I.

EMERGENCY
 Cardiac Arrest & Respiratory Arrest
• A. Adult/child/infant cardiopulmonary resuscitation (CPR)
• 1. Assessment
• shake gently and shout "are you okay?"
• check victim's pulse (for at least 5 seconds, but no more than 10 seconds)
• adult or older child check carotid
• child check carotid (or femoral)
• infant check brachial or femoral
• if victim is breathing and has a pulse, position in a recovery position
• if victim has a pulse but is not breathing
• adult: give 1 breath every 5 to 6 seconds (approximately 10 to 12 breaths/minute) and recheck pulse every 2 minutes
• child and infant: give 1 breath every 3 to 5 seconds (approximately 12 to 20 breaths/minute) and recheck pulse every 2
minutes
• If victim is unresponsive:
• for adult or child with out-of-hospital sudden collapse:first call the emergency response system
• for infants and children: provide 2 minutes of CPR before activating the emergency response system
• call for a defibrillator (AED)
2.Chest compressions
• a. begin chest compressions if pulse is absent or in child/infant if heart rate is less than 60 with signs of poor perfusion
• b. be sure client is on a firm surface and lying face up
• c. hand position
• adult/older child center of chest between nipples; two hands with heel of one hand and the other hand on top
• child center of chest between nipples; one hand or two hands with use of the heel(s) of the hands
• infant just below the nipple line; one rescuer uses two fingers or two rescuers use two thumbs encircling hands around chest
d. compression depth
• adults: at least 2 inches (5 cm)
• child: at least 1/3 anterior-posterior diameter of chest or about 2 inches (5 cm)
• infant: at least 1/3 anterior-posterior diameter of chest or about 1.5 inches (4 cm)
e. compression ratio: at least 100 compressions per minute for all ages
f. push hard and push fast, allowing chest to recoil between compressions
g. minimize interruptions in chest compression keep at 10 seconds or less

3. Open the airway

• a. head tilt-chin lift
• place one hand on victim's forehead and push with your palm to tilt the head back
• place the fingers of your other hand under the bony part of the victim's lower jaw
• lift the jaw to bring chin forward
b. jaw thrust (if trauma is evident or spinal injury suspected)
•
 4. Deliver 2 breaths using barrier devices, such as a face mask with 1-way valve
• a. deliver air over 1 second to make the victim's chest rise
• b. avoid excessive ventilation
• c. advanced airway considerations (laryngeal mask airway, esophageal-tracheal combitube or endotracheal tube)
• give breaths at a rate of 1 breath every 6 to 8 seconds (approximating 8-10 breaths/minute) when an advanced airway is in
place during 2-person CPR for victims of all ages
• asynchronous with chest compressions
• there should be no pause in chest compressions for delivery of breaths
• keep dentures in the mouth if they are secure; remove if loose in mouth

B. Additional Information about CPR

• 1. Compressions - ventilation ratios until advanced airway is placed
• adult 30:2 (30 compressions to 2 breaths) for both one or two rescuers
• child or infant
• one rescuer 30:2 (30 compressions to 2 breaths)
• two rescuers 15:2 (15 compressions to 2 breaths)
• 2. Check pulse about every 2 minutes
• 3. Definition of ages (for health care provider)
• adult: adolescent and older child (health care provider)
• child: 1 year to onset of puberty (about 12 to 14 years old)
• infant: under 1 year
• 4. Apply monitor or defibrillator when available
• 5. Continue until ACLS providers take over or the client starts to move

• C. Automated External Defibrillator (AED)

• 1. Power "ON" the AED
• 2. Attach the pads to the victim's bare chest
• only adult pads can be used on adults; children/infant pads OR adult pads can be used on children
• for victims with lots of chest hair, it may be necessary to either shave area first or use pad to tear off hair
• place one AED pad on the victim's upper right chest (directly below the collarbone) and the other pad to the side of the left
nipple, with the top edge of the pad a few inches below the armpit; for children, can also place one pad on the chest and the
other pad on the victim's back
• 3. Be sure no one touches the victim while the AED analyzes heart rhythm
• 4. AED will prompt when shock is advised; if no shock is needed, immediately resume CPR starting with chest compressions
• 5. After 5 cycles or about 2 minutes of CPR, the AED will prompt and re-analyze rhythm

• D. Differences for lay persons

• 1. Lay rescuers do not need to assess for pulse or signs of circulation for an unresponsive victim
• 2. The American Heart Association supports the use of compression-only CPR (no mouth-to-mouth)

E. Conscious choking
• Age one year and older - use Heimlich maneuver; continue to perform a new abdominal thrust until the obstruction is
removed
• Infants - alternate between delivering 5 back blows and 5 chest thrusts until obstruction is removed or infant loses
consciousness

• F. Unconscious choking
• If it is known that a person was choking and is now unresponsive - activate the EMS system, lower the client to the ground
and begin with compressions (don't check for a pulse)
• If the rescuer does not know there is an airway obstruction - begin CPR
• Open the victim's mouth wide and look for the object before giving breaths; remove object only if able to remove without
further pushing down airway

G. Rapid Response Team (RRT)

• 1. RRT responds to non-ICU adult clients who are demonstrating signs of imminent clinical deterioration
• 2. Goal: to prevent intensive care unit transfer, cardiac arrest, or death
• 3. RRT members usually include: hospitalist or critical care physician, critical care nurses, the bedside nurse, IV
team (if applicable), respiratory therapist
• bedside nurse: identifies the client at risk and activates the RRT, informs RRT of client assessment
• ICU nurses: bring code cart, places leads and monitors cardiac activity, assists with implementation of orders (including
administration of medications), documents
• physician: leads the team
• respiratory therapist: client assessment, provides ventilatory support and airway management, monitors pulse oximetry
• other staff involved may include charge nurse, unit secretary, manager of hospital operations, residents
• 4. Suggested criteria for activating the RRT
• respirations: < 8/min or > 28/min, difficulty breathing
• heart rate: < 40/min or > 140/minute
• systolic blood pressure: < 90 mm Hg or > 180 mm Hg
• acute neurologic change, e.g., acute loss of consciousness, new onset lethargy, sudden loss of movement, change in speech
or vision
• staff member has significant concern about the client's condition
• urine output less than 50 mL over 4 hours
• oxygen saturation less than 90% despite supplementation
• other potential criteria
• chest pain unresponsive to nitroglycerin
• seizure
• acute significant bleeding

Communicating client information to RRT using the acronym: S.A.M.P.L.E.

S = situation - why the client is hospitalized and (significant) findings
A = allergies
M = medications (on MAR)
P = past medical history
L = last meal & (significant) labs
E = event - describe what happened and why RRT was called

 Shock
• Overview
• Definition: a clinical syndrome marked by inadequate tissue perfusion and oxygenation of cells, tissues and organs
• Requirements for homeostatic regulation (if one or more of these components malfunctions shock may follow)
• adequate cardiac output
• uncompromised vascular system
• adequate blood volume
• ability of tissue to extract and use oxygen
• Major categories or types of shock
• 1. Cardiogenic (pump failure or heart failure)
• 2. Obstructive (mechanical interference with ventricular filling or ventricular emptying)
• 3. Distributive (vasogenic)
• septic
• anaphylactic
• 4. Hypovolemic (intravascular volume loss)
• Three stages of shock
• Compensatory (reversible, initial, "warm")
• Progressive stage
• Irreversible stage

Findings - Stage 1
• Findings depend on type of shock
• hypovolemic and cardiogenic shock: decreased cardiac output and perfusion
• anaphylactic, septic, and neurogenic shock: blood vessels dilate, causing the blood to remain in the blood vessels instead of
returning to the heart, which triggers anaerobic metabolism and development of lactic acidosis; blood pressure drops
• Compensatory mechanisms (neural, chemical, and hormonal) act to maintain perfusion
• a. neural compensation
• baroreceptors in carotid sinus aortic arch activate sympathetic nervous system (SNS), which contracts blood vessels so that
skin cools
• SNS releases epinephrine and norepinephrine, which stimulates heart (tachycardia) and blood flow to kidneys and
gastrointestinal system is reduced, pupils dilate
• b. hormonal compensation
• decreased blood flow to kidneys releases angiotensin, which constricts vessels and increases blood pressure
• angiotensin II stimulates the secretion of aldosterone; aldosterone causes kidneys to retain sodium which increases serum
osmolality, which in turn stimulates antidiuretic hormone (ADH)
• ADH causes water retention
• increased sodium and water retention results in increased BP, decreased urine volume and increased urine specific gravity
• anterior pituitary is stimulated to secrete adrenocorticotropic hormone (ACTH); ACTH acts on adrenal cortex to increase
secretion of glucocorticoids, which increases serum glucose
• c. chemical compensation
• decreased pulmonary blood flow causes hypoxemia
• hypoxemia is sensed by chemoreceptors that increase rate and depth of respirations, which results in respiratory alkalosis
• Clinical findings at this stage are vague because of compensatory mechanisms
• a. subjective findings include chest pain, lethargy, somnolence, restlessness, anxiousness, dyspnea, diaphoresis, thirst,
muscle weakness, nausea and constipation
• b. objective physical assessment findings
• hypoxia, tachypnea progressing to 40 breaths/minute, hypocarbia, wheezing
• skin:
• may be pale, mottled or dusky in color, cool, diaphoretic, warm, flushed with fever (distributive shock)
• rash (anaphylactic and septic shock)
• angioedema (anaphylactic shock)
• blood pressure - may be within the expected reference range during the initial stage (but will drop to 50 to 60 mm Hg)
• tachycardia - increasing to 140 beats/minute (pulse is weak, thready or bounding with distributive shock)
• decreased urine output

Findings - Stage 2 (Progressive)

• Compensatory mechanisms can no longer maintain perfusion and organ functions deteriorate
• severe hypoperfusion
• massive cell death
• organs begin to fail
• severe lactic acidosis and metabolic acidosis
• Findings of progressive stage of shock
• neurologic
• altered mental status, depressed level of consciousness due to decreased blood flow to the brain
• cerebral edema and irreversible brain cell damage may occur, leading to coma
• respiratory
• decreased pulmonary blood flow alters the exchange of oxygen and carbon dioxide between the alveoli and capillaries
• decreased oxygen levels and increased carbon dioxide levels, leading to respiratory acidosis, tachypnea with hypoventilation
and adventitious lung sounds (crackles and wheezes)
• cardiovascular
• decreased cardiac output and decreased BP with systolic below 90 mm Hg
• narrowing pulse pressure
• tachycardia and irregular pulse; faint peripheral pulses
• jugular venous distention
• gastrointestinal (GI)
• blood shunted from the GI track and liver to the heart and brain causes organs to become ischemic, resulting in ischemia of
the gastric mucosa
• liver fails as shock progresses, leading to hypoglycemia
• renal/elimination
• hypoperfusion leads to decreased urine output, oliguria, which may result in acute renal failure
• dilute urine osmolality
• absent bowel sounds
• integumentary
• skin color changes - ashen and cyanotic
• due to vasoconstriction, the skin will be cool and moist
• unless this stage of shock is treated rapidly, the client's prognosis is poor

Findings - stage 3 (refractory)

• Death from multi-organ dysfunction syndrome (MODS)
• Findings of refractory stage of shock
• cardiac failure
• respiratory failure
• renal shutdown
• liver dysfunction
• loss of consciousness

REMEMBER: Types of shock are classified according to etiology: CHANS

• Cardiogenic - caused by inability of the heart to pump blood effectively (due to heart attack or heart failure)
• Hypovolemic - caused by inadequate blood volume (due to bleeding or dehydration)
• Anaphylactic - caused by allergic reaction
• Neurogenic - caused by damage to nervous system (due to extreme emotional upset due to personal tragedy or disaster)
• Septic - caused by systemic infection
 Diagnostics
• Bedside data collection used to assess client's condition and identify etiology of shock
• serum lactate - to determine tissue oxygen balance
• procalcitonin - to differentiate between bacterial and nonbacterial infections
• Complete blood count
• hemoglobin & hematocrit - to identify hypovolemic shock; help rule out anemia
• white blood cells - to rule out septic shock (look for neutrophils and shift to the left)
• platelet count - may be low due to coagulopathy related to sepsis
• Brain natriuretic peptide (BNP) - an indicator of congestive heart failure and as an independent prognostic indicator of
survival
• Arterial blood gases (ABGs) - as shock progresses, this can measure metabolic acidosis
• Electrolytes and glucose - to determine the progression of shock (as shock progresses, sodium levels decrease, potassium
levels increase, and glucose levels decrease)
• BUN and creatinine - check for decreased renal perfusion
• Blood cultures - to determine the causative agent in septic shock
• Creatine Kinase-MB (CK-MB) and troponin - to determine cardiogenic shock
• X-ray's, CT, and MRI - to determine the extent of the injury and locate site of internal hemorrhage
• Invasive hemodynamic monitoring (Swan-Ganz catheterization) - to exclude volume depletion, obstructive shock and septic
shock

Management - objective is to correct underlying cause and prevent progression

• 1. Many treatments listed are used for all shock syndromes, e.g., vasopressors, positive inotropic support, oxygen therapy
(intubation), fluid replacement
• 2. Cardiogenic shock - early revascularization in patients with myocardial infarction and intervention in clients with
structural heart disease
• a. pharmacologic treatments
• positive inotropic agents - increase myocardial contractility and improve systolic ejection, e.g., dobutamine, amrinone
• vasodilators - improve heart's pumping action by reducing its workload; e.g., nitroglycerin, nitroprusside sodium; usually
limited to clients with failing ventricular function
• vasopressors - increase peripheral vascular resistance and elevate blood pressure, e.g., norepinephrine, dopamine
• diuretics and digoxin - may be given if the client shows heart failure
• antidysrhythmic agents - may be given to regulate the client's heart rhythm
• b. oxygen therapy - titrated based on ABG analysis and respiratory effort
• c. supportive treatments - to assist with blood circulation
• intra-aortic balloon pump (counterpulsation)
• left and right ventricular assist pumping
• 3. Hypovolemic shock - rapid fluid replacement therapy to replace lost volume; usually given in a 3:1 ratio (300 mL
fluid for every 100 mL of fluid loss)
• crystalloids - 2/3 moves out of vascular space, e.g. 0.9% normal saline or ringers lactate
• colloids (not for sepsis or burn) - 1/3 to 1/2 moves out of vascular space, e.g. albumin, dextrans & hydroxyethylstarches
• hemoglobin-based oxygen carriers
• blood and blood products
• whole blood (autotransfusion an option if they go to surgery/chest tube)
• packed red blood cells - increase the oxygen carrying capacity of blood
• platelets
• fresh frozen plasma - to expand blood volume
• cryoprecipitate - treats clients with clotting factor deficiencies
• 4. Anaphylactic shock
• epinephrine (adrenalin) given IM or IV - for vasoconstriction and bronchodilation
• antihistamines, e.g., diphenhydramine - to reverse the effects of histamine
• corticosteroids - prevent a delayed reaction from the antigen
• albuterol - to reverse bronchospasm
• aminophylline
• 5. Neurogenic - depends on causative agent
• IV fluids are ordered to reverse the peripheral vasodilation
• If cause is severe pain, appropriate analgesic should be ordered
• minimize spinal cord trauma with stabilization of the vertebral column
• 6. Septic shock
• fluid replacement
• anti-infective agents based on culture results
• improve cardiac output with positive inotropes and vasopressors
 Nursing interventions for shock: the cardio-care six except
• Do not elevate or lower head: maintain complete bed rest in flat position or with legs slightly raised to increase venous return
(modified trendelenburg)
• Bed rest
• Turn patient every two hours as tolerated
• Monitor the client's body temperature - prevent shivering and keep client warm
• Assess vital signs every 15 to 30 minutes
• Monitor for restlessness, confusion or mental status changes- this indicates cerebral perfusion
• Monitor for bowel sounds and abdominal distension/pain
• Assess for sudden, sharp chest pains, dyspnea or cyanosis
• Administer parenteral therapy, medications
• Monitor mean hemodynamic indicators as ordered
• Blood plasma expanders or packed cells if hematocrit and hemoglobin low

 Trauma Care
• A. Airway with simultaneous cervical spine immobilization
• Head to neutral position, but do not force if encounter resistance
• Cervical spine immobilization using rigid cervical collar (trauma clients are always presumed to have cervical spine injury)
• Must use jaw thrust - do not use head-tilt chin-lift!
• B. Breathing
• 1. Look, listen and feel for respirations
• Assess for spontaneous breathing, rise and fall of the chest, rate and pattern of breathing, use of accessory muscles
• assess skin color
• assess integrity of soft tissues and bony structures of the chest wall
• 2. Auscultate the lungs bilaterally
• 3. Follow BLS procedures
• 4. Use advanced airway device, e.g., endotracheal tube, with traumatized airway, emesis
• 5. Inspect for tracheal deviation and jugular venous distention

CLIENT CARE- TRAUMA

Assessment and early management of the trauma client includes the following:
• A. Remember A-I mnemonic for trauma client's:
A=Airway with simultaneous cervical spine protection
B=Breathing
C=Circulation
D=Disability (neurologic status)
E=Exposure/environmental controls
F=Full set of vital signs/focused adjuncts/family presence
G=Give comfort measures
H=History and Head to toe assessment
I=Inspect posterior surfaces

Primary survey: ABCs

• A = airway maintenance with spinal cored control, i.e., cervical stabilization
• B = breathing
• C = circulation
• B. Assess cognitive levels: Glasgow Coma Scale
• Provides an objective score based on a 15 point scale (for adults)
• Assesses three categories of responses
• eye opening response
• verbal response
• motor response
• C. Assess: A.M.P.L.E.
• A = allergies
• M = medications
• P = past illness
• L = last meal
• E = events preceding the injury
• D. Types of trauma
• Penetrating
• Blunt
• deceleration
• compression
• E. Findings of trauma
• Deformity/angulation of extremity
• Swelling
• Pain
• Paresis/paralysis
• Pallor
• Absent pulses
• F. Life threatening injuries of an extremity
• Massive open comminuted fractures
• Bilateral femoral shaft fractures
• Vascular injuries
• Crush injuries of the abdomen or pelvis
• Traumatic amputation of an arm or leg
• G. Predictable musculoskeletal injuries
• a. Child/pedestrian injuries
• Waddell's triad
• associated with high-velocity accidents involving children, i.e., motor vehicle, auto-pedestrian, or bicycle crashes
• consists of femur fracture, intra-abdominal or intrathoracic injury, and/or head injury
• take care to determine
• point of impact with the car bumper
• point of impact with the car hood
• point of impact where the body is thrown
• children tend to face car when incident is about to occur
• b. Adult/pedestrian injuries
• take care to determine
• point of impact with the car bumper
• point of impact with the car hood
• injuries to opposing ligaments
• unlike children, adults tend to turn away from car before impact
• c. Unrestrained drivers
• head injuries
• injuries to larynx and sternum
• knee/femur injuries
• posterior hip dislocation
• d. Fall from a height ("Don Juan syndrome")
• lands on feet and fractures ankles: bilateral calcaneal fractures
• falls backwards: L2-L3 injuries
• hyperflexion of the lumbar spine
• bilateral Colles' fractures
• compression fracture of vertebrae
• then may land on hands: fractured wrists
• e. Blast injuries
• gunshot/missile type injuries
• source of infection: when energy travels it leaves a vacuum behind it, drawing in debris and body hair
• results in both an entry and exit wound
• shock waves extend throughout body
• H. Goals of nursing care
• Sustain life
• Maintain function
• Preserve appearance
• I, Goals of rehabilitation
• Decrease pathology
• Prevent secondary disabilities
• Increase function of unaffected and affected systems
REMEMBER: Emergency trauma assessment: ABCDEFGHI
Primary Assessment = A, B, C, D & E
Secondary Assessment = F, G, H & I
A = Airway (with simultaneous cervical spine protection)
B = Breathing
C = Circulation
D = Disability ((neurological status)
E = Examine/expose
F = Full set of vital signs/focused adjuncts
G = Give comfort
H = History and Head-to-toe assessment
I = Inspect the posterior surfaces
 C. Circulation
• 1. Assess pulses
• palpate a central pulse (carotid, femoral, or brachial in infants under one year of age)
• assess for strength (normal, weak, or strong) and rate (normal, slow, or fast)
• 2. Blood pressure
• there is no evidence to support the following widely held assumptions - if a client has a palpable radial pulse, systolic blood
pressure is estimated to be at least 80 mm Hg; a palpable femoral pulse is estimated at 70 mm Hg; if only the carotid pulse
can be palpated the BP is estimated at 60 mm Hg
• taking a formal blood pressure can be deferred until later
• 3. Inspect for any obvious signs of uncontrolled external bleeding (apply direct pressure and elevate area with gross
hemorrhage)
• 4. If pulses are absent, life support measures should be initiated - prepare and assist with an emergency thoracotomy (only in
facilities with the resources to manage post-thoracotomy clients)
• 5. After initial assessment, start two large-bore IVs
• administer warmed isotonic crystalloid solution at a rate appropriate for the client's condition
• interosseous needles may be used for access in the sternum, legs, arms or pelvis if the client's injuries wound not interfere
with the procedure

D. Disability/neurological status
• Assess pupils for size, shape, equality, and reaction to light
• Determine the presence of lateralizing signs - unilateral deterioration in motor movements, along with unequal pupils and
other symptoms help locate the area of injury in the brain
• Ability to move extremities, check for sensation
• Ability to move against resistance
• Score on Glasgow Coma Scale - a quick way to measure the client's level of consciousness (even though it is not a measure
of total neurological function); initial and serial scores provide the trauma team with a good indication as to client outcomes.

• E. Expose/examine
• Undress client carefully and quickly so injuries can be determined
• Inspect for injuries or deformities
Use the A.V.P.U. mnemonic for your initial assessment:

A = Alert
V = Verbal
P = Pain
U = Unresponsive

F. Full set of vital signs/focused adjuncts

• 1. Full set of vital signs - pulse, respiratory rate and blood pressure
• pulse - greater than 120 BPM is of concern
• respiratory rate - greater than 30 breaths per minute is of concern
• blood pressure - less than 100 mm Hg systolic is of concern
• 2. Maintain warmth - warm blankets, warming lights
• 3. Focused adjuncts
• ECG, pulse oximeter
• insert an indwelling catheter and nasogastric tube if needed
• facilitate radiographic and diagnostic studies, including chest x-rays; CT scan of head, abdomen, and chest; cervical spine x-
rays; diagnostic peritoneal lavage if needed
• blood typing, complete blood count, electrolytes
• administer tetanus booster
• G. Give comfort
• 1. Talk to and touch the client
• 2. Pharmacological and non-pharmacological pain management as needed by conscious or unconscious client
• a. unmanaged pain can cause increased heart rate, and increased force of cardiac contraction, increase in blood pressure,
myocardial oxygen consumption; tachypnea, peripheral vasoconstriction and pallor, nausea/vomiting, muscle tension
• b. interventions
• remove any pain producing objects, e.g., shattered glass
• administer prescribed medication and monitor for side effects of the medication, including respiratory depression,
hypotension, nausea/vomiting, bradycardia, and hallucinations
• consider alternative methods, e.g., therapeutic touch, positioning/splinting, application of heat/cold, distraction, relaxation
exercises, guided imagery
• 3. Family presence
• assess the families desires and needs, support the families involvement
• assign a health care professional to provide explanations about the procedures and to be with the family
• utilize resources if needed such as social worker or chaplin
H. History and head-to-toe full assessment
• 1. How did injury occur - mechanism of injury
• knowledge of mechanism of injury and specific injury patterns
• type of motor vehicle, impact of injury, length of time since injury
• Injuries sustained - ask pre-hospital personnel about client's general condition, level of consciousness, and apparent injuries
• 2. Measure vital signs
• 3. If the client is responsive, ask questions to evaluate the client's condition, pain, location, duration, intensity
• 4. Obtain medical history, including age, any premedical conditions, allergies, last tetanus shot, previous
hospitalization/surgeries, use of drugs/alcohol, date of last menstrual period, current medications
• 5. Head to toe - full body system assessment
• general appearance - note body position, guarding, stiffness, or flaccidity of muscles
• note any unusual odors, such as gasoline, chemicals, vomit, alcohol, urine/feces
• head and face
• eyes - visual acuity (hold up fingers), inspect for periorbital ecchymosis (racoon eyes), perform PEARLA
• ears - inspect ecchymosis behind the ear (Battle's sign - late sign of head injury), note any unusual drainage
• nose - inspect any unusual drainage such as blood or clear fluid (may be cerebrospinal fluid if clear - do NOT insert a gastric
tube through the nose)
• neck - inspect for any trauma, position of trachea, palpate for subcutaneous emphysema
• chest
• observe breathing, rate, depth, and use of accessory muscles
• auscultate lungs and heart tones
• palpate sternum and ribs for bony crepitus and deformities
• abdomen
• inspect for lacerations, abrasions, contusions, puncture wounds, impaled objects, ecchymosis, edema
• auscultate for bowel sounds and palpate gently for rigidity, guarding, masses and areas of tenderness
• pelvis/perineum
• inspect for lacerations, abrasions, contusions, avulsions, puncture wounds, impaled objects, ecchymosis and edema
• palpate for instability and tenderness over the iliac crests and symphysis pubis
• inspect for blood at the urethral meatus, inspect penis for priapism (with proper personnel to examine the rectal area in males
to determine anal sphincter tone)
• extremities - inspect color, assess skin temperature and moistness, palpate pulses (comparing one side with the other)
• soft tissue injuries - inspect for bleeding, lacerations, abrasions, contusions, avulsions, puncture wounds, impaled objects,
edema, angulation, deformity or open wounds
• bony injuries - note crepitus, palpate for deformity and areas of tenderness
• motor function - inspect for spontaneous movement of extremities, determine strength and range of motion of all 4
extremities
• sensation - determine client's ability to sense touch in all extremities

I. Inspect posterior surfaces

• maintain cervical spine protection, support extremities with suspected injuries, log roll on the uninjured side
• inspect back, flanks, buttocks, posterior thighs, palpate vertebral column, and all posterior surfaces for deformity and
tenderness

Complications of a trauma client: TRAUMATIC

T = Tissue perfusion problems
R = Respiratory problems
A = Anxiety
U = Unstable clotting factors
M = Malnutrition
A = Altered body image
T = Thromboembolism
I = Infection
C = Coping problems

POINTS TO REMEMBER:
• Along with fluid replacement and medications to increase cardiac output, this type of shock (Septic) must be treated
with the appropriate anti-infective agent(s).
 • The sequence of actions in the initial assessment for trauma care is: airway, cervical spine stabilization,
breathing and then circulation. The cervical spine must be simultaneously stabilized when assessing the airway,
and before breathing and circulation are assessed.
• The essential treatment for clients with hypovolemic shock is to restore fluid volume and blood pressure. The client
may also need medications to help increase cardiac output and mean arterial pressure, such as dobutamine
(Dobutrex) and norepinephrine (Levophed).
• In the initial stage of shock, only subtle changes in clinical signs may be seen. Hypotension does not typically occur
until the progressive stage of shock. Pallor, cool and clammy skin, altered level of consciousness and irregular heart
rhythms are the other classic findings of the progressive stage.
• Acute myocardial infarction (MI) is the most common cause of cardiogenic shock. Cardiogenic shock typically
develops following an acute MI, especially a ST-segment elevation MI (STEMI). However, cardiogenic shock can
result from any cardiac dysfunction that causes acute myocardial ischemia.
• Cardioversion is an elective procedure that is used to treat dysrhythmias, like atrial fibrillation. It involves
synchronized shocks specific to the arrhythmia. Defibrillation is used for the immediate treatment of life-threatening
arrhythmias, like ventricular fibrillation. It involves non-synchronized shocks during the cardiac cycle.
• Paradoxical chest wall movement is a key assessment finding in the client with a flail chest. Flail chest
results when two or more rib fractures occur in two or more places, causing the flail segment to separate from the
rib cage. It often occurs from blunt trauma associated with accidents. Paradoxical respirations are the inward
movement of a part of the thorax during inspiration and the outward movement during expiration. Clients also have
severe chest pain, dyspnea and possible tachycardia and hypotension with flail chest.
• Intracranial pressure is the pressure inside the skull and brain tissue. Altered LOC is often one of the earliest signs
that a client has increased ICP. LOC is also the most important component of the neurological assessment in a high
acuity and emergent client situation. Increased ICP can be caused by trauma, hemorrhage, tumors, edema or
inflammation.
• CPR
•Compressions - Airway - Breathing ("C-A-B")
•The health care provider should not delay activating the EMS but check the victim for two things simultaneously: response
and breathing.
•The current emphasis is on establishing good chest compressions with 30 compressions preceding the 2 ventilations.
•Start compressions within 10 seconds of recognizing cardiac arrest.
•Push hard and fast on the chest, without interruption, at a rate of at least 100 compressions a minute, allowing
complete chest recoil after each compression.
•For adults, compress the chest at least 2 inches using 2 hands.
•For children, compress the chest approximately 2 inches using 1 or 2 hands.
•For infants, compress the chest approximately 1.5 inches using 2 fingers or the thumbs of both hands.
•For the adult victim, give 30 compressions and 2 breaths (30:2 ratio) with either 1 or 2 rescuers.
•For the child or infant victim, give 30 compressions and 2 breaths (30:2 ratio) when there is 1 rescuer; with 2 rescuers, infant
and child CPR becomes 15 compressions and 2 breaths (15:2 ratio).
•Minimize interruptions in compressions to less than 10 seconds.
•Give effective breaths that make the chest rise and avoid excessive ventilation.
•Individuals with ventricular fibrillation or pulseless ventricular tachycardia should receive chest compressions until a
defibrillator is ready; defibrillation should then be performed immediately.
•There are 4 universal steps for using any AED
•POWER ON the AED
•ATTACH the AED pads
•ANALYZE the rhythm
•SHOCK if advised
• SHOCK: Types of shock are classified according to etiology: CHANS (Cardiogenic, Hypovolemic, Anaphylactic, Neurogenic
and Septic shock).
• In shock, the first hour of treatment is most critical; early detection is key.
• There are different ways to categorize shock; basically shock presents three potential problems:
• Not enough fluid in the blood vessels.
• Fluid has moved outside the vessels, so cannot be pumped to the organs.
• Heart cannot pump fluid that is present in the vascular space.
• The major problem in shock is tissue hypoxia.

TRAUMA: The initial assessment of the trauma client is the most important step.
• If client has head injury, the most important data collection is level of consciousness, next is pupil response to light; changes
in vitals signs are very late signs.
• With trauma clients, assume spine is injured until proven otherwise; while the airway is being opened, the cervical spine
should be immobilized.
• When treating a trauma client, a quick check of the ABCs is the priority. After you know the client is breathing and has a
pulse, vital signs can wait while any bleeding is stopped and other interventions (such as starting IVs) are started.