Shock and Trauma

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1

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2

Define shock.

Clinical syndrome characterized by systemic imbalance between oxygen supply and demand.

3

What are the different kinds of shock?

Hypovolemic

Cardiogenic

Distributive

Obstructive (Septic, Neurogenic, Anaphylactic)

4

In order to prevent shock, the body must have certain regulations that maintain cellular metabolism. when one or more are interrupted it causes shock. What are they?

Cardiac output sufficient to meet bodily needs

uncompromised vascular system

Sufficient blood volume

Tissue able to extract and use oxygen from the capillaries

5

What is an early indicator of shock?

Pulse pressure

6

What is shock triggered by?

a sustained drop in MAP

7

What things influence MAP?

Total blood volume

Cardiac output

Capillary Vascular bed

8

How does the capillary vascular bed influence the MAP?

The bigger it is, the lower MAP gets.

9

In hypovolemic shock the total body fluid decreases in all fluid compartments. What are some possible causes of this?

Hemorrhage

Trauma

Surgery

Hemophilia

Inadequate clotting

Dehydration/vomiting/diarrhea

Diabetes insipidus

Diuretic therapy

10

In cardiogenic shock direct pump failure is what happens and fluid volume is not affected. What are examples of cardiogenic shock?

MI (usually of the left anterior wall)

Cardiac arrest

Ventricular dysrhythmias

cardiomyopathies

myocardial degeneration

11

In distributive shock the fluid is shifted from the central vascular space. Total body fluid is normal or increased. What can cause this?

Neural-induced

Pain

Anesthesia

Stress

Spinal cord injury

Sepsis

Capillary leak

Liver transplant

Severe burns

12

In obstructive shock, cardiac function is decreased by NONCARDIAC factors. This is indirect pump failure. What can cause these?

Cardiac tamponade

Arterial stenosis

Pulmonary embolus

Pulmonary hypertension

Constrictive pericarditis

Thoracic tumors

Tension pneumothorax

13

What are the cardiac features of shock?

Decreased cardiac output

Increased HR

Thready pulse

Decreased BP

Narrowed pulse pressure

Postural hypotension

Flat neck veins

Diminished peripheral pulses

Slow capillary refill

14

What are the respiratory features of shock?

Increased resp rate

shallow depth of resp

Increased PaC02

Decreased Pa02

Cyanosis (especially around the mouth and nail bed)

15

What are the GI features of Shock?

decreased motility

diminished or absent bowel sounds

nausea and vomiting

constipation

16

What are the neurological features of shock?

Early - anxiety /restlessness/ increased thirst

Late - Decreased CNS (lethargy to coma)/ General muscle weakness/ diminished or absent deep tendon reflexes/ sluggish pupillary response

17

what are the renal features of shock?

Decreased urine output

increased specific gravity

glucose and acetone present in urine

18

What are the integumentary features of shock?

cool to cold to the touch

pale to mottled to cyanotic

Moist clammy

Mouth dry/paste like coating

19

What collaborative care will we give a patient in shock?

Treat the underlying cause

increase arterial oxygenation

improve tissue perfusion

20

What emergency care do we give some one who is in shock?

oxygen therapy

fluid replacement

medications

21

True or false. All patients with shock should receive oxygen therapy, even those with adequate respirations.

True

22

A goal of a shock victim is to maintain Pa02 > 80 mmHg during the first 4-6 hours of care. If it cannot be maintained with unassisted respirations what is the next step?

Ventilatory assistance

23

What is the most effective treatment for hypovolemic shock?

IV fluids or blood replacement

24

Fluids are not used only for hypovolemic shock treatment. What other forms of shock can benefit from fluid replacement?

Septic

neurogenic

anaphylactic shock

25

Occasionally fluids alone are not enough to treat shock. They may also be delivered with what else?

crystalloid solutions

colloid solutions

blood or blood products

26

When fluids, blood, or other solutions are administered, how are they given?

through two large-bore peripheral lines or a central line

27

What are the key nursing care components for treating shock?

rapid assessment

reaction to subtle symptoms

anticipating potential for shock

28

True or false. You want to use warm fluids for resuscitation.

True

29

To help preserve cardiac output, what steps should you take?

Monitor cardiovascular function (vitals, pulses, etc)

Conduct baseline assessment to establish stage of shock
Measure, record I&O hourly
Monitor bowel sounds, abdominal distention, abdominal pain
Monitor for sudden sharp chest pain, dyspnea, cyanosis, anxiety, restlessness
Monitor for dyspnea
Maintain bedrest, provide a calm, quiet environment

30

How should you monitor tissue perfusion of a patient who is in shock?

Monitor skin color, temperature, turgor, moisture
Monitor cardiopulmonary functioning
Monitor body temperature
Monitor urinary output
Assess mental status, LOC

31

If your patient is receiving a colloid solution and they get an order for a blood product what should you be sure to do?

Change any solutions to normal saline during blood administration

32

Who is the most at risk for a heat related illness?

Older adults (as they have less body fluid volume and can easily become dehydrated), mental health patients, the homeless, drug users (especially cocaine), outdoor athletes, members of the military stationed in countries that are hot, people who work outside in hot climates, people lacking in air-conditioning.

33

What patient education should a nurse give to help prevent dehydration?

avoid alcohol/caffeine

prevent overexposure to sun

use sunscreen with SPF of at least 30 with UVA/UVB protection

rest frequently

taking breaks from being in a hot environment

stay indoors

take cool baths/showers

wear light weight, loose fitting, light colored clothing

34

The clinical manifestations of dehydration/heat exhaustion resemble the ______.

Flu

headache, weakness, n/v, body temp is NOT significantly elevated and the patient may continue to perspire despite the dehydration

35

Profuse diaphoresis can lead to fatal___________ and _____________.

dehydration

hyponatremia

36

Heat exhaustion/dehydration can lead to a ________ _________.

heat stroke

37

True or false. A heat stroke is not considered a medical emergency.

False. It is.

38

To be consider to be in heat stroke, the body temperature must be at least ________ degrees Fahrenheit.

104

usually it is profoundly above this

39

True or false. Without treatment, heat stroke has a high mortality rate.

True

40

What are the s/s of a heat stroke?

Confusion

bizarre behavior

seizures

coma

hypotension

tachycardia

tachypnea

41

What cardiac enzyme is commonly elevated during a heat stroke?

Troponin I

above 1.5 indicates severe myocardial damage

42

What is exertional heat stroke?

The sudden onset from strenuous physical activity in hot, humid conditions.

43

What is non-extertional or classic heat stroke?

Occurs over a period of time from chronic exposure to a hot, humid environment.

44

What are heat stroke complications?

Multiple organ dysfunction syndrome

Renal impairment

Electrolyte and acid-base disturbances

Coagulopathy or abnormal clotting

Pulmonary edema

Cerebral edema

45

What is the treatment for heat stroke/heat exhaustion/dehydration?

Stop physical activity and transfer to a cool place

use cooling methods such as icepacks or cool water

remove constrictive clothing

provide sports drink or oral rehydration therapy solution (drinking plain water can worsen the sodium deficit)

****DO NOT GIVE SALT TABLETS - THEY CAN CAUSE STOMOACH IRRITATION, N/V*****

monitor vitals

rehydrate with IV NS if n/v is persistent

draw blood for serum electrolytes

hospital admission only if the patient has other health problems worsened by the heat related illness or SEVERE dehydration

46

A patient comes into the ED claiming to have been bitten by a snake. you bring the patient back and notice one puncture wound. What do you do?

Start treatment. Sometimes there is only one puncture wound

Supplemental 02

IV line for SSR or RL

Opiods

Tetanus prophylaxis

Wound Care

Broad-spectrum antibiotics

Baseline lab values (CBC, CK, Crossmatch)

47

A patient comes into the ER with complains of a rash, fever, joint pain, and itching. While taking a history, the patient mentions that about 3 days ago he was bit by a snake but did not seek treatment because he didn't think it was poisonous. What condition do you expect?

Serum sickness

This is a type III hypersensitivity reaction that can develop 3 to 21 days after the bite. Anaphylaxis is rare but mild to moderate allergic reactions can occur.

48

A patient comes into the ED with blackened ulcerative lesion that appears to have some necrosis. The patient says that he thinks something bit him in the night but he isn't sure. What do you suspect?

Brown recluse spider bite.

49

The same patient starts to show signs of renal failure, leukopenia, seizures, hemolytic anemia and eventually falls into a coma. This is known as what?

Loxoscelism

50

What care and treatment do you give a patient who has had a brown recluse spider bite?

Topical antiseptic and sterile dressing

possible antibiotics

possible reconstructive surgery

supportive care for loxoscelism

51

What are the possible complications of loxoscelism from a brown recluse bite?

fever/chills

nausea/vomiting

kidney failure

hemolytic anemia

thrombocytopenia

DIC

death

52

What is the treatment for a patient who has had a black widow bite?

Monitor vitals

opioids

muscle relaxants

tetanus prophylaxis

Antihypertensive agents

Treatment for pulmonary edema, uncontrolled hypertension, shock

53

True or false. A sting from a bee or wasp never has an anaphylactic reaction, regardless of who they sting.

False. People who are allergic can have anaphylactic reactions.

54

When a patient comes in who has been stung by a bee/wasp what is the first thing you should do?

ABC's - advanced emergency hospital care to ensure the ABC's

Treat anaphylaxis if that's what's happening (EpiPen)

Remove the stinger and apply ice pack

55

Define anaphylaxis

life-threating allergic response

this is a true medical emergency

56

What are the S/S of anaphylaxis?

Respiratory distress with bronchospasm

Laryngeal edema

hypotension

decline in mental status

cardiac dysrhythmias

57

What is the main problem with an allergic reaction vs. a toxic venom reaction?

They can be indistinguishable. Both can cause the same early signs and symptoms

58

When a lightning strikes a human, what systems are the most affected?

Cardiopulmonary and CNS

59

What is the most lethal initial effect on the cardiopulmonary system from a lightning strike?

Asystole

60

True or false. If you see a person get struck by lightning you should not touch them because that may put you in danger as well.

False. there is no danger to the rescuer from contact with the victim.

61

What are the following Altitude related illnesses?

HAD

AMS

HACE

HAPE

High Altitude disease

Acute mountain sickness

High altitude cerebral edema

High altitude pulmonary edema

62

What is the most common cause of death associated with high altitudes?

HAPE (high altitude pulmonary edema)

63

What are the clinical manifestations of HAPE?

Poor exercise intolerance

persistent cough

cyanosis of the lips

tachycardia

tachypnea

64

Define disaster.

Event in which illness or injuries exceed the resource capabilities of a health care facility or community due to destruction and devastation.

65

What is the difference between an internal and external disaster?

Internal disaster—any event INSIDE a health care facility or campus that could endanger the safety of patients or staff; creates a need for evacuation or relocation; requires extra personnel and the activation of the facility’s emergency preparedness and response plan (ex: fire, explosion, loss of electricity, etc).

External disaster—any event OUTSIDE the health care facility or campus, somewhere in the community, which requires the activation of the facility’s emergency management plan; disasters can be natural or technologic.

66

What is the difference in a mulit-casualty and mass casualty event?

Multi-Casualty: can be managed by a hospital using local resources

Mass Casualty: Local medical capabilities are overwhelmed and may require collaboration of multiple agencies and health care facilities to handle the crisis

67

True or false. According the Life Safety Code that's published by the National Fire Protection Association, every health care facility is required to practice at least ONE fire drill every two years.

False. it has to be every year

68

What event caused HAZMAT training to start becoming implemented?

September 11, 2001 disaster

69

What are the colors of the disaster triage tag system and what do they mean?

Red - Emergent (class I): immediate threat to life i.e. airway obstruction

Yellow - Can wait a short time for care (class II): open fractures w/a distal pulse or large wound that can wait 20-30 min.

Green - Non-urgent or "walking wounded" (class III): closed fractures, sprains, abrasions, contusions

Black - expected to die/are dead (class IV)

70

When disaster strikes, what means of communication are established?

Radio/cellular communication between ED and EMS at the scene

Media broadcast message via radio/TV/electronic media

DMAT team - Disaster Medical Assistance Team

71

What are the nursing roles in hospital incident command system?

Policy development prior to disaster situation

Meet pt needs in collaboration with medical command

Personal emergency preparedness plan

personal readiness supplies or "go bag"

Creativity and flexibility are essential

72

What are the important components of event resolution?

Debriefing: Critical incident stress debriefing and administrative evaluation

Psychosocial response of survivors to mass casualty events

73

In what order should a nurse act in the event of a fire?

R - rescue

A - alarm

C - contain

E - extinguish

E

74

True or false. In the event of a fire it is imperative to shut off all patient oxygen.

False. Only for patients who can breath with out it

75

For patients on life support it is important to maintain their status ______________ until removed from the fire area.

Manually

76

What kind of fire extinguisher should you use?

an ABC extinguisher