Acute biologic crisis Freshwater drowning: loss of surfactant Drowning rescue, board assist: if the water is calm  pit
rescue, board assist: if the water is calm  pit vipers
By: TMREVILLE
Drowning & Near drowning
Definition
Drowning: Death due to submersion in liquid
(usually water)
Near Drowning: is survival for more than 24 hours
from suffocation by submersion.
Common complication: hypoxemia
Classes of drowning
Dry: laryngospasm →water doesn’t enter the lungs
Wet: laryngospasm relaxes→ water enters the
lungs
Types of Drowning
Active Drowning: vertical in water, not kicking, still
breathing and usually moving the arms
Passive Drowning
Causes
 Attempted suicide
 Blows to the head or seizures while in the
water
 Drinking alcohol while boating or
swimming
 Falling through thin ice
 Inability to swim or panicking while
swimming
 Leaving small children unattended
around bathtubs and pools
Summary of the drowning process:
1. Panic & violent struggle
2. Period of Calmness
3. Swallowing of fluid (vomiting)
4. Terminal Gasp
5. Unconsciousness
6. Seizures
7. Death
Pathophysiology: prolonged submersion in
water→ decrease in metabolic demands/diving
reflex/mammalian reflex→ successful resuscitation
with full neurologic recovery→ hypoxia,
hypercabia, acidosis→ cerebral injury, ARDS,
pulmonary damage, cardiac arrest
Saltwater drowning: pulmonary edema (osmosis)
Therapeutic goals: maintaining cerebral perfusion,
adequate oxygenation (prevent further damage to
vital organs)
Immediate CPR-greatest influence on survival
The treatment goal: prevention of hypoxia
 serial vital signs
 ensure an adequate airway &
respiration(ventilation)
 ABGs (determine the type of ventilatory
support needed)
 Supplemental O2, by mask
 ET intubation w/ +P
o improves oxygenation
o Prevents aspiration
o corrects intrapulmonary
shunting
o corrects Ventilation–perfusion
abnormalities (caused by
aspiration of water)
N/I:
 hypothermia
o rectal probe
o rewarming procedures
(extracorporeal warming,
o warmed peritoneal dialysis,
aerosolized O2, torso warming)
 hypotension and impaired tissue
perfusion: Intravascular volume
expansion & inotropic agents
 dysrhythmias: ECG monitoring
 compromised renal function: indwelling
urinary catheter
 decompress the stomach & prevent the
patient from aspirating gastric contents:
NG intubation
Teaching Children to Swim
Drowning rescue, throw assist: if the water is too
deep or dangerous to enter or victim is too far out
to reach with a long object, a throwing assist may
be wisest
and shallow enough (no higher than chest) you can
get into the water to reach the victim
Drowning rescue, reaching assist: if the victim is in
deep or dangerous water but there is a dock to
stand on, try a reaching assist with a long, sturdy
object
Drowning rescue on ice, board assist: if a person
falls through ice, do not go onto ice to attempt a
rescue. From a safe place try a reaching assist with
a long, sturdy object
Drowning rescue on the ice, human chain: if a
person falls through ice and there is more than one
person on solid ground, form a chain of bodies
from a secure location out to the fallen person
INJECTED POISONS: STINGING INSECTS
Hymenoptera allergy
 extreme sensitivity to the venoms of :
bees, hornets, yellow jackets, fire ants &
wasps
 Venom allergy –IgE
 Clinical manifestations range
o generalized urticaria
o Malaise
o laryngeal edema
o severe bronchospasm
o shock, and death.
Management
 stinger removal:venom is assoc. /sacs
around the barb of the stinger
 Wound care w/ soap and water
 Scratching is avoided because (results in
histamine response.
 Ice application (reduces swelling & Management
decreases venom absorption)  Initial first aid: Let victim lie down
 oral antihistamine & analgesic (itching  Remove constrictive items
and pain)  Provide warmth
Severe allergic response: Epinephrine (aqueous),  cleanse the wound
SC, massaged to hasten absorption.  cover w/ a light sterile dressing
SNAKE BITES  immobilize the injured body part below
 1 -9 y.o. high risk the level of the heart.
 daylight hrs. to early evening(summer)  Do not apply: Ice or a tourniquet
Initial evaluation:  total dose :infused during the first 4-6 hrs
 Whether the snake was venomous or after poisoning
non-venomous ANAPHYLACTIC REACTION
 if the snake is dead, it should be  an acute systemic hypersensitivity
transported to the ED with the pt for ID1 reaction that occurs within seconds or
 Where and when the bite occurred minutes after exposure to certain foreign
 Circumstances of the bite substances
 Sequence of events  result of an antigen–Ig interaction in a
 S & Sx (fang punctures, pain, edema, and sensitized individual who, as a
erythema of the bite and nearby tissues) consequence of previous exposure, has
 Severity of poisonous effects developed a special type of Ig that is
 V/s specific for that particular allergen.
 Circumference of the bitten extremity or  fullness in the face, urticaria, pruritus,
area at several malaise, and apprehension→
 Points (compare w/ the other extremity) tachycardia, SOB, hypotension, and shock
 Laboratory data (CBC, UA & clotting → stop: Diphenhydramine, vasopressors,
studies) E cart (standby)
Management
 Do not use during the acute stage (first 6
to 8 hrs): ice, tourniquets, heparin,
Corticosteroids are contraindicated in
after the bite: may depress antibody
production, hinder the action of
antivenin
 For hypotension: Parenteral fluids &
vasopressors (short-term)
 Surgical exploration of the bite
 Pt. is observed closely for at least 6 hours
: Never leave unattended
ANTIVENIN (ANTITOXIN)
 antitoxin manufactured from the snake
venom
 admin. w/n 12 hours after the snake bite
 Children may require more dose
 Skin test
 15 mins. before & after: the
circumference of the affected part is
measured proximally
 Premedicate w/: diphenhydramine and Management
cimetidine  establishing a patent airway & ventilation
 IV (slow), IM  administer epinephrine
 diluted in 500 -1000 mL of NSS
  Early ET intubation is essential (to avoid
loss of the airway)
 oropharyngeal suction (remove excessive
secretions)
 Resuscitative measures (pts with stridor
and progressive pulmonary edema)
 O2 therapy
Pharmacologic management
• Antihistamines: to block further histamine
binding at target cells
• Aminophyllin: slow intravenous infusion for
severe bronchospasm and wheezing refractory to
other treatment
• Albuterol inhalers or humidified treatments: to
decrease bronchoconstriction;
crystalloids, colloids, or vasopressors; to treat
prolonged hypotension
• Isoproterenol or dopamine: for reduced cardiac
output
• Intravenous benzodiazepines: control of seizures;
corticosteroids f; for prolonged reaction with
persistent hypotension or bronchospasm
Poisoning
Poison: any substance that, when ingested,
inhaled, absorbed, applied to the skin, or produced
w/n the body in relatively small amounts, injures
the body by its chemical action.
 Pesticide poisoning

INGESTED (SWALLOWED) POISONS

Emergency Tx goals:
• To remove or inactivate the poison before it is
absorbed
• To provide supportive care in maintaining vital
organ systems
• To administer a specific antidote to neutralize a
specific poison
• To implement treatment that hastens the
elimination of the absorbed poison
Corrosive poisons include
 alkaline and acid agents
  cause tissue destruction after coming in  the amount; time since ingestion;  Blood specimens are obtained to test for possible(to reverse or diminish the
contact with mucous membranes  signs and symptoms, such as pain or concentration of drug or poison. effects of the toxin)
o drain cleaners burning sensations  The patient who has ingested a corrosive  If these measures are ineffective,
o toilet bowl cleaners  any evidence of redness or burn in the poison is given water or milk dilution is procedures are initiated to remove the
o Bleach mouth or throat, pain on swallowing not attempted if the patient has acute ingested subs. such as:
o detergents  inability to swallow, airway edema or obstruction, o Administer of multiple doses of
o oven cleaners  vomiting, or drooling; esophageal, gastric, or intestinal burn or charcoal
o button batteries  age and weight of the patient; perforation. o diuresis (for substances
o metal cleaners  Pertinent health history. The following gastric emptying procedures may be excreted by the kidneys)
o Rust removers Management used as Prescribed: o Dialysis
o battery acid  Control of the airway, ventilation, and  Syrup of ipecac (induce vomiting) o Hemoperfusion: detoxification
Shock, may result from: oxygenation are essential.  Gastric lavage for the obtunded patient of the blood by processing it
 cardiodepressant action of the substance  (-) cerebral or renal damage, patient’s  Gastric aspirate –send to the laboratory through an extracorporeal
ingested prognosis depends largely on successful for testing(toxicology screens) circuit and an adsorbent
 venous pooling in lower extremities management of respiration and  Activated charcoal ADMIN. cartridge containing charcoal or
 reduced circulating blood volume circulation.  Cathartic, when appropriate resin, after which the cleaned
(increased capillary permeability)  ECG, vital signs, and neurologic status Antidote blood is returned to the
ASSESSMENT  An indwelling urinary catheter is inserted  The specific chemical or physiologic patient.
 determine what substance was taken; to monitor renal function. antagonist; administer as early as

Carbon monoxide poisoning
CO2 High Hgb affinity: 250x stronger than O2
Carboxyhemoglobin: CO–bound Hgb, Doesn’t
transport O2
Goals of management:
 to reverse cerebral and myocardial
hypoxia
 hasten elimination of carbon monoxide.
 Whenever a patient inhales a poison, the
following general measures apply:
• Carry the patient to fresh air
immediately; open all doors &
windows.
• Loosen all tight clothing.
• Initiate CPR if required;
 Administer oxygen.
• Prevent chilling; wrap the
patient in blankets.
• Keep the patient as quiet as
possible.
• Do not give alcohol in any form.
 100% oxygen is administered at
atmospheric or hyperbaric pressures: to
reverse hypoxia,To accelerate the
elimination of carbon monoxide.
 O2 is admin. until the carboxyhemoglobin
level <5%.
Symptoms of permanent brain damage
 Psychoses
 Spastic paralysis
 Ataxia
 visual disturbances
 deterioration of mental status and
behavior
Hemorrhage
 results in the reduction of circulating
blood volume is
 a primary cause of shock.
 fluid volume deficit
 decreased cardiac output
Management
 Direct, firm pressure is applied over the
bleeding area or the involved artery
 Firm pressure dressing is applied, and the
injured part is elevated (to stop venous &
capillary bleeding if possible)
 Immobilize AFFECTED extremity to
control blood loss.
 Tourniquets: last resort when the
external hemorrhage cannot be
controlled in any other way.; Applied just
proximal to the wound and tied tightly
enough to control arterial blood flow.;
Periodically, the tourniquet is loosened
(to prevent irreparable vascular or
neurologic damage.); For arterial
bleeding, the tourniquet is removed and
a pressure dressing is applied.; For
traumatic amputation with
uncontrollable hemorrhage, the
tourniquet remains in place until the
patient is in the OR
 Replacement fluids may include: isotonic
electrolyte solutions (LR, NSS),
 colloid, and blood component therapy:
platelets and clotting factors
 Packed RBCs are infused when there is
massive blood loss. In emergencies: O-
negative blood is used for women of
childbearing age and O-positive blood is
used for men & postmenopausal women
 ABG (evaluate pulmonary function and
tissue perfusion and to establish baseline
hemodynamic parameters): index for
determining the amount of fluid
replacement the patient can tolerate and
the response to therapy.
 supine position and monitored closely
Hypovolemic Shock: a condition in which there is
loss of effective circulating blood volume.
Inadequate organ and tissue perfusion follow,
ultimately resulting in cellular metabolic
derangements.
Nrsg. Dx.:
 Altered tissue perfusion related to failing
circulation
 Impaired gas exchange related to a
ventilation–perfusion imbalance
 Decreased cardiac output related to
decreased circulating blood volume
*In the event of acute hemorrhaging (internal
bleeding), the venous blood, the blood volume
and consequently cardiac output are reduced, and
progresses inevitably to inadequate tissue
perfusion and cardiocirculatory arrest and death.
*Hypovolemic shock is a severe and acute
metabolic disturbance caused by a reduction in
volume of blood as from hemorrhage or
dehydration. Blood loss from the vascular
system reduces the volume of venous blood
returning to the heart.
Goals of treatment: to restore and maintain
tissue perfusion and to correct physiologic
abnormalities.
Large-gauge IV needles or catheters are
inserted into peripheral veins.
 Two or more catheters are necessary for
rapid fluid replacement & reversal of
hemodynamic instability.
 emphasis : volume replacement
Management
 indwelling urinary catheter is inserted
 Serial Hct values
 Place the victim in shock position
 Keep the person warm and comfortable
 Turn the victim’s head to one side if neck
injury is not suspected
Central venous pressure (CVP) catheter
 Inserted (in or near the right atrium) to
serve as a guide for fluid replacement.
 Continuous CVP readings give the
direction & degree of change from
baseline readings.
 The catheter is also a vehicle for
emergency fluid volume replacement.
 Infusion of LR (approximates plasma
electrolyte composition & osmolality)
Seizures
 the result of a sudden disruption of the person does not remember the episode when it
orderly communication among nerve is over.
cells in the brain, called neurons. 3. Generalized seizures/grand mal seizures:
 can lead to a number of symptoms, intense rigidity of the entire body may occur,
which vary depending on where the followed by alternating muscle relaxation and
disruption occurs in the brain and where
the abnormal electrical activity spreads.
1. simple partial seizures: finger or hand may
shake, mouth may jerk uncontrollably, person may
talk unintelligibly, may be dizzy, and may
experience unusual or unpleasant sights, sounds,
odors, or tastes, but without loss of consciousness
 
2. complex partial seizures: the person either
remains motionless or moves automatically but
inappropriately for time and place, he or she may
experience excessive emotions of fear, anger,
elation, or irritability. Whatever the manifestations,
contraction (generalized tonic–clonic contraction),
simultaneous contractions of the diaphragm and
chest muscles may produce a characteristic
epileptic cry, tongue is often chewed, and the
patient is incontinent of urine and feces.
 
After 1 or 2 minutes: convulsive movements begin
to subside; patient relaxes and lies in deep coma,
breathing noisily. Respirations at this point are
chiefly abdominal.
 Postictal state: patient is often confused and hard
to arouse and may sleep for hours. May report
headache, sore muscles, fatigue, and depression.
Tonic-clonic seizures
Absence seizures
Atonic seizures : "drop attack," atonic seizures
cause a sudden loss of muscle tone. ; may result in
the dropping of the head or a limb, or lead a
student to fall to the ground.; There also may be a
brief loss of consciousness.
Myoclonic seizures
 typically affecting children and young
adults.
 involves a sudden contraction of muscles
and can appear as a jerk of one or both
arms or sometimes the head.
 may cause just a single jerk or several
jerking movements.
 seizure is so brief that although the pt.
loses consciousness, he or she may
appear conscious.