Shock and Trauma
Clinical syndrome characterized by systemic imbalance between oxygen supply and demand.
What are the different kinds of shock?
Obstructive (Septic, Neurogenic, Anaphylactic)
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
What is an early indicator of shock?
What is shock triggered by?
a sustained drop in MAP
What things influence MAP?
Total blood volume
Capillary Vascular bed
How does the capillary vascular bed influence the MAP?
The bigger it is, the lower MAP gets.
In hypovolemic shock the total body fluid decreases in all fluid compartments. What are some possible causes of this?
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)
In distributive shock the fluid is shifted from the central vascular space. Total body fluid is normal or increased. What can cause this?
Spinal cord injury
In obstructive shock, cardiac function is decreased by NONCARDIAC factors. This is indirect pump failure. What can cause these?
What are the cardiac features of shock?
Decreased cardiac output
Narrowed pulse pressure
Flat neck veins
Diminished peripheral pulses
Slow capillary refill
What are the respiratory features of shock?
Increased resp rate
shallow depth of resp
Cyanosis (especially around the mouth and nail bed)
What are the GI features of Shock?
diminished or absent bowel sounds
nausea and vomiting
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
what are the renal features of shock?
Decreased urine output
increased specific gravity
glucose and acetone present in urine
What are the integumentary features of shock?
cool to cold to the touch
pale to mottled to cyanotic
Mouth dry/paste like coating
What collaborative care will we give a patient in shock?
Treat the underlying cause
increase arterial oxygenation
improve tissue perfusion
What emergency care do we give some one who is in shock?
True or false. All patients with shock should receive oxygen therapy, even those with adequate respirations.
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?
What is the most effective treatment for hypovolemic shock?
IV fluids or blood replacement
Fluids are not used only for hypovolemic shock treatment. What other forms of shock can benefit from fluid replacement?
Occasionally fluids alone are not enough to treat shock. They may also be delivered with what else?
blood or blood products
When fluids, blood, or other solutions are administered, how are they given?
through two large-bore peripheral lines or a central line
What are the key nursing care components for treating shock?
reaction to subtle symptoms
anticipating potential for shock
True or false. You want to use warm fluids for resuscitation.
To help preserve cardiac output, what steps should you take?
Monitor cardiovascular function (vitals, pulses, etc)
Conduct baseline assessment to establish stage of
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
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
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
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.
What patient education should a nurse give to help prevent dehydration?
prevent overexposure to sun
use sunscreen with SPF of at least 30 with UVA/UVB protection
taking breaks from being in a hot environment
take cool baths/showers
wear light weight, loose fitting, light colored clothing
The clinical manifestations of dehydration/heat exhaustion resemble the ______.
headache, weakness, n/v, body temp is NOT significantly elevated and the patient may continue to perspire despite the dehydration
Profuse diaphoresis can lead to fatal___________ and _____________.
Heat exhaustion/dehydration can lead to a ________ _________.
True or false. A heat stroke is not considered a medical emergency.
False. It is.
To be consider to be in heat stroke, the body temperature must be at least ________ degrees Fahrenheit.
usually it is profoundly above this
True or false. Without treatment, heat stroke has a high mortality rate.
What are the s/s of a heat stroke?
What cardiac enzyme is commonly elevated during a heat stroke?
above 1.5 indicates severe myocardial damage
What is exertional heat stroke?
The sudden onset from strenuous physical activity in hot, humid conditions.
What is non-extertional or classic heat stroke?
Occurs over a period of time from chronic exposure to a hot, humid environment.
What are heat stroke complications?
Multiple organ dysfunction syndrome
Electrolyte and acid-base disturbances
Coagulopathy or abnormal clotting
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*****
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
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
IV line for SSR or RL
Baseline lab values (CBC, CK, Crossmatch)
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?
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.
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.
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?
What care and treatment do you give a patient who has had a brown recluse spider bite?
Topical antiseptic and sterile dressing
possible reconstructive surgery
supportive care for loxoscelism
What are the possible complications of loxoscelism from a brown recluse bite?
What is the treatment for a patient who has had a black widow bite?
Treatment for pulmonary edema, uncontrolled hypertension, shock
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.
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
life-threating allergic response
this is a true medical emergency
What are the S/S of anaphylaxis?
Respiratory distress with bronchospasm
decline in mental status
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
When a lightning strikes a human, what systems are the most affected?
Cardiopulmonary and CNS
What is the most lethal initial effect on the cardiopulmonary system from a lightning strike?
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.
What are the following Altitude related illnesses?
High Altitude disease
Acute mountain sickness
High altitude cerebral edema
High altitude pulmonary edema
What is the most common cause of death associated with high altitudes?
HAPE (high altitude pulmonary edema)
What are the clinical manifestations of HAPE?
Poor exercise intolerance
cyanosis of the lips
Event in which illness or injuries exceed the resource capabilities of a health care facility or community due to destruction and devastation.
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.
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
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
What event caused HAZMAT training to start becoming implemented?
September 11, 2001 disaster
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)
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
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
What are the important components of event resolution?
Debriefing: Critical incident stress debriefing and administrative evaluation
Psychosocial response of survivors to mass casualty events
In what order should a nurse act in the event of a fire?
R - rescue
A - alarm
C - contain
E - extinguish
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
For patients on life support it is important to maintain their status ______________ until removed from the fire area.
What kind of fire extinguisher should you use?
an ABC extinguisher