Chapter 33 Emergency Nursing

2 Emergency Care Area  Requirements  Central location  Easy access  Dedicated “crash table”  Basic necessary equipment  Oxygen source  Suction unit  Surgical lighting  Multiple electrical outlets

3 Crash Cart  Organize and prioritize drawers according to the ABC’s  A=airway  B=breathing  Thoracocentesis materials for emergency respiratory patient  Venous access (C=circulation)  Venous access drawer  Various sizes and lengths catheters

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5 Emergency Drugs  Well organized and labeled  Current dose chart  Syringes and saline flush nearby

6 Laboratory Equipment  Minimum database “QATS”  Lactate testing  Additional testing  Blood gases  Coagulation testing  Commercial test kits  Ethylene glycol

7 Fluid Therapy  Goals and objectives  Maintaining hydration  Replacing fluid losses  Treatment of shock  Treatment of hypoproteinemia  Increase urine output  Correcting acid–base or electrolyte disturbances  Providing nutritional support

8 Fluid Therapy in Shock  To correct poor perfusion, replace deficits rapidly  Goal: expand and maintain the intravascular space  Shock fluid rates  Combination of therapy crystalloids and colloids

9 Principles of Triage  Set protocols for a consistent, thorough response  CRASH PLAN  Be well-organized  Expect the unexpected

10 Cardiopulmonary Arrest  Cessation of breathing and effective blood circulation

11 Cardiopulmonary Arrest  Complication of any critical illness  Potential complication in healthy patients undergoing anesthesia

12 Definitions  CPR = Cardiopulmonary Resuscitation  Providing ventilation and assisted circulation  CPCR = Cardiopulmonary Cerebral Resuscitation  Acronym emphasizes the importance of maintaining perfusion and oxygen delivery to the central nervous system during and after an arrest

13 Patients at Risk For an Arrest  Respiratory difficulty  Heart disease  Severe hypothermia  Multi-organ failure  Trauma  Shock

14 Patients at Risk for an Arrest  Anesthetized patients  Monitor for unexplained changes in anesthetic depth  Frequently monitor vital signs during entire procedure  Monitor closely after anesthesia  Support perfusion with fluids, heating pads

15 Vagal Arrest  Caused by heightened vagus nerve stimulation or vagal tone  Common diseases associated with vagal arrests  Gastrointestinal disease  Respiratory disease  Neurological disease  Ophthalmic disease

16 CPCR Protocols  First step: Call for help!

17 CPCR Protocols  Second step: Basic life support  A irway  B reathing  C irculation  Current protocols may advocate the “CABs” to reflect the importance of restoring perfusion during the resuscitation efforts.

18 CPCR Protocols  A = Airway  If respirations are absent or weak, the mouth should be opened and examined for possible obstruction

19 CPCR Protocols  B = Breathing  If the animal does not begin to breathe, the patient must receive ventilation assistance  Mouth-to-nose resuscitation may be performed by sealing the lip margins and blowing into the animal’s nose  Neonates may be intubated with a small red rubber catheter; oxygen can be delivered carefully by blowing through the tube

An endotracheal tube connected to an Ambu bag and oxygen source provides an ideal means to supply 100% oxygen and manual assisted ventilation.

21 CPCR Protocols  B = Breathing  Visualize airway with laryngoscope  Pull tongue forward with dry gauze to facilitate tube passage  Suction readily available  Stylets readily available

22 CPCR Protocols  B = Breathing  Begin ventilation  First two breaths administered should be long breaths lasting a full 2 seconds followed by patient assessment  If voluntary breathing is not immediate, manually ventilate

23 CPCR Protocols  Ventilation  Manually ventilated at a rate slightly higher than the expected normal  Goal: expand the chest by 30% with a slightly longer expiration than inspiration  Inspiratory Pressures  20 cm H 2 O dog  15 cm H 2 O cat

24 CPCR Protocols  Failed respiratory resuscitation may respond to acupuncture to labial fulcrum  Insert 25 g needle 1.0 mm and twist

25 CPCR Protocols  C = Circulation  Once the airway is established and ventilation provided, assess circulation  Palpation of pulses (or apex heart beat)  Auscultation of the heart

26 CPCR Protocols  Once cardiac arrest has been confirmed, initiate chest compressions  Positioning of animal  Depends on the animal’s size  Shape of the chest (barrel chest vs. deep and narrow chest)  The caregiver’s ability to deliver adequate compressions

27 CPCR Protocols  Place palm over heart; hand-over-hand  Compress with elbows and weight of body  Place stack of towels under patient’s heart  Small dogs or cats may place sternal and compress ventrally  “Tennis-ball” technique

29 CPCR Protocols  Allow time between compressions for adequate ventricular filling  Intermittent abdominal compression  Alternate with external chest compression

30 CPCR  Effectiveness of CPCR  Assessed by palpating for a pulse and evaluating mucous membrane color  Use ECG if available  Use ultrasound if available to assess the heart

31 Open-Chest CPCR  Indicated in animals with chest trauma  Open-chest CPCR is only beneficial if initiated early in the resuscitation effort  Open-chest CPCR should be made within 2 minutes of cardiopulmonary arrest