data (ABC)
● Carry out lifesaving measures as indicated by the priority assessment
○ DOB → oxygen
○ Pain → pain meds
○ Wound dressing
● Do a head-to-toe assessment (secondary assessment) before initiating first aid
measures
○ i.e. cases like stab wounds, traumatic pts
○ Change pt to hospital gown to assess any further injuries
● Obtain data from the patient (secure consent)
○ Mentally fit people can sign consent
○ If pt is unable (i.e. drug intoxication), the watcher can give consent
● Avoid unnecessary handling or moving of victim (esp. if spinal cord injury); move only
if danger is present
● Do not transport the victim until all first aid measures have been carried out and
appropriate transportation is available

EMERGENCY DEPARTMENT
MAJOR GOALS:
● To preserve life
● To prevent deterioration before more definitive treatment can be given
● To restore the patient to useful living
● To determine the extent of injury or illness
● To establish priorities for the initiation of treatment
DIFFERENT AREAS IN EMERGENCY DEPARTMENT
● Resuscitation Area
○ Code Blue
○ Need immediate attention
● Medical Area (IM cases like GERD, cardio, pneumonia, etc)
● Pediatric Area (17 years old below)
● Surgical Area (example: suture, dog bite, industrial incidents)
● OB-GYNE Area (abnormal uterine bleeding, pregnancy)
● Minor OR (pt who needs suture, cdt insertion, excision of sebaceous cysts)
● OPD (patient who don't want to be admitted, check up only)

CARE OF EMERGENCY PATIENT

● Main Goal: recognizing life-threatening illness or injury

● Priority: initiating interventions to reverse or prevent a crisis before making a medical
diagnosis
● This process begins with your first contact with a patient.
● Prompt identification of patients who need immediate treatment and
● Determining appropriate intervention are essential nurse competencies.

POSITION STATEMENTS OF EMERGENCY ASSOCIATION ON DIFFERENT ISSUES

ACCESS TO HEALTH CARE

A. All individuals must have equitable access to comprehensive health care services.
B. All factors impeding access to quality health care must be removed
C. The use of Emergency Departments for primary care and for non-urgent needs be
alleviated by expanding primary and preventive health care services.
D. The lack of appropriately prepared nurses and nurse educators deepens health
disparities, inflates costs, and exacerbates health care outcomes.
E. Emergency nurses must be actively involved in research that contributes to equitable
access to health promotion and critical, acute, and chronic health care; and
F. Emergency nurses must maintain ongoing continuing education to acquire and
enhance knowledge and skills related to community and patient needs, institutional
efficiencies, and other issues concerning equitable access to health care.

ADVANCED PRACTICE IN EMERGENCY NURSING

● ENA recognizes the contributions of clinical nurse specialists and nurse practisioners
in emergency care settings.
● Advanced practice registered nurses have a broad depth of knowledge and expertise
in their specialty area and manage complex and systems issues.

ALL HAZARDS
● All-hazards planning should begin at home
● Response to a mass casualty event should be organized and coordinated as to
maximize the number of lives saved
 ● It is essential to integrate responding entities using a common framework applicable
to all-hazards
● All-hazards planning includes utilizing a coordinated community-wide plan that links
local, stage, regional, and national resources.
● The active participation of emergency nurses in hospitals and community-wide drills
in preparing for, responding to , and recovering from all-hazards incidents is
essential.
● All-hazards planning must involve care individuals across all age groups and diverse
populations.
● Volunteer responders should participate and deploy as a requested individual, group,
or team.
● Situations arise during the disaster when it may become necessary to provide care
using altered care standards and/or in an altered or less than ideal environment.
● Development of basic and advanced continuing education course and training is
essential to prepare emergency nurses in the care and treatment of all-hazard patient
● Content of all-hazards disaster medicine and emergency response should be
included core curricula for emergency nurses and other health care professionals
● Emergency nurses should be involved in research related to disaster preparedness
topics.

HAZARDOUS MATERIAL EXPOSURE

● A comprehensive and multidisciplinary approach shall be taken for the prevention of
hazardous material exposure;
● Efforts toward an all hazards approach mitigation, planning, and response of
hazardous material exposure shall be undertaken;
● The development of appropriate hazardous material exposure guidelines shall be
based on evidence-based practice.
● Emergency care personnel shall be prepared and knowledgeable regarding the
recognition and management of patients exposed to or contaminated with hazardous
material;
● Emergency departments and their associated hospitals shall be prepared to receive
and care contaminated patients;
● Emergency departments and their associated hospital’s staff shall use the
appropriate personal protective equipment (PPE) for the management of hazardous
material exposure;
● Best practice is the regionalization and standardization of equipment, supplies,
education, and hands-on training as it pertains to the care of contaminated patients;

PATIENT SATISFACTION IN THE EMERGENCY DEPARTMENT

● The primary customers of the emergency department are patients, families, and
significant others;
● Respect for the diversity of patients, families, and significant others are inherent in
emergency nursing practice;
● The actions and interaction of the emergency nurse consistently demonstrate efforts
to meet customers’ needs for respect, dignity, and quality care;
● The emergency department is a unique health care delivery system and that
instruments to measure customer service, quality of care, and patient satisfaction
must recognize that uniqueness;
 ● Standardized measurement and monitoring of customer service, quality of care, and
patient satisfaction should be an on-going process within the emergency department
and at the national level;
● The dissemination of accurate information to the public about emergency department
services is critical to the perceptions of patients and their families concerning the
care they can expect to receive;
● Continuing education on customer service may improve both patient and staff
satisfaction with emergency department care delivery; and
● Research is needed to measure patient outcomes related to the quality care in
emergency departments.

ISSUES IN NURSING CARE

ETHICO-MORAL
Advance directives
● Documents that indicate what is to be done for a patient in extreme who is no longer
able to give or withhold permission for medical treatment
● Usually written to avoid prolonging an inevitable, often painful or non-sentiment dying
process.
Do not resuscitate order
● A physician order in the hospital chart informing other medical personnel that they
should not institute CPR in the event of cardiopulmonary arrest.
Duty to Act
● Duty of a party to take necessary action to prevent harm to another party or the
general public
● Breach of duty to act may make a party liable for damages depending on the
circumstances and relationship between the parties

CONSENT TO TREATMENT - THROUGH INFORMED CONSENT

● Means that the client is knowledgeable of ALL treatment and procedures and
AGREE to these before implementation
● Must be presented in language in cc the patient understands the implications of any
treatment.
● By being informed:
○ Clients have the right to refuse any treatment or procedures
● HOWEVER CONSENT IS VALID ONLY
○ If client is of adult years and sound MIND.
● But Not all adults can give consent especially if HYPOXIC, INTOXICATED OR
ALTERED LEVEL OF CONSCIOUSNESS.

EMERGENCY DOCTRINE
● Emergency treatment can be provided under this doctrine
● The client would have been able to consent to this IF ABLE because the alternative
would have been death or disability
● This removes the needs for obtaining informed consent before emergency treatment
and care are initiated.
RIGHT TO PRIVACY AND CONFIDENTIALITY
● Not allowing unauthorized people into the hospital area.
● Not disclosing private facts.

MANDATORY REPORTING
● Laws require hospitals, nurses, physicians as well to notify appropriate local, state or
agencies when incidents occur.
● Ex. Communicable disease: meningitis, meningococcemia, food poisoning.

PHYSICAL EVIDENCE AND CHAIN CUSTODY

● All evidences must be recorded during examination
● Should be maintained in its natural condition
● Secure consent to do picture-taking for evidence

Examples:
● Clothings – paper bag to prevent decomposition
● Bullets – MD usually marks the bottom of the bullet and refers to later during
investigation or trial. They are placed in a sealed bag, labeled and given to proper
authorities.
● Gunshot wound – photograph and describe the wound
● Specimen are obtain for legal purposes
○ Ex: Sexual assault victim – tested for alcohol level by propoer person must be
documented on his clinical records.

TRANSFER LAWS
● Nurses should be aware of the hospital transfer policies, guidelines and protocols
(Prior notification to the hospital is needed)
● This is done bc of lack of facilities or medical expertise
● Stabilization, documentation, and specific guidelines must be observed
● Receiving institution must accept the transfer
● Transfer will not endanger the patient
● Qualified personnel in attendance and proper medical equipment should be available

REASONS FOR MEDICAL ERRORS

1. Poor training of healthcare staff
2. Patient overcrwoding and doctor understaffing.
3. Patient medical history is mystery to attending staff/personnel
4. Unsanitary or ill equipped facilities
5. Inefficient or effective record keeping policies
6. Unsafe or negligent medication distribution procedures

ISSUES IN NURSING CARE

LEGAL ERRORS
● Common Emergency Room Errors have have legal impact are the following:
1. Prescription drug errors or negligent administration of medication
2. Failure to thoroughly assess the patient
3. Performing procedures without securing consent from the patient or relatives
DOCUMENTATION AND PRIVACY
● Patients should be provided with a statement of the privacy policy of the healthcare
agency
● Access to the medical record, both paper and electronic, are strictly held confidential
as to provide privacy to the patient.

CULTURAL
● Sociocultural differences between patient and provider may result in
miscommunication, distrust, poor treatment adherence, and worse outcomes.
● Improperly trained clinicians may resort to stereotyping and even biased or
discriminatory treatment of patients based on race, ethnicity, culture, language
proficiency, or social status

ADDITIONAL ISSUES IN EMERGENCY NURSING CARE

● Documentation of Consent and Privacy
● Limiting exposure to Health Risks
● Violence the Emergency Department
● Providing Holistic Care

DOCUMENTATION OF CONSENT AND PRIVACY

● Consent to examine and treat the patient is part of the ED record.
● The patient needs to give consent for invasive procedures (e.g. angiography, lumbar
puncture).
● Unconscious or in a critical condition and unable to make decisions-
DOCUMENTATION

THE NURSE MUST DOCUMENT:

● The patient’s unconscious and brought to the ED without family or friends
● Monitoring patient’s condition
● All instituted treatment and the times at which they were performed
● Response to the treatment
● Condition at discharge or transfer
● About instructions given to the patient and family for follow-up care.

LIMITING EXPOSURE TO HEALTH RISKS

● This risk is further compounded in the ED because of the common use of invasive
treatments in patients who may have a wide range of conditions and unable to
provide a comprehensive medical history.
● All emergency health care providers must adhere strictly to standard precautions for
minimizing exposure.
● Early identification and strict adherence is crucial.

VIOLENCE IN THE EMERGENCY DEPARTMENT

Causes:
● The effects of substance abuse, injury or other emergencies
● Emotionally volatile patient and families
● The environment of the ED, including being subjected to long wait times and crowded
conditions
SAFETY IS THE FIRST PRIORITY
● PHYSICAL THREATS ARE MOST OFTEN ACCOMPANIED BY VERBAL ABUSE,
which is the most common type of violence
● A patient or family member may come to the ED armed
● To avoid angry confrontations, members of gangs and families who are feuding need
to be separated in the ED

The Joint Commision has strict standards regarding documentation of the reason, monitoring
for safety, and ensuring the dignity of the patient who is restrained (Solheim, 2016).

Precautions to be taken to avoid injury include the following situations:

● For prisoners, the hand or ankle restaurant (handcuff) is never released, and a guard
is always present in the room.
● A mask can be placed on the patient to prevent spitting or biting
● Non restraint techniques should be tried when possible - e.g. talking with the patient,
minimizing environmental stimulation
● Physical restraints are used on any patient who is violent only as needed and, if used
used, should be humanely and professionally given (ACEP)
● Distance should be maintained from the patient to avoid grabbing;
● Staff should not wear items that can be grabbed by the patient, such as dangling
jewelry and stethoscopes.
● Furthermore, distance should be maintained between the patient and the door so that
an escape route for the staff member is preserved.
● Objects should not be left within patient reach; even an intravenous (IV) line spike
can be a tool of violence if the patient is determined.
● Courses on safety (de-escalation and physical restraint techniques) assist the staff
with preparing for various violent situations.

In the case of gunfire in the ED, self-protection is a priority.

● Security officers and police must gain control of the situation first, and then care is
provided to the injured.

PROVIDING HOLISTIC CARE

● Patients and families are overwhelmed by anxiety because they have not had time to
adapt to the crises
● They experience real and terrifying fear of death, mutilation, immobilization, and
other assaults on their personal identity and body integrity.
● When confronted with trauma, severe disfigurement, severe illness, or sudden death,
the family experiences several stages of crisis.
● The initial goal for the patient and family is anxiety reaction, a e to effective and
appropriate coping prerequisite
● SAFETY is of prime importance.
● Close observation and pre planning are essential.
● Security personnel are stationed nearby in the event that a patient or family member
responds to stress with physical violence

Assessment of the patient and family’s psychological function includes evaluating emotional
expression, degree of anxiety, and cognitive functioning
 ● Possible nursing diagnoses include:
○ Anxiety or death anxiety related to uncertain potential outcomes of the illness
or trauma
○ Ineffective coping related to acute situational crisis.
● Possible nursing diagnoses for the family include:
○ Grieving Interrupted family processes
○ Compromised or disabled family coping related to acute situational crisis

TWO TYPES OF INTERVENTIONS IN ER

Patient-Focused Intervention
● Act confidently and competently to relieve anxiety and promote a sense of security.
● Explanations should be given so that the patient can understand
● Human contact and reassuring words reduce the panic of the person who is severely
injured or ill and aid in dispelling fear of the unknown
● The patient who is unconscious should be treated as if conscious
● Ensuring patient safety is a major focus in clinical practice settings.
● Some of the most common sentinel in the ED include delays to care and medication
errors
● Common root causes for these sentinel events revolve around
○ Nurse staffing patterns
○ Patient volume
○ Specialty availability
● Solutions to patient safety issues in the ED include:
○ Ensuring optimal nurse staffing,
○ Pharmacy presence
○ Rapid diagnostic turnaround times
➔ To minimize wait time to diagnosis and fostering teamwork and support by leadership

Family Focused-Intervention
● The family is kept informed about where the patient is, how he is, how he or she is
doing, and the care that is being given.
● Encouraging family members to stay with the patient, when possible, also helps allay
their anxieties.

HELPING FAMILY MEMBERS COPE WITH SUDDEN DEATH

1. Take the family to a private place.
2. Talk to the family together so that they can grieve together and hear the information
given together
3. Reassure the family that everything possible was done; inform them of the treatment
rendered.
4. Avoid using euphemisms such as “passed on”.
5. Encourage family members to support each other and to express emotions freely.
6. Avoid giving sedation to family members
7. Encourage the family to view the body if they wish.
8. Spend time with the family, listening to them and identifying any needs that they may
have for which the nursing staff can be helpful.
 9. Allow family members to talk about the deceased and what he or she meant to them.
Encourage the family to talk about events preceding admission to the emergency
department.
10. Avoid volunteering unnecessary information.

TOPIC 2: APPROACHES TO EMERGENCY CARE

ER Concept

TRIAGE
● A French word tier meaning “to sort,” refers to the process of rapidly determining
patient acuity. Entails fast assessment of the patient
● Process of assessing patients to determine management priorities.
● A method of prioritizing patient care according to the type of illness or injury and the
urgency of the patient’s condition.
● Used to ensure that each patient receives care appropriate to his needs and in a
timely manner.
https://youtu.be/mygmoUzjrB4

OBJECTIVES OF THE TRIAGE

● Identify patients who require immediate care.
● Use space and resources efficiently
● Facilitate patients flow in the ED
● Provide assessment and reassessment of patient
● Alleviate fear and anxiety of patients or visitors
● Initiate legal responsibility.

TRIAGE IN HOSPITAL SETTING

THREE-TIER TRIAGE
● Emergent
○ Patients require immediate treatment within minutes or patients may die
○ Involves emergency cases with problems in the ABC’s (airway, breathing, and
circulation).
○ Within 15-30 minutes.
○ Ex: unconscious, abnormal breathing, lacerated wound (bleeding), eclampsia
● Urgent
○ Evacuation is required within two hours to save life or limb;
○ Delay in care may occur for a limited time without significant mortality;
○ Can wait up to 2 hours
● Non-Urgent
○ Patients have non-life threatening conditions and likely need only one
resource to provide for their needs.
○ More than 2 hours
○ Ex: dysmenorrhea, sebaceous cysts
FIVE-TIER TRIAGE
Based on ENA (Emergency Nursing Association) 2011
● Level 1: Resuscitation
○ This level Includes patients who need immediate nursing and medical
attention, such as those with cardiopulmonary arrest, major trauma, severe
respiratory distress and seizures.
● Level 2: Emergent
○ These patients needs immediate nursing assessment and rapid treatment
such as head injuries, chest pain (gastric or cardiac problem), stroke, asthma,
and sexual assault injuries (only considered if the patient has active
bleeding).
● Level 3: Urgent
○ These patients need quick attention but can wait as long as 30 minutes for an
assessment and treatment, such as signs of infection (fever), mild respiratory
distress or moderate pain.
● Level 4: Less Urgent
○ Patients in this triage category can wait up to 1 hour for an assessment and
treatment such as earache, chronic back pain, upper respiratory symptoms
and mild headache
● Level 5: Nonurgent
○ These patients can wait up to 2 hours for an assessment and treatment such
as sore throat, menstrual cramps, and other minor symptoms.
EMERGENCY SEVERITY INDEX (ESI)
● A 5-level triage system that incorporates concepts of illness severity and resource
use (e.g., electrocardiogram (ECG), laboratory tests, radiology studies, IV fluids) to
determine who should be treated first.
● The Emergency Severity Index (ESI) is simple to use, five-level triage instrument that
categorizes emergency department patients by evaluating both patient acuity and
resources.
● The triage nurse estimates resource needs based on previous experience with
patients presenting with similar injuries or complaints.
● Resource needs are defined as the number of resources a patient is expected to
consume in order for a disposition decision to be reached.

1. First, assess the patient for any threats to life (ESI-1)

a. Ask “Is the patient in imminent danger of dying?”
2. For ESI-2, “is this a high risk…
3. Next, evaluate patient who do not meet the criteria for ESI-1 or ESI-2 for the number
of anticipated….
4. Assign patients to ESI-3, ESI-4, or ESI-5….
5. Vital signs are important. Patients assigned to ESI-3 must have normal vital signs.
6. Patients with abnormal vital signs may be reassigned to ESI-2.
ESI ALGORITHM
A. lImmediate life-saving intervention required: airway, emergency medications, or other
hemodynamic interventions (IV, supplemental O2, monitor, ECG or labs DO NOT
count); and/or any of the following clinical conditions: intubated, apneic, pulseless,
severe respiratory distress, SPO2<90, acute mental status changes, or unresponsive
Unresponsiveness is defined as a patient that is either:
(1) Nonverbal and not following commands (acutely); or
(2) Requires noxious stimulus (P or U on AVPU) scale.
B. High Risk Situation: a patient you would put in your last open bed
○ Severe pain/distress is determined by clinical observation and/or patient
rating of greater than or equal to 7 on a 0-10 scale
C. Resources: count the number of different types of resources, not the individual tests
or x-rays (examples: CBC, electrolytes and coags equals one resourceful CBC plus
chest-xray equals two resources).

Resources Not Resources

● Labs (blood urine) ● History and physical (including

● ECG, X-rays pelvic
● CT- MRI-ultrasound-angiography ● Point-of-care testing

● IV fluids (hydration) ● Saline or heplock

● IV or IM or nebulized medications ● PO medications

● Tetanus immunization
● Prescription refills

● Specialty consultation ● Phone call to PCP

 ● Simple procedure = 1 (lac repair, ● Simple wound care (dressings,
foley cath) recheck); wound is not active
● Complex procedure = 2 (conscious ● Crutches, splints, slings
sedation)

D. Danger Zone Vital Signs

● Consider triage to ESI 2 if any vital sign criterion is exceeded.
Pediatric Fever Considerations
● 1 to 28 days of age: assign at least ESI 2 if temp >38.0 C (100.4F)
● 1-3 months of age: consider assigning ESI 2 if temp. >38.0 C (100.4F)
● 3 months to 3 years of age: consider assigning ESI3 if: temp >39.0 C
(102.2F), or incomplete immunizations, or no obvious source of fever

EMERGENCY HOSPITAL TRIAGE

● Category I: Obvious Emergency
○ Treatable life threatening illness or injury
○ Ex: cardiac arrest, chest pain, severe bleeding, shock
● Category II: Strong Potential for Emergency
○ Serious but not life threatening needs full evaluation/treatment by the
physician
○ Acute DOB
○ Burns without airway problems
○ Multiple bone or joint injuries
○ Back injuries with or without spinal damage
● Category III: Potential Emergency
○ Pending emergency condition
○ Abdominal pain
○ High fever
● Category IV: No Reason for Emergency
○ Outpatient Department (OPD) Cases
 ○ Mild URTI
○ Sore Throat
○ Low Grade Fever

TRIAGE IN MASS CASUALTIES (COLOR CODED)

Triage categories
EXPECTANT- black triage tag node
● Victim unlikely to survive given severity of injuries, level of available care, or both
● Palliative care and pain relief should be provided
IMMEDIATE - thick border red triage tag node
● Victim can be helped by immediate intervention and transport
● Requires medical attention within minutes for survival (up to 60)
● Includes compromises to patient’s airway, breathing, circulation
DELAYED - dotted border yellow triage tag node
● Victim’s transport can be delayed
● Includes serious and potentially life-threatening injuries, but status not expected to
deteriorate significantly over several hours
MINOR - Dashed border green triage tag node
● Victim with relatively minor injuries
● Status unlikely to deteriorate over days
● May be able to assist in own care; “walking wounded”

Triage (sorting casualties)

RED: Priority I (Immediate)
● Urgent resuscitative interventions are required for survival. It is likely that individuals
will die within 2 hour earlier without treatment
● Ie: airway obstruction shock, severe trauma
YELLOW: Priority 2 (Urgent)
● Require early treatment, for example surgery, and patients should be evacuated to a
surgical facility within 6 hours of injury.
● Ie. visceral injuries, limb fractures, closed head injury, eye injury, burns.
GREEN: Priority 3 (Delay or Hold)
● Treatment can be deferred if there are other casualties requiring evacuation. These
patients are ambulatory and follow commands.
● I.e: closed fractures, soft tissue injury, closed chest injury, maxillofacial injury
BLACK: Priority 4 (expectant or deceased)
● Minimal chance of survival, and if there is competition for limited medical resources,
such cases will have lower priority for evacuation and treatment
PRIMARY SURVEY
● aims to identify life-threatening conditions so that appropriate interventions can be
started

A- AIRWAY AND ALERTNESS

B- BREATHING
C- CIRCULATION
D- DISABILITY
E- EXPOSURE
F- FACILITATE ADJUNCT AND FAMILY
G- GET RESUSCITATION ADJUNCTS

A – Airway and Alertness

● Saliva, bloody secretions, vomitus, laryngeal trauma, dentures, facial trauma,
fractures, and the tongue can obstruct the airway
● Patients at risk for airway compromise include those who drown or have seizures,
anaphylaxis, foreign body obstruction, or cardiopulmonary arrest
● If an airway is not maintained, obstruction of airflow, hypoxia, and death will result
● Signs and symptoms in a patient with a compromised airway include:
○ dyspnea
○ inability to speak
○ Gasping (agonal) breaths
○ Foreign body in airway
○ Trauma to the face and neck
● The patient’s alertness level is a crucial factor for choosing the right airway
interventions.
● Determine level of consciousness (LOC) by assessing the patient’s response to
verbal and/or painful stimuli.
● A simple mnemonic to remember is AVPU:
○ A- Alert
○ V- responsive to voice
○ P- responsive to pain
○ U- unresponsive
● Airway maintenance should progress rapidly from the least to the most invasive
method.
● Treatment includes:
1. Opening the airway using the jaw-thrust maneuver (avoiding hyperextension
of the neck)
2. Suctioning and/or removal of foreign body
3. Inserting a nasopharyngeal or oropharyngeal airway (in unconscious patients
only
4. Endotracheal intubation
● Rapid-Sequence Intubation
○ The preferred procedure for securing an unprotected airway in the ED.
○ It involves the use of sedatives and paralytic drugs.
○ These drugs aid in intubation and reduce the risk for aspiration and airway
trauma.
7 P’s of RSI
● Preparation: for 10 minutes, to see and assess the patient if i intubate or not,
part of preparation is “Imaging”
● Pre-oxygenation: give oxygen to the patient prior to intubation, patient were
given high flow oxygen if oxygen saturation of the patient is low
(hyperoxygenation: to maintain 95 to prevent hypoxia); for 3-5 minutes
● Pre-Treatment: LOAD; will last for 3 minutes
L- Lidocaine
O- Opioids
A- Atropine
D- Defasciculation
● Paralysis with Induction: we give succinylcholine 1.5mg/kg IVP (IV push);
sedative to calm patient and makes it easier to intubate
● Protection: this is when we do the Sellick’s Maneuver (hyperextend pt’s neck
to make laryngeal area more visible, then apply gentle pressure to the
anterior neck)
● Placement of intubation set: ready to intubate pt; do within 45 seconds to 1
minute
● Post-Intubation Management (Plaster - secure the tube) (after this, we
can place the patient into mechanical vetilator)

● If the patient has a suspected spinal cord injury and is not already immobilized, the
cervical must be stabilized at the same time as the assessment of the airway.
● This can be done with manual stabilization or the use of rigid cervical collar (C collar)
● Keep the bed flat and continue to monitor airway patency and breathing
effectiveness.
 Alertness and Airway WIth Cervical Spine Stabilization and/or Immobilization

Assessment Interventions

● Assess for catastrophic external ● Control bleeding with direct pressure

bleeding and pressure dressings.

● Assess alertness (e.g., AVPU) ● Open airway using jaw-thrust

maneuver

● Assess for respiratory distress ● Remove or suction any foreign

bodies

● Determine airway patency ● Insert oropharyngeal or

nasopharyngeal airway,
tracheostomy

● Check for loose teeth or foreign ● Initiate rapid sequence intubation

bodies

● Assess for bleeding, vomitus, or ● Immobilize cervical spine using rigid

edema cervical collar and cervical
immobilization device.

B – Breathing
● Adequate airflow through the upper airway does not ensure adequate ventilation
● Many problems cause breathing changes. Common one include:
○ Fractured ribs
○ Pneumothorax
○ Penetrating injury
○ Allergic reactions
○ Pulmonary emboli
○ Asthma attacks
● The patient may have:
○ Dyspnea
○ Paradoxical or asymmetric chest wall movement
○ Decreased or absent breath sounds on the affected area
○ Visible wounds to the chest wall
○ Tachycardia
○ Hypotension

Breathing

Assessment Interventions

● Assess ventilation ● Give supplemental O2 via

appropriate delivery system (eg. non
rebreather mask).

● Scan chest for signs of breathing ● Ventilate with a bag-valve-mask with

 100% O2 if respirations are
inadequate or absent. (10L/min)
95 below pwde pa mag nasal cannula

● Look for paradoxical movement of ● Prepare to intubate if severe

the chest wall during inspiration and respiratory distress (e.g. agonal
expiration breaths) or arrest

● Note use of necessary muscles or ● Have suction if available.

abdominal muscles

● Observe and count respiratory rate ● If absent breath sounds, prepare for
needle thoracostomy and chest tube
insertion.

● Note color of nail beds, mucous

membranes

● Auscultate lungs

● Assess for jugular venous distention

and trachea position

C – Circulation
● An effective circulatory system includes the heart intact blood vessels, and adequate
blood volume
● Uncontrolled internal or external bleeding places a person at risk for hemorrhagic
shock.

Circulation

Interventions Interventions

● Check carotid or femoral pulse ● If absent pulse, start

cardiopulmonary resuscitation and
advanced life support measures

● Palpate pulse for quality and rate ● If shock symptoms or hypotensive,

start 2 large- bore (14-16 gauge) IVs
and start infusion of normal saline or
lactated Ringer’s solution

● Assess skin color, temperature, ● Consider intraosseous or central

moisture venous access if IV access cannot
be rapidly obtained

● Check capillary refill ● Give blood products if ordered.

D – Disability
● Conduct a brief neurologic examination as part of the primary survey.
● The patient’s LOC is a measure of the degree of disability.
● Use the Glasgow Coma Scale (GCS) to determine the LOC.
 ● This allows for consistent communication among the inter professional care team
● Remember! The GCS is not accurate for intubated or aphasic patients.
● Last, assess the pupils for size, shape, equality, and reactivity.
E – Exposure and Environmental Control
● Remove clothing from all trauma patients to perform a thorough physical
assessment. This often requires cutting off the patient’s clothing
● Be careful not to cut through any area that is forensic evidence (e.g., bullet hole).
● Do not remove any impaled objects (e.g. knife) . Removing these could result in
serious bleeding and further injury
● Once the patient is exposed, use warming blankets, overhead warmers, and warmed
IV fluids to limit heat loss, prevent hypothermia, and maintain privacy
F – Facilitate Adjunct and Family
● Research supports the benefits for patients, caregivers, and staff of allowing family
presence during resuscitation and invasive procedures.
● Patients report that caregivers provide comfort, serve as advocates for them, and
help remind the care team of their “personhood”
● Caregivers who wish to be present during invasive procedures and resuscitation view
themselves as active participants in the care process.

Facilitate Adjuncts and Family

Assessment Interventions

● Assess vital signs and pulse ● Obtain bilateral blood pressure if

oximetry patients have sustained or are
suspected of having sustained chest
trauma, or if the BP is abnormal.

● Determine caregiver’s desire to be ● Assign health team members to

present during invasive procedures support caregiver(s).
and/or cardiopulmonary
resuscitation

● Provide emotional support to

patient and caregiver.

G – Get Resuscitation Adjuncts

● L: Laboratory tests
● M: Monitor ECG for heart rate and rhythm
● N: Nasogastric (NG) tube - for oral medication
● O: Oxygenation and ventilation assessment
● P: Pain assessment and management - if there is a present of pain to the patient.
SECONDARY SURVEY
● An assessment of the patient triaged to the emergent or resuscitation category that
commences after the primary survey is completed and life-threatening insults
addressed.
● It includes obtaining vital signs, completing a head-to-toe examination, and obtaining
the patient’s pertinent medical-surgical history, including the history of the current
event.
● A brief, systematic process that aims to identify all injuries.
● It is valuable for discovering unknown problems in patients with a poor or confusing
history.

HISTORY AND HEAD-TO-TOE ASSESSMENT

● Obtain a history and mechanism of the injury or illness. These details provide clues
to the cause and guide specific assessment and interventions
● The patient may not be able to give a history. However, caregivers, friends,
bystanders, and pre-hospital personnel can often give necessary information.

SAMPLE is a memory aid that prompts you to ask about:

➔ S: Symptoms/ Subjective cues
➔ A: Allergies and tetanus status
➔ M: Medication history
➔ P: Past health/ medical history
➔ L: Last meal/ oral/ menses
➔ E: Event or environmental factors leading to injury

S: Symptoms/ Subjective Cues

● What does the patient say?
● How did the accident occur?
● Does he remember?
● What symptoms does he report?

A: Allergies
● Does the patient have allergies?
● What are they allergic to?
● Is he wearing a medical identification bracelet?

M: Medication History
● Does the patient take medications on a regular basis?
● What are the medications?
● What medications has he taken in the past 24 hours?

P: Past Health/ Medical History

● Has the patient been treated for medical conditions and if so, which ones?
● Has the patient had surgery?
● What type of surgery? When? Which doctor?
L: Last meal/ oral/ menses/ tetanus shot
● When was the last time the patient had anything to eat or drink?
● When did he have his most recent tetanus shot?
● If the patient is a female of childbearing age, when was her last menses?
● Could she be pregnant?

E: Events or environmental factors leading to injury

● How does the accident occur?
● NOI (Nature of Incident), TOI (Time of Incident), DOI (Date of Incident), POI (Place of
incident) - commonly asked questions for patient suffering from falls or vehicular
accidents

ASSESSMENT

Types of Assessment

Type Time Performed Purpose Example

Initial ● Performed ● To establish a ● Nursing admission

Assessment within specified complete assessment
time after database for
admission to a problem
health care identification,
agency. reference, and
future comparison

Problem-focus ● Ongoing ● To determine the ● Hourly assessment

ed process status of a specific of client’s fluid intake
assessment integrated with problem identified and urinary output in
nursing care in an earlier an ICU.
assessment. ● Assessment of
client’s ability to
perform self-care
while assisting a
client to bathe.

Emergency ● During any ● To identify ● Rapid assessment

assessment physiological or life-threatening of an individual’s
psychological problems airway, breathing
crisis of the status, and
client ● To identify new or circulation during a
overlooked cardiac arrest .
problems Assessment of
suicidal tendencies
or ptotaential for
violence.

Time-Lapsed ● Several months ● To compare the ● Reassessment of a

Reassessment after initial client’s current client’s functional
assessment status to baseline health patterns in a
 data previously home care or
obtained outpatient setting or,
in a hospital, at shift
change.

HEAD, NECK, AND FACE

Head, neck, and face ● Note general appearance, including
skin color.
● Assess face and scalp for
laceration, bone of soft tissue
deformity, tenderness, bleeding ,
foreign bodies.
● Inspect eyes, ears,nose, and mouth
for bleeding, foreign bodies,
drainage, pain, deformity, bruising ,
lacerations.
● Palpate head for depressions of
cranial or facial bones , contusions,
hematomas, areas of softness, bony
crepitus.
● Assess neck for stiffness, pain in
cervical vertebrae, tracheal
deviation,distended neck veins,
bleeding edema, difficulty
swallowing bruising subcutaneous
emphysema, bony crepitus.
● Check eyes for extraocular movements.
● A disconjugate gaze is a sign of neurologic damage.
● Battle’s sign, or bruising directly behind the ears, may indicate a fracture of the base
or posterior part of the skull.
● “Raccoon eyes” or periorbital bruising, usually occurs with a fracture of the base of
the frontal part of the skull.
● Check the ears for blood and cerebrospinal fluid.
● Do not block clear drainage from the ear or nose.

CHEST
Chest ● Observe rate, depth, and effort of
breathing, include chest wall
movement and use of accessory
muscles
● Palpate for bony crepitus and
subcutaneous emphysema
● Auscultate breath sounds
● Obtain 12-lead ECG and chest x-ray
● Inspect for external signs of injury:
petechiae, bleeding cyanosis,
bruises, abrasions, lacerans, old
scars
 ● Inspection and palpation of the chest will clue the nurse for heart and lung injuries
● These may be life threatening and may need immediate intervention

ABDOMEN AND FLANKS

Abdomen and Flanks ● Look for symmetry of abdominal wall
and bony structures
● Inspect for external signs of injury:
bruises, abrasions, lacerations,
punctures, old scars.
● Auscultate for bowel sounds
● Palpate for masses, guarding, femoral
pulses.
● Note type and location of pain, rigidity,
or distention of abdomen

● Frequent evaluation for subtle changes in the abdomen is essential

● Motor vehicle crashes and assaults can cause blunt trauma.
● Penetrating trauma tends to injure specific organs. Stabilize, but do not remove any
implanted objects.
● They must be removed in a controlled environment, such as the operating room
● Focused abdominal sonography for trauma (FAST)- hemorrhage and Cardiac fnx- CT
scan is better.

PELVIS AND PERINEUM

Pelvis and Perineum ● Gently palpate the pelvis.
● Assess genitalia for blood at the
meatus, priapism, bruising, rectal
bleeding, and sphincter tone.
● Determine ability to void.

● Inspect and gently palpate the pelvis. Do not rock the pelvis.
● Pain may indicate a pelvic fracture and the need for imaging.
● Assess for bladder distention, hematuria, dysuria, or inability to void.
● The HCP may perform a rectal examination to check for blood, prostate gland
problems, and loss of sphincter tone (e.g. spinal cord injury.

EXTREMITIES
Extremities ● Inspect for signs of external injury:
deformity, bruising, abrasions,
lacerations, swelling.
● Observe skin color and palpate skin
for pain, tenderness, temperature,
and crepitus.
● Evaluate movement, strength, and
sensation in arms and legs.
● Assess quality and symmetry of
peripheral pulses.
 ● Assess the upper and lower
● If not done prehospital, splint injured extremities above and below the injury to
decrease further soft tissue injury and pain.
● The HCP should realign deformed, pulseless extremities before splinting
● Check pulses before and after movement or splinting of an extremity
● A pulseless extremity is a time-critical emergency
● Immobilize and elevate injured extremities and apply ice packs. Antibiotics are given
for open fractures to prevent infection.
● Assess extremities for compartment syndrome

INSPECT POSTERIOR SURFACES

Inspect posterior surfaces ● Logroll and inspect and palpate
back for deformity, bleeding,
lacerations, bruises. Maintain
cervical spine immobilization, if
appropriate.

● An often overlooked part of the assessment is the back of the patient.

● Logroll the trauma patient while protecting the cervical spine.
● Up to 4 or more people with 1 person supporting the head may be needed to
complete this assessment.

COMPLETE HISTORY
● Pre-Hospital Information (MIVT)
○ Mechanism of Injury
○ Injury sustained/suspected
○ Vital signs
○ Treatment
● Patient’s Data
● Past Medical History/Client’s Healthcare History

PQRST
Component Sample Questions

P (Provokes) What provokes the symptoms?

Q (Quality) What makes it better? What makes it

worse? What does it feel like?

R (Radiation) Where is it? Where does it go? Is it in one

or more spots?

S (Severity) If we gave it a number from 0 to 10, with 0

being none and 10 being the worst you can
imagine, what is your rating?

T(Time) How long have you had the symptoms?

When did it start? When did it end? How
 long does it last? Does it come and go?

ACUTE CARE AND EVALUATION

● Once the secondary survey is complete, record all findings
● Give tetanus prophylaxis based on vaccination history and the condition of any
wounds
● Ongoing monitoring and evaluation are critical
● The evaluation of airway patency and the effectiveness of breathing is always the
highest priority.
● Monitor respiratory rate and rhythm, O2 saturation, and ABGs (if ordered) to evaluate
the patient’s respiratory status
● Closely monitor LOC
● Insert an indwelling catheter when indicated
● Depending on the patient’s injuries or illness, the patient may be:
○ Transported for diagnostic tests (e.g., CT Scan, angiography) or to the
operating room for immediate surgery;
○ Admitted
○ Transferred to another facility
● You may go with critically ill patients on transport

CARDIAC ARREST AND TARGETED TEMPERATURE MANAGEMENT

● Many patients arrive at the ED in cardiac arrest
● Patients with non traumatic, out-of-hospital cardiac arrest benefit from a combination
of good chest compressions and rapid defibrillation, targeted temperature
management (TTM), and supportive care.
● TTM for at least 24 hours after the return of spontaneous circulation (ROSC)
decreases mortality rates and improves neurologic outcomes in many patients

DEATH IN THE EMERGENCY DEPARTMENT

● Death occurs when all vital organs and bloody systems cease to function. It is the
irreversible cessation of cardiovascular, respiratory, and brain function.
● End-of life care EOL care focuses on physical and psychosocial needs for the patient
and family.
● The goals of EOL care are to:
○ Provide comfort and supportive care during the dying process
○ Improve the quality of the patient’s remaining life
○ Help ensure a dignified death
○ Provide emotional support to the family
● An autopsy may be done at the family’s request, or if death occurred within 24 hours
of ED admission, from suspected trauma or violence, or in an unusual way.
● Potentially be candidates for non-heart-beating donation. (corneas, heart valves,
skin, bone, and kidneys).
● Organ procurement organizations aid in screening potential donors, counseling donor
families, obtaining informed consent, and harvesting organs from patients who are on
life support or who die in the ED.
● The act of donation may be the first positive step in the grieving process.
GERONTOLOGIC CONSIDERATIONS: EMERGENCY CARE
● Regardless of a patient’s age, aggressive interventions are provided unless,
extremely low chance of survival, or an advance directive indicating a different course
of action.
● Falls are the leading cause of injury .
● The most common causes of falls in older adults are generalized weakness,
environmental hazards, syncope, and orthostatic hypotension.
● When assessing a patient who has fallen, determine whether the physical findings
may have caused the fall or are due to the fall itself.

TOPIC 3: MEDICAL EMERGENCIES

AIRWAY OBSTRUCTION - Acute upper airway obstructions is a life-threatening medical

emergency

Pathophysiology
● Partially completely occluded.
● Partial obstruction of the airway can lead to progressive hypoxia, hypercarbia, and
respiratory and cardiac arrest.
● Completely obstructed absent air movement causes permanent brain injury or death
will occur within 3 to 5 minutes secondary to hypoxia.
● The airway prevents entry of air into the lungs causing decreased oxygen saturation.
● Decrease oxygen in the brain, resulting in unconsciousness, with death following
rapidly.

Causes
● Common causes (vomitus, food, edema, tongue, teeth, saliva)
● Aspiration of foreign bodies
● Anaphylaxis- most common- causing laryngospasm
● Inhalation or chemical burns to head, face, or neck areas
● Viral or bacterial infection in the laryngeal area
● Tenacious secretions in the airway
● Cerebral Disorders (stroke: dysphagia causes saliva to build up in oral cavity)
● Trauma of the face, trachea or larynx
● Croup (excessive coughing)
● Peritonsillar or pharyngeal abscesses
● Epiglottitis
● Acute infectious processes of the posterior pharynx

Causes in Older Adults

● Sedative and hypnotic medications
● Diseases affecting motor coordination (e.g., Parkinson disease)
● Asphyxiation (e.g., dementia, intellectual disability)
● Atrophy of the posterior pharynx- resulting in aspiration or difficulty swallowing.
 ● Aspiration of a bolus of meat is the most common cause of airway obstruction

Clinical Manifestations
Partial Airway Obstruction
● Restlessness
● Agitation and anxiety
● Diaphoresis
● Tachycardia
● Coughing
● Stridor
● Respiratory distress
● Elevated blood pressure

Complete Airway Obstruction

● Universal choking sign- clutches throat with hands
● Inability to talk
● Sudden onset of choking or gagging
● Stridor
● Cyanosis
● Wheezing, whistling or any unusual breath sound that indicates breathing difficulty
● Diminished breath sounds (bilateral/unilateral)
● Sense of impending doom
● Progression to unconsciousness

ASSESSMENT AND DIAGNOSTIC FINDINGS

Conscious
● Conscious: Ask whether he or she is choking and requires help
● Unconscious: inspection of the oropharynx may reveal the offending object
● Chest and neck X-rays, laryngoscopy, or bronchoscopy, CT scan
● Auscultation
● Oxygen supplementation should be considered immediately

MANAGING PARTIAL OBSTRUCTION

● Patient can breathe and cough spontaneously -wheezing between coughs.
● Encouraged to coughing forcefully.
● Persistent spontaneous coughing - leading to good air exchange exists

MANAGING COMPLETE AIRWAY OBSTRUCTION

Head-Tilt Chin-Lift Maneuver & Jaw Thrust
Maneuver
● Rapid assessment of airway patency, breathing,
and circulation are foremost.
● Promptly assess the cause of obstruction
● Promptly remove objects visible in the mouth
● ET intubation and removal of foreign object
during insertion of the laryngoscope enables
visualization of the obstruction
 ● Emergency cricothyrotomy is indicated.

.
NASOPHARYNGEAL AIRWAY
● Provides the same airway access but is inserted through the nares.
● CI: potential facial trauma or basal skull fracture.
● If breathing is ineffective or absent, bag-valve- mask ventilation is necessary

BAG- VALVE- MASK (BVM) VENTILATION

● Is the standard method for rapidly providing rescue ventilation to patients with apnea
or severe ventilatory failure.
● BVM ventilation, a self-inflating bag (resuscitator bag) is attached to a non
rebreathing valve and then to a face mask that conforms to the soft tissues of the
face.
● The opposite end of the bag is attached to an oxygen source (100% oxygen) and
usually a reservoir bag.
● The mask is manually held tightly against the face, and squeezing the bag ventilate
the patient through the nose and mouth

Successful BVM ventilation requires technical competence and depends on 4 things:

● A patent airway
● An adequate mask seal
● Proper ventilation technique
● PEEP valve as needed to
improve oxygenation
ENDOTRACHEAL INTUBATION
Purpose:
● To establish and maintain the
airway in patients with respiratory
insufficiency
● Bypass an upper airway
obstruction,
● Prevent aspiration
● Permit connection of the patient to
a resuscitation bag or mechanical
ventilator
● Facilitate the removal of
tracheobronchial secretions
Indication:
● Patient who cannot be adequately
ventilated with an oropharyngeal or nasopharyngeal airway
● Surgical procedures - medications used to facilitate rapid sequence intubation
include a sedative, an analgesic, and a neuromuscular blockade agent.
Performed only by:
● Those who have had extensive training
● Physicians
● Nurse anesthetists
● Respiratory therapists
● Flight nurses
● Nurse practitioners
● The emergency nurse commonly assists with intubation

CRICOTHYROIDOTOMY
(CRICOTHYROID MEMBRANE PUNCTURE)
● Cricothyroidotomy is the opening of the cricothyroid membrane to establish an
airway.
 ● This procedure is used in emergency situations in which endotracheal intubation is
either not possible or contraindicated,

INDICATION:
● Extensive maxillofacial trauma
● Cervical Spine Injuries
● Laryngospasm, Laryngeal edema (after an allergic reaction or extubation)
● Hemorrhage into neck tissue
● Obstruction of the Larynx

➔ A cricothyroidotomy is replaced with a formal tracheostomy when the patient is able

to tolerate this procedure.

TOPIC 4: ACUTE HEMORRHAGE/BLEEDING

● Abnormal internal or external blood may be caused by suture failure, clotting

abnormalities, dislodged clot, infection, or erosion of a blood vessel by a foreign
object (tubing, drains) or infection process
● A rapid loss of circulation intravascular volume
○ Also called BLEEDING or BLOOD LOSS
○ Internal bleeding- refer to blood loss inside the body
■ Occurs when blood leaks out through a damaged blood vessel or
organ
○ External Bleeding- or blood loss of the body
■ Happens when blood exits through a break in the skin.
● Hemorrhage that results in the reduction of circulating blood volume is the main
cause of shock.
● Minor bleeding, which is usually venous, generally stops spontaneously - unless the
patient has a bleeding disorder or has been taking anticoagulant agents.
● Retroperitoneum, pelvis, chest, thighs, etc.

Hemorrhage/Bleeding
● The goals of emergency management are to:
1. Control the bleeding
2. Maintain adequate circulating blood volume for tissue oxygenation
3. Prevent shock

MANIFESTATIONS
● Cool, moist skin (resulting from poor peripheral perfusion
● Decreasing blood pressure
● Increasing heart rate
● Delayed capillary refill
● Decreasing urine volume
➔ HYPO TACHY TACHY - shock
MANAGEMENT
Hemorrhaging- externally or internally- a loss of circulating blood results in a fluid volume
deficits and decreased cardiac output

FLUID REPLACEMENT
1. IV catheters are inserted- 2 large bore cannula uninjured extremity
2. Blood samples are obtained for analysis, typing, and cross-matching
3. Replacement fluids-isotonic electrolyte solutions (e.g., lactated Ringer’s, normal
saline), colloids, and blood component therapy
4. Massive blood loss-PRBC, PLT, Clotting factor

CONTROL OF EXTERNAL HEMORRHAGE

● Rapid physical assessment- identify the area of hemorrhage-cut clothing
● Calm the patient - anxiousness increases BP
● Apply direct, firm pressure- bleeding area or the involved artery-proximal to the
wound.
● Elevate affected part- to stop venous and capillary bleeding
● Immobilized if the affected part is extremity
● Apply tourniquet - external hemorrhage cannot be controlled-until surgery can be
performed - proximal to the wound
● Patient is tagged with, location & time at forehead
● Traumatic amputation with uncontrollable hemorrhage - tourniquet remains in place
until OR
● Time of application and removal should be documented.

CONTROL OF INTERNAL BLEEDING

Manifestation:
● Internal hemorrhage exhibits tachycardia, falling blood pressure, thirst, apprehension,
cool and moist skin, or delayed capillary refill.
Treatment:
● Packed red blood cells, plasma, and platelets are given at a rapid rate.
Definitive Treatment:
● Surgery, pharmacologic therapy, arterial blood gas
 ● Establish baseline hemodynamic parameters
● The patient is maintained in the supine position and monitored closely until
hemodynamic or circulatory parameters improve, or until he or she is transported to
the operating room or intensive care unit.

WOUND
A break in the continuity of
a tissue of the body either
internal or external.

OPEN WOUND
● The skin is
interrupted,
exposing the
tissues underneath.
Results from
interruption from
outside (e.g. laceration or from inside like the fractured bone end tears outward
through the skin.
CLOSED WOUND
● Internal injury; no open pathway to the injured site. Results from an impact of a blunt
object (e.g. motor vehicle accidents, falls)

TYPES OF WOUNDS
CLOSED WOUND
● Contusion - bleeding beneath the skin into the soft tissue
● Hematoma - also called blood tumor; caused by damage to a blood vessel
that in turn causes blood to collect under the skin
● Bruises
● Crash Injuries
OPEN WOUND
● Abrasion- simple scratches and scrapes (outer skin is damage)
● Puncture- occurs when the skin is penetrated by a pointed object. Can be
penetrating or perforating.
● Laceration- a wound that occurs when skin, tissue, and/or muscle is torn or
cut open.
● Avulsion- involves a tearing off or loss of a flap of skin.
- flaps of skin and tissues are torn loose or pulled off completely.
● Amputation - traumatic cutting or tearing off of a finger, toe, arm or leg
➔ NOTE: Wrap or place the amputated part in a plastic bag.
Place it in a cooler container so that it is on top of a cold pack!
➔ DO NOT IMMERSE THE AMPUTATED PART IN ICE, COOL
WATER OR SALINE

FOUR MAJOR PROCEDURES IN CONTROLLING BLEEDING:

➔ Direct Pressure
➔ Elevation
➔ Pressure Points
 ➔ Tourniquet

HYPOVOLEMIC SHOCK
The sequence of events in hypovolemic shock begins with the following:
● Decrease in the intravascular volume
● This results in decreased venous return of blood to the heart and subsequent
decreased ventricular filling
● Decreased ventricular filling results in decreased stroke volume (amount of blood
ejected from the heart) and decreased cardiac output
● When cardiac output output drops, bp drops and tissues cannot be adequately
perfused
● Resulting to shock

EMERGENCY CARE FOR OPEN WOUNDS

● Expose the wound
● Clean the wound surface
● Control bleeding
● Prevent further contamination
● Bandage the dressing in place after bleeding has been controlled
● Keep patient lying still
● Reassure patient
● Care for shock

DRESSING/ COMPRESS
● Any material use to cover a wound that will help in
○ Controlling bleeding
○ Preventing infection and contamination
○ Absorbing blood and fluid drainage
○ Protecting the wound from injury

TYPES OF DRESSING

BULKY DRESSING
● Thick single dressing or a build up of thin dressing for profuse bleeding, stabilization
of impaled objects and covering of large open wounds. E.g. sanitary napkins, layers
of gauze.
OCCLUSIVE DRESSING
● A dressing used to create an airtight seal or close an open wound of an air tight seal
or close an open wound of a body cavity. Usually made of folded plastic wrap or bag.
LATEST TREND IN WOUND DRESSING
● Dry wound dressing - OS pack
● Moist wound dressing- e.g bactederm

BANDAGES
➔ Any material that is used to hold a dressing in place.
Purposes
● Hold a dressing in place
● Apply direct pressure over a dressing
 ● Prevent or reduce swelling
● Provide stability for an extremity
● Extend (e.g. broken bones)

Types of Bandages
● Triangular Bandage
● Roller / Elastic Bandage
● Muslin Binder - Abdominal Binder
● Adhesive Tapes
● Adhesive Strips

RULES FOR DRESSING AND BANDAGES

RULES FOR DRESSING

● Control bleeding
● Use sterile or clean materials
● Cover the entire wound
● Do not remove the dressing

RULES FOR BANDAGES

● Do not bandage too tightly or too loosely
● Do not leave loose ends
● Do not cover fingers toes
● Bandage from the bottom of a limb to the top (distal to proximal) in elastic bandage
● Do not square knot tying and should be clean, fast, and smooth.

Hypovolemic Shock

External: Fluid losses Internal: Fluid shifts

● Trauma ● Hemorrhage
● Surgery ● Burns
● Vomiting ● Ascites
● Diarrhea ● Peritonitis
● Diuresis ● Dehydration
● Diabetes Insipidus ● Necrotizing Pancreatitis

Major goals in the treatment of hypovolemic shock:

● Restore intravascular volume to reverse the sequence of events leading to
inadequate tissue perfusion.
● To redistribute fluid volume.
● To correct the underlying cause of the fluid loss as quickly as possible.

ANAPHYLAXIS
● A clinical response to an immediate (type 1 hypersensitivity) immunologic reaction
between a specific antigen and an antibody.
● The reaction results from a rapid release of IgE-mediated chemicals, which can
induce a severe, life-threatening reaction (Abbas et al., 2014).
 ● The reaction typically occurs within minutes but can occur up to 1 hour after
exposure to antigen. It produces physical distress within seconds or minutes after
exposure.
○ A delayed or persistent reaction may occur up to 24 hours.
○ The severity of the action is inversely related to the intervals between
exposure to the allergen and the onset of the symptoms.

WHAT CAUSES IT?

ANAPHYLAXIS usually results from ingestion of, or other systemic exposure to, sensitizing
drugs or other substances such as:
● Serum (horse serum) ● Local anesthetics
● Vaccines ● Salicylates
● Allergen extracts ● Polysaccharides
● Enzyme (L-asparginase) ● Diagnostic chemicals
● Hormones ● Food protein
● Penicillin or other ● Food additives containing
antibiotics sulfite
● Sulfonamide ● Insect Venom

RESPONSE TO ANTIGEN
● Upon exposure, IgM and IgG recognize the antigen and bind to it.
● Patient has no signs and symptoms at this stage.
RELEASED CHEMICAL MEDIATORS
● Activated IgE on basophils promotes the release of mediators including HISTAMINE,
SEROTONIN and LEUKOTRIENE
● Patient begins to have sudden nasal congestion; itchy, watery eyes; flushing;
sweating; weakness and anxiety.
INTENSIFIED RESPONSE
● Activated IgE stimulates mast cells in connective tissue along the venule walls to
release more histamine and eosinophil chemotactic factor of anaphylaxis (ECF-A).
● Patient may experience red, itchy skin; wheals and swelling appear.
DISTRESS
● In the lungs, fluids leak into the alveoli thus reducing pulmonary compliance.
● Patient may experience tachypnea, crowing, use of accessory muscles and cyanosis
signal respiratory distress.
 ● Neurologic function involves changes in the level of consciousness, severe anxiety
and possibly, seizure.
DETERIORATION
● Basophils and mast cells begin to release prostaglandins and bradykinin along with
histamine and serotonin
● These substances increase vascular permeability causing fluid to leak from the
vessels
● Patient become confuse with cool pale skin, generalized edema, tachycardia and
hypotensive thus signals rapid vascular collapse
FAILED COMPENSATORY MECHANISM
● Further deterioration occurs as the body’s compensatory mechanisms fail to respond.
● Additional substances are released to neutralize the mediators.
● These events can’t reverse anaphylaxis.
● Patient may experience hemorrhage, disseminated intravascular coagulation and
cardiopulmonary arrest.

CLINICAL MANIFESTATION
In the skin, the following s/s:
● Well circumscribed, discrete cutaneous wheals with erythematous, raised indented
borders and blanched center.
● Coalesce to form giant hives.
Other s/s includes:
● ANGIOEDEMA
- that may cause patient to complain of a lump in his throat or you may hear
hoarseness or stridor
- Is swelling in the deep layers of the skin and other tissues
- It may be accompanied by an itchy, raised rash
● BRONCHIAL OBSTRUCTION
- Wheezing, dyspnea and chest tightness
- Early indication of impending airway compromise leading to respiratory failure
● GASTROINTESTINAL AND GENITOURINARY EFFECTS
- Severe stomach cramps, nausea, diarrhea, urinary urgency, incontinence
● NEUROLOGIC EFFECT
- Dizziness, drowsiness, headache, restlessness, seizure
● CARDIOVASCULAR EFFECT
- Hypotension, shock, cardiac arrhythmias(vascular collapse)

TREATMENT
 Focus:
1. Maintaining a patent airway
2. Ensuring adequate oxygenation
3. Restoring vascular volume
4. Controlling and counteracting the effects of the chemical mediators released.
● Immediate administration of epinephrine (1:1000 or 1mg/mL)
● Tracheostomy or endotracheal intubation and mechanical ventilator to maintain
patent airway
● Oxygen therapy to increase tissue perfusion
● Administration of histamine blockers
● Albuterol nebulizer treatment
● Aminophylline to treat bronchospasm
● Volume expanders to maintain and restore circulating plasma volume
● IV vasopressors to stabilize blood pressure
● CPR to treat cardiac arrest

EPINEPHRINE ADMINISTRATION
● May give thru IM or IV if the patient is severe
● SITE: Mid-outer aspect of the thigh (vastus lateralis muscle)
● Ineffective if patient is taking beta-adrenergic blockers (Glucagon)
→ Repeating dosage every 5 to 20 minutes in severe cases if needed (IV)
→ if given IM or SQ may repeat every after 5 to 10 minutes
→ if patient is in cardiac arrest, may repeat dose every 3-5 minutes

NURSING MANAGEMENT
● Administer epinephrine as ordered
● Assess ABC. May begin CPR if patient is in cardiac arrest
● Administer supplemental oxygen and observe positive response
● Assess VS every 5 to 15 minutes
● Note for continued evidence of hypotension. May administer vasopressor as ordered
● Auscultate the lungs for decreased adventitious sounds
● Be alert of decreased wheezing
● May begin IV fluid replacement
● Monitor level of consciousness
● Evaluate peripheral tissue perfusion including skin color, temperature, pulses and
capillary refill
● Institute measures to control itching
● Reassure the patient and stay with him and let him relax as much as possible

TOPIC 5: FOREIGN BODY AIRWAY OBSTRUCTION

● A condition when solid materials like chunked foods, coins, vomitus, small toys, etc,
are blocking the airway

Causes
● Improper chewing of larger pieces of food
● Excessive alcohol intake
 ● Presence of loose upper and lower dentures
● Small children of hand-to-mouth stage left unattended
● Children who are running while eating

Two Types of Obstruction

● Anatomical Obstruction
○ It happens when the tongue drops back and obstructs the throat. Other
causes are acute asthma, croup, diphtheria, swelling and whooping cough
● Mechanical Obstruction
○ When foreign object lodges in the pharynx or airways, fluids accumulate in
the back of the throat

Universal Sign of Choking

● A sign wherein the victim is clutching his/her neck with one or both hands and
gasping for breath
● Universal Stunt: Put your one or two hands around your neck. People around you will
know and will come to the rescue

Classification of Obstruction Signs

● Mild Obstruction
○ Good air exchange
○ Responsive and can cough forcefully
○ May wheeze between cough
○ May increases respiratory difficulty and possible cyanosis
● Severe Obstruction
○ Poor or no air exchange
○ Weak or ineffective cough or no cough at all
○ HIgh pitched noise while inhaling or no noise at all
○ Increased respiratory difficulty
○ Cyanotic
○ Unable to speak
○ Clutching the neck with the thumb and fingers making the universal sign of
choking
○ Movement of air is absent

Classification of Obstruction: Rescuer Action

● Mild Obstruction
As long as good air exchange continues
○ Encourage the victim to continue spontaneous coughing and breathing efforts
○ Do not interfere with the victim’s own attempts to expel the foreign body, but
stay with the victim and monitor his/her condition
○ If patient becomes unconscious and unresponsive, activate the emergency
response system.
● Severe Obstruction
○ Ask the victim is he/she is choking
 ○ If the victim nods and cannot talk, severe airway obstruction is present and
you must perform the abdominal/chest thrust
○ If the patient becomes unconscious and unresponsive, activate the
emergency response system
LINKS: https://youtu.be/SwJlZnu05Cw
https://youtu.be/ZHRbhllcV-Y
https://youtu.be/SwJlZnu05Cw
https://youtu.be/5kmsKNvKAvU (Adult Management)
https://youtu.be/gHZdBY-CkGw (Pedia Management)

Abdominal Thrust with Victim Standing or Sitting

● Stand or kneel behind the victim and wrap your arms around the victim’s waist
● Make a fist with one hand
● Place the thumb side of your fist against the victim’s abdomen, in the midline, slightly
above the navel and well below the breastbone
● Grasp your fist with your other hand and press your fist into the victim’s abdomen
with a quick, forceful upward thrust.
● Repeat thrust until the object is expelled from the airway or the victim becomes
unresponsive
● Pedia Patients: Give each new thrust with separate distinct movement to relieve the
obstruction.
● Pregnant and obese victims

Choking Relief in an Unresponsive Adult or Child

● A choking victim’s condition may worsen and he may become unresponsive, if you
are aware that the victim’s condition is caused by a foreign body airway obstruction,
you will know to look for foreign bodies in the throat.
● Scoop foreign body with finger, do not push it.
● Shout for help. If someone else is available, send that person to activate the
Emergency Response System.
● Gently lower the victim to the ground if you see that he is becoming unresponsive.
● Begin CPR.
● Each time you open the airway to give breaths. Open the victim’s mouth wide. Look
for the object.
○ After about 5 cycles or 2 minutes or CPR, activate the ERS if someone has
not already done so.

Choking Relief In A Responsive Infant

● Kneel or sit with the infant in your lap.
● If it is easy to do, remove clothing from the infant's chest.
● Hold the infant face down with the head slightly lower than the chest, resting on your
forearm. Support the infant’s head and jaw with your hand. Take care to avoid
compressing the soft tissues on the infant's throat. Rest your forearm on your lap or
thigh to support the infant.
● Deliver up to 5 back slaps forcefully between the infant’s shoulder blades, using the
heel of your hand. Deliver each slap with sufficient force to attempt to dislodge the
foreign body.
 ● After delivering up to 5 back slaps, place your free hand on the infant’s back
supporting the back of the infant’s head with the palm of your hand. The infant will be
adequately cradled between your 2 forearms, with the palm of one supporting the
face and jaw while the palm of the other hand supports the back of the infant’s head.
● Turn the infant as a unit while carefully supporting the head and neck. Hold the infant
faceup, with your forearm resting on your thigh. Keep the infant’s head lower than the
trunk.
● Provide up to 5 quick downward thrusts in the middle of the chest, over the lower half
of the breastbone.
● Deliver chest thrusts at a rate of about 1 second, each with the intention of creating
enough force to dislodge the foreign body.
● Repeat the sequence of up to 5 chest thrusts until the object is removed or the infant
becomes unresponsive.

Choking Relief in an Unresponsive Infant

● Shout for help. If someone responds, send that person to activate the ERS. Place the
infant on a firm, flat surface.
● Begin CPR (starting with chest compressions) with 1 extra step:
- Each time you open the airway, look for the object in the back of the throat. If
you seen an object and can easily remove it, remove it.
● After about 2 minutes of CPR, activate the ERS (if no one has done so).
● If the infant becomes unresponsive, stop giving back slaps and begin CPR, starting
with chest compressions.

Blind Finger Sweeps

● Do not perform a blind finger sweep because it may push the foreign body back into
the airway causing further obstruction or injury

TOPIC 6: INHALATION INJURIES

Inhalation Injury
● Results from trauma to pulmonary system after inhalation of toxic substance or
inhalation of gases that are nontoxic but interfere with cellular respiration.
● Inhaled exposure forms include fog, mist, fume, dust, gas, vapor or smoke.
● Inhalation injuries commonly accompany burns.
● Inhalation injury is caused by inhalation of thermal and/or chemical irritants.
● Injuries above the vocal cords can be thermal or chemical.
● Whereas injuries below the vocal cords are usually chemical.
● Singed facial hair or carbonaceous sputum are indicators
for the presence of smoke inhalation injury. .

CAUSES: CARBON MONOXIDE POISONING

● Carbon monoxide is a colorless, odorless, tasteless gas
produced as a result of combustion and oxidation
● Inhaling small amounts of gas over a long period of time
can lead to poisoning
● Carbon monoxide is considered a chemical asphyxiant
 ● Accidental poisoning can result from exposure to heaters, smoke from a fire or use of
a gas lamp, gas stove or charcoal grill in a small, poorly ventilated area.

* Chemical asphyxiants, which interfere with the transportation or absorption of oxygen in

the body, include hydrogen cyanide and carbon monoxide.

*Carboxyhemoglobin

CARBON MONOXIDE POISONING: CLINICAL MANIFESTATION

MILD POISONING
● Indicates CO level from 11% to 20%
○ Slight shortness of breath
○ Headache
○ Decreased visual acuity
○ Decreased cerebral function
MODERATE POISONING
● Indicates a CO level from 21% to 41%
○ Altered mental status
○ Confusion and headache
○ Tinnitus and dizziness
○ Drowsiness and irritability
○ Nausea and changes in skin color
○ Tachycardia and hypotension
○ stupor

SEVERE POISONING
● Indicates a CO level from 42-60%
● Convulsion
● Coma o Generalized instability
FINAL STAGE
● CO level reaches 61% to 80% resulting in DEATH.

CAUSES: CHEMICAL INHALATION

● Wide variety of gases may generated when materials burn
● The acids and alkalis produced in the burning can produce chemical burns when
inhaled
● The inhaled substances can reach the respiratory tract as insoluble gases and lead
to permanent damage
● Inhaling unburned chemical in a powder or liquid form can also cause pulmonary
damage.
SIGNS AND SYMPTOMS
The most common side effects of smoke or chemical inhalation includes
● Atelectasis (lung collapse)
● Pulmonary edema
● Tissue edema
● Respiratory distress (occurs early)
● Hypoxia
CAUSES: THERMAL INHALATION
● Pulmonary complications remain the leading cause of death following thermal
inhalation trauma
● Commonly caused by inhalation of hot air or steam
● Mortality rate exceeds 5% when inhalation injury accompanies burns of the skin

SIGNS AND SYMPTOMS

Initial symptoms include:
● Ulcerations
● Erythema
● Edema of the mouth and epiglottis

Edema may rapidly progress to upper airway obstruction which may have the following”
● Stridor/ wheezing/ crackles
● Increased secretions
● Hoarseness
● Shortness of breath

DIAGNOSTIC TEST
● Electrolytes
● Liver function Studies
● BUN and creatinine
● CBC
● ABG - acid base status, ventilation and oxygenation
● Cardiac monitoring- to monitor ischemic changes
● ECG - common finding is depressed ST segment (CO poisoning)
● Chest X-ray

TREATMENT
● Assessment of the patient’s ABC is the first step
● Obtain the history of the exposure and attempt to identify the toxic agent of exposure
● Immediately provide oxygen to the patient
● Upper airway edema requires emergent ET intubation
● Bronchodilators, antibiotics and IV fluids may be prescribed
● Chest physiotherapy may assist in the removal of necrotic tissue
● Fluid resuscitation is important in component in managing inhalation injury but careful
monitoring of fluid status is essential because of the risk of pulmonary edema.

WHAT TO DO?
● Remove the patient’s clothing
● Establish IV access for medication, blood products and fluid administration
● Obtain laboratory specimens to evaluate ventilation, oxygenation and baseline values
● Implement cardiac monitoring
● Monitor for pulmonary edema
● Provide oxygen
● Monitor fluid balance and input and output closely
● Assess lung sounds frequently
 ● Provide a supportive and educative environment.
● Monitor laboratory studies for changes that may indicate multisystem complications.
LINK: https://youtu.be/CB10airH5Sg (Inhalation Injuries)

TOPIC 7: SUDDEN CARDIAC ARREST

SUDDEN CARDIAC ARREST

- The absence of mechanical functioning of the heart muscle.
- The heart stops beating or beats abnormally and doesn’t pump effectively
- If blood circulation isn’t restored within minutes cardiac arrest can lead to the loss of
arterial blood pressure, brain damage and death.
LINKS: https://youtu.be/7IMiXJH_bw4
https://youtu.be/69CQsdPC2i8 (Difference between cardiac arrest and heart attack)

CAUSES
● Acute Myocardial infarction
● Ventricular Fibrillation
● Ventricular tachycardia
● Severe Trauma
● Hypovolemia
● Metabolic disorders
● Brain injury
● Respiratory arrest
● Drowning
● Drug overdose

PATHOPHYSIOLOGY
- Myocardial contractility stops, resulting in a lack of cardiac output.
- An imbalance in myocardial oxygen supply and demands follows, leading to
myocardial ischemia, tissue necrosis and death.

Mag sent daw later si maam ug notes, i sulat ko lang na later sakit akong pus on :( huhu

CLINICAL MANIFESTATION
● Loses consciousness
● Absent spontaneous respiration
● No palpable pulse gasping
● Dilated pupil in less than a minute
● Pallor and cyanosis

ADULT CARDIAC ARREST ALGORITHM

*insert pic (nawala tung naa diri ganina

ADULT CARDIAC ALGORITHM

CPR Quality
● Push hard 9at least 2 inches (5 cm)) and fast (100-120/min) and allow complete
chest recoil.
● Minimize interruptions in compressions.
● Avoid excessive ventilations.
● Change compressor every 2 minutes, or sooner if fatigued.
 ● If no advanced airway 30:2 compression-ventilation ratio.
● Quantitative waveform capnography
- If PETCO2 is low or decreasing, reassess CPR quality.

Shock Energy for Defibrillation

● Biphasic: Manufacturer recommendation (eg. initial dose of 120-200 J); if unknown,
use maximum available. Second and subsequent doses should be equivalent, and
higher doses may be considered.
● Monophasic: 360 J

Drug Therapy
● Epinephrine IV/IO doses: 1 mg every 3-5 minutes
● Amiodarone IV/IO doses:
- First dose: 300 mg bolus
- Second dose: 150 mg or
Lidocaine IV/IO dose:
- First dose: 1-15 mg/kg
- Second dose: 0.5-0.75 mg/kg

Advance Therapy
● Endotracheal intubation or supraglottic advanced airway.
● Waveform capnography or capnometry to confirm and monitor ET tube placement.
● Once advanced airway in place, give 1 breath every 6 seconds (10 breaths/min) with
continuous chest compression.

Return of Spontaneous Circulation (ROSC)

● Pulse and blood pressure.
● Abrupt sustained increase in PETCO2 (typically > 40 mmHg).
● Spontaneous arterial pressure waves with intra-arterial monitoring.

Reversible Causes
● Hypovolemia
● Hypoxia
● Hydrogen ion (acidosis)
● Hypo-/ hyperkalemia
● Hypothermia
● Tension pneumothorax
● Tamponade, cardiac
● Toxins
● Thrombosis, pulmonary
● Thrombosis, coronary