Priorities in care

Emergency management

First

Deal with conditions or injuries interfering with vital physiological function. This will normally be,

Airway

Breathing

Circulation

Haemorrhage

Head injury

Fractures

Other damage

Place a number to show the order of priority you would give to each of the following features in a newly admitted unconscious patient.

Fractured wrist with bony displacement

Blood oozing from a head wound

Patient starts to vomit

Compound Fracture of the Fibula

Rapidly cyanosing patient

Unequal pupils are observed

Rapid loss of BP with tachycardia

Patient smells of alcohol

Nose bleed

Airway/Breathing

Assess Position Inhalation of vomit Obstruction Chest injury

C Spine Assume damage until proved otherwise

Cardiac output Assess

Haemorrhage Internal External

Monitor Rapid change in condition

Wounds Protect with sterile dressings

Fractures Emergency traction Immobilisation with splints

Record B.P. and P. Level of consciousness

Look for Diabetic card Relevant information eg. patient on steroids

Pain Relieve as soon as possible without drugs

Treat with analgesia as soon as diagnosis is made

Intra-abdominal injuries

Penetrating injuries

Objectives - control of bleeding, maintain blood volume, prevention of contamination prepare for surgery.

Obtain history Remove clothing from wounds

Observe pulse and respiration, emergency equipment to hand

Control external bleeding Keep patient flat and comfortable

Nurse still to prevent any clot displacement over bleeding vessels Reassure

Constantly assess and observe for signs and symptoms of haemorrhage, CVP, BP, P,

R and neurological status

Gastric aspiration - helps assess gastric wounds, reduces danger of aspiration

Cover and keep moist abdominal viscera

Nil by mouth, prevents increased peristalsis and vomiting

Urinary catheter - urinary output, haematuria Prevent infection - anaerobic bacteria, tetanus

Pre-op preparation

Blunt abdominal trauma

Delayed complications possible, liver, spleen, pancreas, kidneys

Signs and symptoms of organ damage

• hypovolaemia • pain, worse on movement • rebound tenderness

• guarding • diminished bowel sounds and activity

Management

History Complicating chest/rib injuries

Avoid movement

Observe for bluish discoloration, asymmetry, abrasions, contusions

Abdominal girth, ? distension Systemic signs of haemorrhage - frequent obs.

Avoid analgesic before diagnosis X-Rays

N/G Tube Pre-op care for laparotomy

Crush injuries

Loss of circulating blood volume into wound site, inflammation

Paralysis of part, swollen, tense, hard

Rhabdomyolysis - myoglobinuria, (dark brown urine, positive for blood, but with no cells)

Renal hypoperfusion Acute renal failure

Wounds

Objectives - control haemorrhage, avoid complications, promote healing, minimise scarring and prevent deformity.

Remove any contamination, foreign bodies Dressings

Prevent Infection - tetanus, antibiotics, passive immunoglobulin

Clean area round the wound, remove hair

Wound Closure, (when clean), primary and delayed primary closures, secondary healing

Haemorrhage

Assess - remove clothing

Firm, direct pressure, but do not compress fractures or foreign bodies

Pressure dressings Intravenous cannula

Whole blood or plasma expanders given at rate of loss, pre-op emergency care

Shock - possible cardiac arrest, treatment for shock

Family following a patients death

Communicate in private Talk to family together with Doctor

Reassure everything possible was done

Allow family to talk about patient and ventilate feelings

Avoid unnecessary information eg. re. alcohol or drugs

Avoid sedating family - this masks or delays the grieving process, so making depression more likely

Allow family to view the body