Rapid Access Guide for Triage and Emergency Nurses: Chief Complaints with High Risk Presentations [Team-IRA] [1 ed.] 0826196276, 9780826196279

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Rapid Access Guide for Triage and Emergency Nurses Chief Complaints With High-Risk Presentations Lynn Sayre Visser Anna Sivo Montejano

Second Edition

CONTACT INFORMATION AND RESOURCE PHONE NUMBERS RAPID ACCESS GUIDE OWNER Name Facility Number EMERGENCY RESOURCE NUMBERS

OTHER RESOURCE NUMBERS

Law Enforcement 

Trauma Surgeon 

Poison Control 

Donor Hotline 

Translator 

Nurse Manager/Director 

Security 

Nursing Supervisor 

Facility Emergency Number 

Environmental Services 

Charge Nurse 

Laboratory 

Respiratory Therapy 

Radiology 

Other 

Child Life 

Other 

Social Worker 

Other 

Child Protective Services 

Other 

Adult Protective Services 

Other 

Intimate Partner Violence 

Other 

Transporter 

Other 

Burn Center 

DISCLAIMER: This reference guide is not intended to replace formalized triage education, didactic experience, time spent with an experienced triage preceptor, Advanced Cardiac Life Support, Pediatric Advanced Life Support, Emergency Nurse Pediatric Course, Trauma Nurse Core Course, or Advanced Burn Life Support. Rather, this resource is to be used as a supplement placing valuable information into the user’s fingertips at a moment’s notice.

RAPID ACCESS GUIDE FOR TRIAGE AND EMERGENCY NURSES

Lynn Sayre Visser, MSN, RN, PHN, CEN, CPEN, FAEN, has devoted her 28-year career to emergency nursing, triage education, mentoring others, and writing about topics that impact nursing. Her career has been complemented by experience in prehospital care, ICUs, postanesthesia care units, and as an organ procurement coordinator. Her passion for quality patient care led her to play instrumental roles in the implementation of a provider in triage, rapid triage assessment, and immediate bedding processes along with formalized triage education in multiple facilities. She is a change-agent and philanthropist and has been published in a variety of arenas. She is the coauthor of Fast Facts for the Triage Nurse: An Orientation and Care Guide, Essentials for the Triage Nurse, Rapid Access Guide for Triage and Emergency Nurses, and Rapid Access Guide for Pediatric Emergency Nursing. Her work has been recognized with two American Journal of Nursing Book of the Year awards, the 2019 Emergency Nurses Association (ENA) Media Award, the 2021 ENA Team Award, as well as the 2019 Sigma Theta Tau Edith Moore Copeland Founders Award for excellence in creativity. She holds a Master of Science Degree in Nursing with an emphasis in education and a double Bachelor of Science degree in nursing and exercise physiology. Anna Sivo Montejano, DNP, RN, PHN, CEN, has over three decades of experience in emergency nursing and triage education. She has taught nursing theory and aided the professional development of nurses as a preceptor, mentor, and clinical instructor. She has been a certified emergency nurse for more than 30 years. Her ED contributions include work as a staff nurse, primary preceptor, and assistant nurse manager, as well as in educational development. Dr. Montejano has worked to improve the quality and efficiency of patient care through projects such as the change process of rapid medical screenings and rapid triage assessments; as a project manager for a major ED expansion; and as an advanced cardiac life support instructor. She authored Fast Facts for the Triage Nurse: An Orientation and Care Guide in a Nutshell, which won third place in the 2015 American Journal of Nursing Book of the Year awards in the critical care/emergency category, the ENA Media Award in 2019, and the Assessment Technologies Institute (ATI) Nurse Educator of the Year. This book has since become available in the United Kingdom under the title Essentials for the Triage Nurse: An Orientation and Care Guide. She has her Doctor of Nursing Practice degree from California State University, Northern Consortium (Fresno and San Jose State University), her Master’s Degree in Nursing with a focus on education, and her Bachelor of Science degree.

R APID ACCE SS G UI D E F O R T RI AGE A ND E ME RGE NC Y N U R S E S C H I EF COM P L A INT S W IT H H IGH - RI SK P RE S E NTAT IO NS S e c o n d E d i t io n Lynn Sayre Visser, MSN, RN, PHN, CEN, CPEN, FAEN Anna Sivo Montejano, DNP, RN, PHN, CEN

Copyright © 2024 Springer Publishing Company, LLC All rights reserved. First Springer Publishing Edition: 9780826196279 (2018) No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, LLC, or authorization through payment of the appropriate fees to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, info@ copyright.com or on the Web at www.copyright.com. Springer Publishing Company, LLC 11 West 42nd Street New York, NY 10036 www.springerpub.com Acquisitions Editor: Elizabeth Nieginski Content Development Editor: Brenna Croker Compositor: diacriTech Production Editor: Joseph Stubenrauch ISBN: 978-0-8261-6975-4 ebook ISBN: 978-0-8261-6976-1 DOI: 10.1891/9780826169761 23 24 25 26 / 5 4 3 2 1 The author and the publisher of this Work have made every effort to use sources believed to be reliable to provide information that is accurate and compatible with the standards generally accepted at the time of publication. Because medical science is continually advancing, our knowledge base continues to expand. Therefore, as new information becomes available, changes in procedures become necessary. We recommend that the reader always consult current research and specific institutional policies before performing any clinical procedure or delivering any medication. The author and publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance on, the information contained in this book. The publisher has no responsibility for the persistence or accuracy of URLs for external or third-party Internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Library of Congress Control Number: 2023932677 Contact [email protected] to receive discount rates on bulk purchases. Printed in the United States of America.

To the frontline healthcare providers who deliver care often under the most unimaginable circumstances. You capture the spirit of compassion and healing through your creativity, dedication, and devotion to your patients and their loved ones. Some shifts may be extremely challenging, but you make a difference each and every day.

CONTENTS Contributors and Reviewers   ix Testimonial  xv Preface  xvii Acknowledgments  xix Abbreviations  xxi Part I: INTRODUCTION TO TRIAGE AND EMERGENCY CARE........................................................ 1 1. The Secrets to Using This Guide................................ 1 2. Triage........................................................................... 8 Part II: ESSENTIALS IN EMERGENCY NURSING........................................................................ 20 3. Screening Tools and Checklists................................ 20 4. Pediatric Considerations........................................... 25

6. Waiting Room Issues.............................................. 67 7. Legal Issues............................................................ 72 Part III: HIGH-RISK PRESENTATIONS BY BODY SYSTEM.......................................................................... 79 8. Introduction to High-Risk Presentations................. 79 9. Respiratory Emergencies........................................ 84 10. Cardiac Emergencies.............................................. 93 11. Neurologic Emergencies....................................... 109

5. Older Adult Considerations....................................... 53 vii

viii Contents

12. Abdominal Emergencies......................................... 125

24. Behavioral Health Emergencies.............................. 301

13. Endocrine Emergencies.......................................... 142

25. Sexual Assault and Intimate Partner Violence........ 320

14. Obstetric Emergencies............................................ 152

26. Human Trafficking................................................... 329

15. Gynecologic Emergencies...................................... 174

Part V: TRAUMA CARE................................................ 336

16. Male Reproductive Emergencies............................ 183

27. Trauma Emergencies............................................... 336

17. Ocular Emergencies................................................ 192

28. Burn Emergencies................................................... 357

18. Dental, Ear, Nose, Throat, and Facial Emergencies....212

Part VI: DISASTER EMERGENCIES........................... 372

19. Musculoskeletal Emergencies................................. 224

29. Active Shooter/Active Threat.................................. 372

Part IV: SPECIAL ISSUES IN EMERGENCY CARE.... 241

30. Emergency Management During a Disaster........... 379

20. Infectious and Communicable Disease Emergencies............................................................ 241

Notes............................................................................. 401 References.................................................................... 411 Additional Reading........................................................ 417 Index.............................................................................. 437 Appendix A: Normal Pediatric Vital Signs..................... 457 Appendix B: The A-B-C-D-E Assessment: A Review.... 458

21. Hematologic and Oncologic Emergencies.............. 253 22. Toxicology Emergencies......................................... 267 23. Bite and Sting Emergencies.................................... 286

CONTRIBUTORS AND REVIEWERS A special thanks to these talented individuals for bringing their years of experience, knowledge, and expertise to this publication. Their critical eye in writing, reviewing, and researching content brought this book to life.

CONTRIBUTORS TO THE SECOND EDITION Erik Angle, RN, MICN, MEP Emergency Preparedness Program Coordinator Sutter Roseville Medical Center Roseville, California Teri Campbell, MSN, RN, CEN, CFRN, PHRN, FAEN, FASTN UCAN, University of Chicago Chicago, Illinois Shelley Cohen, RN, MSN, CEN Educator/Consultant, Health Resources Unlimited Staff Nurse, Williamson Medical Center Franklin,Tennessee

Dawn Friedly Gray, MSN, RN, CEN, CCRN Norristown, Pennsylvania Deb Jeffries, MSN, RN, CEN, CPEN, TCRN, FAEN Nursing Content Specialist Emergency Nurses Association Schaumburg, Illinois Rebecca S. McNair, RN Principal Consultant MetaVerge Consultancy, LLC; Founder, Triage First, Inc. Fairview, North Carolina

ix

x Contributors and Reviewers

Andrea Perry, MSN, RN, CNL, CEN, CPEN, TCRN Clinical Nurse Educator Sutter Health Sacramento, California

Amanda Rose, MSN, RN, CEN, TCRN, PHRN, CNOR Clinical Nurse Educator, Surgical Specialties Bryn Mawr Hospital, Main Line Health Bryn Mawr, Pennsylvania

REVIEWERS OF THE SECOND EDITION Chelsea Allen, BSN, RN, CPN, CPHON Pediatric Hem/Onc/BMT RN Children’s Hospital Colorado Aurora, Colorado Kara Bauman, MN, RN, CEN, CPEN, TCRN Emergency Department Educator Benefis Health System Great Falls, Montana Bethany M. Beard, MSN, MBA-HC, RN, CEN, CPEN, TCRN Program Accreditation Coordinator-Sepsis HCA Florida Oak Hill Hospital Brooksville, Florida

Joop Breuer, RN, FAEN Staff Nurse Emergency Department Leiden University Medical Centre Leiden, The Netherlands Kristen M. Cline, BSN, RN, CEN, CPEN, TCRN, CFRN, CTRN, CCRN Trauma Program Manager Sutter Eden Medical Center Castro Valley, California Liz Cloughessy, AM, Mast Health Mgt, RN, MCNA, FAEN Executive Director Australian College of Emergency Nursing Sydney, Australia

Shelley Cohen, RN, MSN, CEN Educator/Consultant, Health Resources Unlimited Staff Nurse, Williamson Medical Center Franklin, Tennessee

Lori Gallian, EMT-P, BS Senior Project Manager – Education Projects Summit Services Sacramento, California

Teresa Coyne, BSN, RN, CEN, Retired 2021 & 2022 Texas 10-59 ENA Chapter President Memorial Hermann Katy, Texas

Dawn Friedly Gray, MSN, RN, CEN, CCRN Norristown, Pennsylvania

Mary Fardanesh, BSN, RN Staff Nurse II Kaiser Permanente Inpatient Pediatrics Roseville, California Andi Foley, DNP, RN, APRN-CNS, EMT, FAEN Emergency Clinical Nurse Specialist St. Luke’s Health System Boise, Idaho Luke Galea, BSc (Hons) (Nurs. Stud.), MSc (Nursing) (Melit.), MA (Bioethics) (Melit.) Senior Staff Nurse [Emergency Department] Mater Dei Hospital Msida, Malta

Valerie Aarne Grossman, MALS, BSN, RN, NE-BC, FAEN, FAARIN Nurse Manager Highland Hospital Rochester, New York Charlie (Christine) Hawknuff, MSN, APRN, FNP-BC, CEN, TCRN, NE-BC, NPD-BC Director of Clinical Education Carle Health Urbana, Illinois Laura Hromanik, MSN, FNP-C, RN Sutter Medical Center Sacramento Sacramento, California

Contributors and Reviewers xi

xii Contributors and Reviewers

Deb Jeffries, MSN-Ed, RN, CEN, CPEN, TCRN, FAEN Nursing Content Specialist Emergency Nurses Association Schaumburg, Illinois Larry Masterman, CEM, NHDP, MICP, CHEC Preparedness Consulting & Training International Weaverville, California Justin Milici, MSN, RN, CEN, CPEN, CPN, TCRN, CCRN, FAEN Clinical Editor, Elsevier Dallas, Texas Christian “Paige” Owen, MSN, RN, CEN Manager, Educational Resources Sigma Theta Tau International Houston, Texas Andrea Perry, MSN, RN, CNL, CEN, CPEN, TCRN Clinical Nurse Educator Sutter Health Sacramento, California

Cheryl Randolph, MSN, RN, CCRN, CEN, CPEN, TCRN, FNP-BC, FAEN Emergency Department Staff RN San Francisco General Hospital San Francisco, California Jamla Rizek, MBA, MSN, RN, CEN, CPEN, NHDP-BC, NRP Lieutenant, U.S. Public Health Service Commissioned Corps (USPHS) Rockville, Maryland Amanda Rose, MSN, RN, CEN, TCRN, PHRN, CNOR Clinical Nurse Educator Surgical Services Bryn Mawr Hospital Bryn Mawr, Pennsylvania Kenneth Scerri, BSc (Hons) (Melit.), RN Chairperson The Maltese Emergency Nurses’ Association Senior Staff Nurse Emergency Department Mater Dei Hospital Malta

Sandra Schindler, MSN, APRN, FNP-C, CEN, CPEN, SANE-A Family Nurse Practitioner Reliance, South Dakota

Bri Walsh, RN ER Nurse Michigan

CONTRIBUTORS TO THE FIRST EDITION Erik Angle, RN, MICN, MEP Shelley Cohen, MSN, RN, CEN Dawn Friedly Gray, MSN, RN, CEN, CCRN Andrea Perry, MSN, RN, CNL, CEN, CPEN Amanda Rose, MSN, RN, CEN, TCRN, PHRN Polly Gerber Zimmermann, RN, MS, MBA, CEN, FAEN

Contributors and Reviewers xiii

xiv Contributors and Reviewers

REVIEWERS OF THE FIRST EDITION Daniel A. Belajic, OD, FAAO

Deb Jeffries, MSN Ed, RN-BC, CEN, CPEN

Shelley Cohen, MSN, RN, CEN

Kim Johnson, LCSW

Mary Fardanesh, BSN, RN

Kati Kleber, BSN, RN, CCRN

Lori Gallian, EMT-P, BS

Andrea Perry, MSN, RN, CNL, CEN, CPEN

Dawn Friedly Gray, MSN, RN, CEN, CCRN

Lauren Schlavin Pittman, BSN, RN, CPEN, MICN

Valerie Aarne Grossman, MALS, BSN, RN

Amanda Rose, MSN, RN, CEN, PHRN, TCRN

Yvonne Hansen, MS, RN, CCRN

Cheri Sabella, RN, MEd, BS

Laura B. Hromanik, MSN, FNP-C, RN, Major, USAF, NSC (Ret.)

Polly Gerber Zimmermann, RN, MS, MBA, CEN, FAEN

TESTIMONIAL EXACTLY WHAT YOU’VE BEEN WAITING FOR! The second edition of Rapid Access Guide for Triage and Emergency Nurses has taken its top-rated book and enhanced it with new content to meet the changing clinical environments nurses are experiencing. The award-winning authors brought together an expert panel of contributors and reviewers to bring this book’s users the latest evidence-based information, providing the reader with the highest quality of peer-reviewed content. This well-organized guide makes it easy to find the answer to your question in a matter of moments. —Valerie Aarne Grossman, MALS, RN, NE-BC, FAEN, FAARIN, FAAN

xv

P R E FAC E Every nurse has a fear of missing a life-threatening or high-risk patient presentation that deteriorates while awaiting care. This guide is designed to help any healthcare provider (ED/urgent care/clinic nurse, paramedic/emergency medical technician) determine the urgency of a patient’s condition and prevent those misses or near misses. This rapid access guide is the result of over six decades of combined emergency nursing experience building upon what we call our pocket-sized “Book of Brains.” As colleagues and friends, we focused on continually learning by enhancing our critical thinking skills, improving our decision-making, and being on a quest to acknowledge what we did not know, yet needed to know, as nurses in a busy urban emergency department. Designed with the user in mind, there are screening tools and checklists, commonly needed contact numbers, and space to customize the book. Also included are blank pages to write out or paste facility-specific policies and procedures along with quick-reference tables and resources to help you efficiently identify and initiate care for the sickest patients. Content includes triage, waiting room and legal issues, high-risk medical conditions, special issues in emergency care, trauma, burns, active shooter/active threat, and emergency management of disasters, providing you with action steps to help with prioritizing during crisis moments. Each body system chapter covers the most common chief complaints and lists questions, assessments, and interventions that are of utmost priority in determining the patient’s level of urgency. In the second edition, expanded red flags throughout the sections bring attention to the most critical signs and symptoms that can be quickly located by the flag icon. Triage considerations and worst-case scenarios are interwoven throughout the body system chapters along with more comprehensive key tips. New chapters include endocrine emergencies, hematologic and oncologic emergencies, sexual assault and intimate partner violence, and xvii

xviii Preface

human trafficking. The pediatric and older adult chapters are extensively expanded with assessment, triage pearls, and key tips for age-related emergencies. The Pediatric Assessment Triage and Pediatric Vital Signs are easily accessible on the Appendix A, and you can find detailed information for performing the A-B-C-D-E assessment on the Appendix B. We sincerely hope you utilize this guide in your daily practice, adding essential need-to-know content as new insights arise, so that soon you will own a “Book of Brains” that is customized just for you.

AC K N OW L E D G M E N T S To our editor, Elizabeth Nieginski: From day one of working together you never stopped believing in us. Thank you for your continued enthusiasm, never-ending support, and always amazing ideas. We love that we share a common goal of serving nurses, so they can, in turn, serve their patients. If only every author could have the opportunity to work with you! To our production team Joanne Jay and Joseph Stubenrauch, and those working behind the scenes at Springer Publishing: Our heartfelt gratitude for your creative ideas and attention to detail. We hope this second edition has been smoother sailing for you! To our contributors and reviewers: You stepped up to the plate each time we needed you. Your ideas, comments, suggestions, and words of encouragement were integral to the development of this rapid access guide. So many of you juggled the challenging times of the pandemic while simultaneously participating in this project. Thank you for sharing the gift of time. Your belief in serving your profession and your colleagues is admirable. We appreciate you for being on our team! From Lynn Sayre Visser To Anna, my amazing colleague, stellar personal nurse, and always reliable friend: Thank you for being the role model I needed to find early in my career. As I watched you and learned from you, I admired your patient advocacy (thank you man who needed the fan!), critical thinking, clinical excellence, compassion (and so on) . . . and your ability to coordinate a darn good potluck! I’m so proud of all you have accomplished throughout your 37-year nursing career and for touching so many lives, including mine. You will be missed at the bedside and in the classroom, but after xix

xx Acknowledgments

years of giving your heart and soul to caring for others, it is time for you to focus on you. Congratulations on your well-deserved retirement! To my husband, Scott: Thank you for sticking with me through the roller coaster of life! Love you always. To my now adult children, Chase, Colton, and Brody: I hope I’ve been an example to you to always chase your passions no matter how hard things may be at times. Grit and perseverance will take you far in life! Love you to the moon and back! Deb Jeffries: My journey with you writing the pediatric book brought new ideas to this second edition. Thank you for jumping in when life threw some curveballs. You lifted a weight off my shoulders and gave me the time I needed to focus on me. From Anna Sivo Montejano Lynn, how does one express the amazing friendship between us over the last 28 years? You have been such an amazing colleague and friend, and now we are both on a new path filled with adventures and the excitement of the unknown. I feel such joy to have you as my friend. Phil, thank you for supporting me through these past several years, which have sometimes been overwhelming with changes beyond our control. Now is our time to relax and have fun in retirement! Zsuzsa, Michael, and Marcus, I cannot express how our time spent together these past few years has been such a blessing. Enjoy what the future holds, and never let fear hold you back.

A B B R E V I AT I O N S A/O: alert and oriented AAA: abdominal aortic aneurysm ABC: airway breathing circulation A-B-C-D-E: airway; breathing; circulation; disability; exposure/ environment ABG: arterial blood gas abx: antibiotics AC: alternating current ACE: angiotensin-converting enzyme ACLS: advanced cardiac life support ACOG: American College of Obstetrics and Gynecology ACS: acute coronary syndrome ACTH: adrenocorticotropic hormone ADH: antidiuretic hormone ADLs: activities of daily living AFB: acid-fast bacillus a-fib: atrial fibrillation AICD: automatic implantable cardiac defibrillator ALTE: apparent life-threatening event AMA: against medical advice AMI: acute myocardial infarction AMS: altered mental status

ANC: absolute neutrophilic count APGAR: appearance, pulse, grimace, activity, and respiration APR: air purifying respirator ARDS: acute respiratory distress syndrome ASA: aspirin ASAP: as soon as possible ASQ: ask suicide-screening questions ATV: all-terrain vehicle AVM: arteriovenous malformation AWD: alcohol withdrawal delirium BC: blood culture BiPAP: bilevel positive airway pressure BLS: basic life support BM: bowel movement BNP: brain natriuretic peptide BP: blood pressure BPH: benign prostate hyperplasia BRUE: brief resolved unexplained event BSA: body surface area BVM: bag valve mask

xxi

xxii Abbreviations CA: cancer C-ABC: circulation, airway, breathing, circulation C-A-B-D-E: circulation, airway, breathing, disability, exposure/ environment CAD: coronary artery disease CAT: combat application tourniquet CBC: complete blood count CBG: capillary blood glucose CBRN: chemical, biological, radiological, nuclear, and explosive CDC: Centers for Disease Control and Prevention C. diff: Clostridioides difficile CHF: congestive heart failure CIWA: Clinical Institute Withdrawal Assessment of Alcohol Scale CK: creatine kinase CMP: comprehensive metabolic panel CMS: Centers for Medicare and Medicaid Services CNS: central nervous system C/O: cause of; complaining of CO: carbon monoxide COPD: chronic obstructive pulmonary disease CP: chest pain CPAP: continuous positive airway pressure CPOE: computerized provider order entry CPR: cardiopulmonary resuscitation C&S: culture and sensitivity CSF: cerebrospinal fluid

CSM: color, sensation, motor function c-spine: cervical spine CST-WMD: Civil Support Team for Weapons of Mass Destruction CTA: computed tomography angiography CVA: cerebrovascular accident CVC: central venous catheter CVP: central venous pressure CXR chest x-ray CT: computed tomography d: day DAI: diffuse axonal injury decon: decontamination DC: direct current DIC: disseminated intravascular coagulation DKA: diabetic ketoacidosis DM: diabetes mellitus DMAT: Disaster Medical Assistance Team DMORT: Disaster Mortuary Operations Response Team D5NS: dextrose 5% normal saline DOB: date of birth DVT: deep vein thrombosis dx: diagnosis, diagnosed ECG: electrocardiogram ECMO: extracorporeal membrane oxygenation

EtCO2: end tidal carbon dioxide ED: emergency department EDC: estimated date of confinement EEG: electroencephalogram e.g.,: example EM: emergency management EMC: emergency medical condition EMS: emergency medical service EMTALA: Emergency Medical Treatment and Active Labor Act ENA: Emergency Nurses Association EOC: emergency operations center EOP: emergency operations plan ESR: erythrocyte sedimentation rate ETOH: alcohol ETT: endotracheal tube FAST: face numbness, arm weakness, speech difficulty, time FBI: Federal Bureau of Investigation FHT: fetal heart tones FLACC Pain Scale: Face, Legs, Activity, Cry, Consolability Pain Scale ft: feet GC: gonorrhea/chlamydia GCS: Glasgow Coma Scale GDS: geriatric depression scale

GERD: gastroesophageal reflux disease GI: gastrointestinal GPAL: gravida, para, abortions, living GSW: gunshot wound HA: headache HCC: hospital command center HCG: human chorionic gonadotropin HELLP: hemolysis, elevated liver enzymes, low platelets HEPA: high-efficiency particulate air HF: heart failure HHS: hyperosmolar hyperglycemia syndrome HICS: hospital incident command system HIE: hypoxic ischemic encephalopathy HIMT: Hospital Incident Management Team HIPAA: Health Insurance Portability and Accountability Act HIV: human immunodeficiency virus HR: heart rate HTN: hypertension HVA: hazard vulnerability analysis hx: history IAP: incident action plan IBS: irritable bowel syndrome IC: incident commander ICB: intracranial bleed

Abbreviations xxiii

xxiv Abbreviations ICD: implantable cardioverter defibrillator ICP: intracranial pressure ID: identification IDLH: immediately dangerous to life and health IED: improvised explosive device IIAMI: Impression of caregiver if applicable (geriatric, pediatric, and/or cognitive/developmentally delayed), Intake and output, Medications and past medical/surgical history, Allergies, and Immunizations IM: intramuscular IMCI: intentional mass casualty incident INH: isoniazid INR: international normalized ratio IO: intraosseous IPV: intimate partner violence IR: interventional radiology IUD: intrauterine device IV: intravenous JVD: jugular vein distention kg: kilogram KUB: kidneys, ureter, bladder L&D: labor and delivery LFTs: liver function tests

LGBTQ: lesbian, gay, bisexual, transgender, and queer LLL: left lower lobe LLQ: left lower quadrant LMP: last menstrual period LOC: level of consciousness LOQ: line of questioning LOS: length of stay LP: lumbar puncture LPMSE: left prior to the medical screening exam LR: Lactated Ringers LUQ: left upper quadrant LWBS: left without being seen LWT: left without treatment MAP: mean arterial pressure MASS: move, assess, sort, send MCC: motor cycle collision MCI: mass casualty incident Meds: medications MI: myocardial infarction mL: milliliter MMR: measles, mumps, and rubella MNRIA: mode of arrival, neurological status, respiratory status, integumentary status, abnormal observations MOI: mechanism of injury MONA: morphine, oxygen, nitroglycerin, aspirin

MRI: magnetic resonance imaging MRSA: methicillin-resistant Staphylococcus aureus MS: multiple sclerosis MSDS: Material Safety Data Sheets MSE: medical screening exam MTP: massive transfusion protocol MUDDLES: miosis, urination, defecation, diaphoresis, lacrimation, excitation, salivation MVC: motor vehicle crash N/V: nausea/vomiting N/V/D: nausea/vomiting/diarrhea NGASR: nurse’s global assessment of suicide risk NHTRC: National Human Trafficking Resource Center NICU: neonatal intensive care unit NIHSS: National Institutes of Health Stroke Scale NP: nurse practitioner NPA: nasopharyngeal airway NPO: nothing by mouth NRP: neonatal resuscitation NS: normal saline NSAID: nonsteroidal anti-inflammatory drug OPA/NPA: oropharyngeal/nasopharyngeal airway ox: oximetry O2: oxygen

O2 sat: oxygen saturation PA: physician assistant PA/Lat: posterior-anterior/lateral PALS: pediatric advanced life support PAPR: powered air purifying respirator PAT: Pediatric Assessment Triangle PCI: percutaneous coronary intervention PE: pulmonary embolism PEEP: positive end expiratory pressure PID: pelvic inflammatory disease PIO: public information officer PMH: past medical history PO: by mouth POC: point of care PPE: personal protective equipment PPV: positive pressure ventilation PQRST: provokes/palliates; quality; region/radiation; severity/ associated symptoms; timing/temporal relations PR: per rectum PRO-BNP: pro-brain natriuretic peptide PT: prothrombin time PTA: prior to arrival PTT: partial thromboplastin time PUD: peptic ulcer disease

Abbreviations xxv

xxvi Abbreviations RA: room air R.A.I.N.: recognize, avoid, isolate, notify RAM: risk assessment matrix Rh: Rhesus RHCC: Regional Hospital Coordination Center RICE: rest, ice, compression, elevation RLL: right lower lobe RN: registered nurse RS: respiratory syncytial RLQ: right lower quadrant RR: respiratory rate RSQ: risk of suicide questionnaire RSV: respiratory syncytial virus r-tPA: tissue plasminogen activator RUQ: right upper quadrant r/o: risk of; rule out s/sx: signs/symptoms SALT: sort, assess, lifesaving interventions, treatment/transport SANE: sexual assault nurse examiner SAR: supplied air respirator sat: saturation SBP: systolic blood pressure SCBA: self-contained breathing apparatus SCC: squamous cell carcinoma SCD: sickle cell disease

SCIWORA: spinal cord injury without radiographic abnormality SDS: safety data sheets SIADH: syndrome of inappropriate antidiuretic hormone SIQ: suicidal ideation questionnaire SIQ-Jr: suicidal ideation questionnaire-junior SIRS: systemic inflammatory response syndrome SNRI: serotonin-norepinephrine reuptake inhibitor SNS: Strategic National Stockpile SOB: shortness of breath SSRI: selective serotonin reuptake inhibitor START: simple triage and rapid treatment/transport STEMI: ST-elevation myocardial infarction STI: sexually transmitted infection SWAT: special weapons and tactics TACO: time of rupture, amount of fluid estimated, color of fluid, odor present TB: tuberculosis TBI: traumatic brain injury TCA: tricyclic antidepressant TEE: transesophageal echocardiography temp: temperature T.H.R.E.A.T: threat suppression, hemorrhage control, rapid extrication to safety, assessment by medical providers, triage/ transport for care TIA: transient ischemic attack

TICLS: tone, interactiveness, consolability, look or gaze, speech, or cry TKO: to keep open TPAL: term, preterm, abortions/miscarriages, now living TSH: thyroid-stimulating hormone TSS: toxic shock syndrome Tx, tx: treatment TXA: Tranexamic UA: urinalysis URI: upper respiratory infection US: ultrasound UTD: up to date UTI: urinary tract infection

VAN: vision, aphasia, neglect VASA: violence and suicide assessment form VQ: ventilation/perfusion VS: vital signs VTE: venous thromboembolism WBC: white blood cells WCS: worst-case scenario WMD: weapons of mass destruction yr: year yrs: years %: percent >: greater than 2 sec with other abnormal findings Obvious significant bleeding

Figure 2.1: Pediatric Assessment Triangle (PAT) Note: General appearance = TICLS – Tone, Interactiveness, Consolability, Look or gaze, Speech or cry (ENA, 2020) CHAPTER 2 Triage

17

18 PART I Introduction to Triage and Emergency Care

PATIENT PRESENTATIONS USING THE PEDIATRIC ASSESSMENT TRIANGLE (PAT) Child is in respiratory distress 1. Normal appearance 2. Increased work of breathing 3. Normal circulation to skin Child is in respiratory failure 1. Abnormal appearance 2. Abnormal work of breathing (increased or decreased) 3. Normal or abnormal circulation to skin Child is likely in shock 1. Abnormal appearance 2. Normal work of breathing 3. Abnormal circulation to skin Child likely has a primary central nervous system or metabolic abnormality 1. Abnormal appearance 2. Normal work of breathing 3. Normal circulation to skin

ID:c0004-p1297 ID:c0004-p1296 ID:c0004-p1295 ID:c0004-p1290 ID:c0004-p1285 ID:c0004-p1280 ID:c0002-p0685 ID:c0002-p0680

KEY TIPS FOR PEDIATRIC TRIAGE SPECIFIC ISSUES

• Remember, pediatric patients have different physical and cognitive developmental issues that need to be considered. • Do not delay placing a pediatric patient who meets Level 1 or Level 2 acuity criteria to take a full set of vital signs. • The RN must accompany all patients who meet Level 1 criteria from triage to the pediatric treatment room. • Accompany the patient or give a telephone report of Level 2 patients from triage to the pediatric treatment room. • Do not rely only on across-the-room assessments for neonates and infants! Approach and remove blankets or clothing to visualize the child’s skin and effort of respiration as they may have hidden deficits. • A child with a respiratory complaint who appears ill or tired may be fatigued and on the verge of respiratory failure. • A child who is irritable (not just fussy) and/or a child who is lethargic (not just drowsy) indicates a serious neurologic event and should be taken seriously!

LENGTH-BASED TAPE • • • • •

Use of length-based tape sets up a common language from initial assessment through discharge. CAUTION: Using any length-based pediatric tape requires training and familiarization with the tool! Measure “Head to Red,” from head to heel. Post length-based tape near the triage area. CAUTION: Tapes may be unreliable in overweight children. As soon as possible obtain an actual weight in kilograms; children must always be weighed in kilograms.

CHAPTER 2 Triage

19

Part II: Essentials in Emergency Nursing

3

SCREENING TOOLS AND CHECKLISTS

Andrea Perry

SCREENING TOOLS The checklists that follow include time-sensitive diagnoses. Research has proven that patient outcomes are better and mortality decreases when the time standards indicated within the checklists are met. Following your own hospital policies and procedures is essential, but the checklists that follow provide guidance in the event your facility does not utilize screening tools. If immediate bedding is available, do not delay bedding the patient to complete Potential Triage Interventions.

ST-ELEVATION MYOCARDIAL INFARCTION (STEMI) CHECKLIST Potential Triage Interventions designated with ** ☐ **Identify a patient with a potential STEMI (ST-elevation myocardial infarction)** (See Chapter 10) ☐ **Obtain a STAT EKG within 10 minutes of patient arrival** ☐ **Activate an alert (e.g., Code STEMI) per hospital policy** ☐ **Place orders per RN Standardized Orders/Advanced Triage Protocols or expedite provider order entry** (e.g., Complete blood count [CBC]. chemistry panel, troponin I, chest x-ray) 20

☐ Obtain vascular access with two large-bore IVs (consider obtaining vascular access prior to giving nitroglycerin) ☐ Consider MONA: Morphine, Oxygen, Nitroglycerin, Aspirin Oxygen is suggested for patients with an oxygen saturation less than or equal to 90% ☐ Consider oral anti-platelet medications and heparin ☐ If the cardiac catheterization lab is available, door to catheterization lab goal is less than 30 minutes and the door to needle goal is less than or equal to 90 minutes ☐ If the cardiac catheterization lab is unavailable, door to thrombolytic goal is less than 30 minutes

SUSPECTED STROKE CHECKLIST Potential Triage Interventions designated with ** Upon Patient Arrival ☐ **Identify patient with a potential stroke** (See Chapter 11, Neurologic Emergencies) ☐ **Activate an alert (e.g., Code Stroke) per hospital policy** ☐ **Document the Time of Symptom Onset; if unknown, Time Last Seen Normal and the Time of Arrival** ☐ **Obtain fingerstick blood glucose** ☐ Provider/Stroke Team assessment **Triage RN may need to help expedite** (e.g., National Institutes of Health Stroke Scale [NIHSS], vision, aphasia, neglect [VAN]) ☐ STAT CT brain/computed tomography angiography (CTA) head and neck order (transport directly to CT scan from ED triage per facility protocol) **Triage RN may need to help expedite** ☐ CT scan completed (within 25 minutes of arrival and interpretation within 45 minutes of arrival) ☐ Obtain vascular access with two large-bore IVs and draw labs; the goal is results no later than 30 minutes after ED arrival CHAPTER 3 Screening Tools and Checklists 21

22 PART II Essentials in Emergency Nursing

☐ Neurologic assessment re-evaluation per hospital policy (e.g., NIHSS) ☐ Once intracranial hemorrhage has been ruled out and eligibility for a thrombolytic has been established, initiate preparation of the thrombolytic and administer thrombolytic within 60 minutes of arrival (less than 45 minutes is desired) ☐ Consider the need for blood pressure control ☐ Achieve door-to-device times (thrombectomy) within 90 minutes for direct arriving patients and 60 minutes for transfer patients ☐ Initiate frequent neurologic checks and vital signs per facility policies ☐ Swallow screen completed per facility policy Within 24 hours of ED Arrival if no thrombolytic has been given: ☐ Aspirin 324 mg by mouth/rectally The Joint Commission specifies parameters for Certified Stroke Centers requiring neurologic assessments and vital sign checks every 15 minutes × 2 hours, then every 30 minutes × 6 hours, then every 1 hour × 16 hours, followed by every 4 hours or per department standard of care.

SUSPECTED SEVERE SEPSIS SCREENING AND TREATMENT CHECKLIST Potential Triage Interventions designated with ** Adult Severe Sepsis Screening Criteriaa **Part I: Infection (Meets criteria if YES to ONE or MORE questions, proceed to Part II)** ☐ Suspicion/presence of infection ☐ Patient is currently on antibiotics

**Part II: Systemic inflammatory response syndrome (SIRS) Criteria (Meets criteria if YES to TWO or MORE criteria, proceed to Part III)** ☐ Altered mental status (different from baseline) ☐ Temp >101.0°F (38.3°C) or 90 bpm ☐ RR >20 breaths/min ☐ Hyperglycemia >140 mg/dL in the nondiabetic ☐ WBC >12,000 or 40 mmHg from baseline thromboplastin time (PTT) >60 seconds ☐ Increased oxygen needed to keep O2 saturation >90% ☐ Lactate >2 mmol/L If the patient meets criteria in Parts I, II, and III: ☐ **Document sepsis screen and Time Zero** ☐ **Activate an alert (e.g., Code Sepsis) per hospital policy** ☐ Initiate Hour-1 Bundleb ☐ Measure lactate level; remeasure if initial lactate level is elevated (>2) after fluid administration ☐ Obtain blood culture prior to administering antibiotics ☐ Administer broad spectrum antibiotics ☐ Begin rapid administration of 30 mL/kg crystalloid fluids if the patient is hypotensive (SBP 104°F (40°C) • Fever with incomplete immunizations or immunocompromised • Fontanel (bulging or sunken) • Inconsolable • Increased work of breathing (retractions, accessory muscle use, head bobbing, abnormal positioning, grunting) • Legs with bicycling movement • Lip-smacking • Mottled skin • Neonate: respiratory rate >60 breaths/min • Petechial or purpuric rash • Polyuria with polydipsia • Poor feeding in neonates or younger infants ID:c0004-p00280

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26 PART II Essentials in Emergency Nursing

• Seizure • Severe pain or psychological distress • Sunken eyes ID:c0004-p0865

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QUICK ASSESSMENT—PEDIATRIC

• Suspicion of child maltreatment • Syncope • Unresponsive ID:c0004-p0565

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STEP 1: PEDIATRIC ASSESSMENT “Across-the-Room Assessment” or “Quick Look” also known as the Pediatric Assessment Triangle (PAT) • A rapid initial “hands off,” observational assessment; 95% on room air

>8 years

70–100

18–20

>95% on room air

MNEMONICS The use of mnemonics helps to create a systematic format to assist the healthcare professional in assessing the pediatric patient. ID:c0004-ti0015

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Table 4.3: Mnemonics for Systematic Assessment ID:c0004-p1320

CIAMPEDS Chief complaint Immunizations, isolation Allergies Medications Past medical history, parent’s impression Events surrounding illness or injury Diet, diapers

AVPU Alert Verbal Painful stimuli Unresponsive

TICLS Tone Interactiveness Consolability Look or gaze Speech or cry

SAMPLE Signs/symptoms Allergies Medications Past medical problems Last food or liquid Events leading to injury/ illness

Source: Emergency Nurses Association. (2020a). Emergency nursing pediatric course provider manual (5th ed.). Author.

PEDIATRIC TRIAGE PEARLS Initial Assessment ID:c0004-ti0020

• All neonates, infants, and children must be visualized, and the Pediatric Assessment Triangle must be performed upon arrival. • Remove any blankets, even if the child is “sleeping,” you must visualize them. • When possible, assess the child while in the caregiver’s arms. • When a parent or caregiver says something is wrong, believe them! Ask them what is “typical” or “usual” for their child. ID:c0004-ti0025

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CHAPTER 4 Pediatric Considerations

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32 PART II Essentials in Emergency Nursing

• Grunting in the presence of significantly increased work of breathing is a sign of respiratory failure. Infants and young children often cannot verbalize their distress, discomfort, or pain; observe the pitch of their cry, facial expressions, and their ability to be consoled. • If a child is verbal, listen closely to what they say. • Initiate appropriate isolation precautions if a communicable disease is suspected. ID:c0004-p0425

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Triage Considerations ID:c0004-p0435

• All pediatric patients must be weighed in kilograms (clothing and diaper should be removed). • If unable to obtain an actual weight, then consider using a length-based resuscitation tape; an actual weight in kilograms should be obtained as soon as possible following the use of the length-based resuscitation tape. • Children often present with vague/nonspecific signs and symptoms. • Pediatric patients without health issues often have strong compensatory mechanisms; however, when they decompensate, they do so quickly, and it is difficult to resuscitate the child or reverse that process! • If an injury is inconsistent with developmental stages and/or history, consider the possibility of child maltreatment. • Follow your intuition when you sense something is not right with the child; no harm is done in getting the child to a treatment team immediately. Utilize all available resources if unsure of the seriousness of a presentation or the correct acuity. • Children have a higher metabolic rate with increased glucose utilization and limited glycogen stores; check the capillary blood glucose early and frequently! • Prevent hypothermia by keeping children warm by using a warm blanket, ambient lights, or increasing the room temperature; infants can be kept warm during and after assessment with a radiant warmer. • Be familiar with the anatomical, physiological, and developmental differences of children. • Allow the child to hold onto comfort toys (e.g., favorite stuffed animal). Use water-filled wands, bright toys on a stethoscope, finger puppets, or bubbles to distract children during the assessment. ID:c0004-ti0030

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• Recommendations for pediatric immunization schedules are continually updated; refer to the American Academy of Pediatrics at https://www.aap.org for the most up-to-date recommendations. ID:c0004-p0490

Communication • • • • • • • • • ID:c0004-ti0035

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Recognize the importance of nonverbal communication. Create a therapeutic environment based on the unique needs of each child. Call the child by their name and communicate at eye level. Maintain a calm and nonjudgmental attitude. Explain procedures and processes to the child and family in a language they can understand. Employ cultural competence. Encourage the child to express any fears and/or to talk about previous experiences in an emergency department. Involve a child life specialist (if available). Teenagers may prefer to communicate outside the presence of their parents.

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KEY TIPS FOR PEDIATRIC EMERGENCIES ID:c0004-p0535

RESPIRATORY EMERGENCIES (See also Chapter 9) ID:c0004-ti0040

• Brief Resolved Unexplained Event (BRUE) (Previously known as apparent life-threatening event): An episode of apnea lasting 20 seconds or longer, with color change (pale or cyanosis), and the absence of muscle tone; they may also have choking or gagging. A BRUE is often described by caregivers as terrifying event. The child must NOT be placed in the waiting room even if well-appearing on arrival; initiate immediate cardiac monitoring and pulse oximetry. • Other respiratory conditions are often related to infection (e.g., bronchiolitis, croup), diseases of the respiratory tract (e.g., asthma, cystic fibrosis), or structural (e.g., foreign body obstruction). See Table 4.4: Pediatric Infectious Respiratory Emergencies. ID:c0004-ti0045

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CHAPTER 4 Pediatric Considerations

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34 PART II Essentials in Emergency Nursing

Table 4.4: Pediatric Infectious Respiratory Emergencies DIAGNOSIS Croup (laryngeotrache obronchitis) Epiglottitis

Measlesa Diphtheria

Pertussisb

SIGNS AND SYMPTOMS Barking cough, inspiratory stridor, hoarseness, symptoms worse at night, moderate fever, looks well Drooling, difficulty swallowing, tripod positioning with mouth open and tongue out, high fever, looks toxic

Fever (first to appear), cough, coryza, conjunctivitis, Koplik spots, rash Sore throat, mild fever, bull neck, progressive paralysis, infants may exhibit hoarseness, upper respiratory infection, and/or foul odor from nose/mouth Signs/symptoms of the common cold, paroxysmal coughing, cyanosis during coughing, vomiting after coughing, whooping sound, exhaustion

TRIAGE INTERVENTIONS

PRECAUTIONS

Keep the patient in a position of comfort Isolate from other patients (generally caused by parainfluenza or respiratory syncytial virus [RSV])

Contact and droplet

Airway is the priority Keep the patient in a position of comfort Do not perform procedures that may agitate the patient Isolate from other patients (caused by Haemophilus influenzae B) Isolate from other patients

Contact and droplet

Airway is the priority Isolate from others

Contact and droplet

Minimize stimulation Support ABCs Isolate from others

Contact and droplet

Contact and airborne

Measles considered emergent due to high contagion and increase in unvaccinated population.

a

Pertussis is highly communicable due to an increase in the unvaccinated population. It is more concerning in children. Adults have better accessory muscle development, so can better tolerate paroxysmal coughing spells. Infants and children will become fatigued and are more prone to periods of apnea. b

Source: Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2017, October). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. CDC. https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines.pdf

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• Remember, children will compensate for a long time and then rapidly deteriorate. • For any child who is suddenly short of breath or with a partial/complete airway obstruction, think of a foreign body in the airway especially if left alone in a playroom and so forth. Toddlers/school-age children like to explore with their mouths. • Beans (that kids eat) can become lodged in the esophagus. The child may initially cough and then stop. Over time the bean swells within the esophagus and can cause obstruction. If no known object was aspirated, ask what the child ate last. • Allow children to maintain a position of comfort. • Keep a child calm by limiting activities that can increase the child’s anxiety or stress; this may worsen respiratory distress. • Children can tripod backward placing their arms behind their back; abnormal posturing is a sign of respiratory distress. • Children have smaller airways so consider possible airway obstruction early when facial swelling is present. ID:c0004-p0550

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CARDIAC EMERGENCIES (See also Chapter 10) ID:c0004-p0580

• Inadequate perfusion is caused by one or more of the following: inadequate circulating volume, changes in vascular tone, inadequate myocardial contractility, or inadequate cardiac output (e.g., pulmonary embolus, pericardial tamponade). • Tachycardia is the earliest sign of shock in children; hypotension is a LATE finding. • Assess capillary refill and central and peripheral pulses in children. • Sunken fontanels indicate significant volume loss. • Congenital heart disease should be considered in infants up to 6 months of age. Cyanosis, tachycardia, and dyspnea are common before the diagnosis accompanied by congestive heart failure, irritability, and/or ID:c0004-ti0050

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CHAPTER 4 Pediatric Considerations

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36 PART II Essentials in Emergency Nursing

diaphoresis with feeding. If a parent states they saw the child blue (but they appear pink at triage), believe them and assign the appropriate acuity. • For children with known cardiac disease or anomaly, immediately inquire with the caregiver about the child’s baseline pulse oximetry and general assessments (e.g., usual skin color). • Sources of chest pain that may occur in children include cardiac ischemia, acute chest syndrome, pulmonary embolism, pneumothorax, endocarditis, pericarditis, myocarditis, or pneumonia. ID:c0004-p0610

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Note: High concentrations of oxygen may cause deterioration in children with cyanotic heart disease.

NEUROLOGIC EMERGENCIES (See also Chapter 11) ID:c0004-p0620

• Initiate isolation precautions if an infectious etiology is suspected (e.g., meningitis). • Immediately assess the capillary blood glucose for any child with an altered mental status or who is seriously ill. • Consider obtaining a head circumference measurement if increased intracranial pressure is suspected. • Assess for bulging or sunken fontanels. • Assess for signs and symptoms of increased intracranial pressure including headache, nausea, vomiting, altered mental status, abnormal pupil size or reaction, sunsetting eyes, bulging fontanels, abnormal posturing, and/or seizure. • Inconsolability is a serious finding and may be indicative of a neurologic event. • Headaches worsening over time or are worse when awakening may be serious such as arteriovenous malformation, intracranial bleeding, tumor, malfunctioning shunt (hydrocephalus), or infection (e.g., meningitis, encephalitis). • Neonate and infant seizures may be manifested by lip smacking, bicycling movement of legs, or a blank stare. If eyes are closed, gently open them and check for nystagmus. • Refer to Table 4.5: Pediatric Glasgow Coma Scale for Children Less Than 18 Months for Glasgow Coma Scale scoring. ID:c0004-ti0055

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Table 4.5: Pediatric Glasgow Coma Scale for Children Less Than 18 Months ID:c0004-p2015

EYE OPENING

VERBAL RESPONSE

MOTOR RESPONSE

Spontaneous

4

Babbles, coos

5

Spontaneous movement

6

Voice

3

Irritable/cries

4

Pulls away with touch

5

Pain

2

Cries to pain

3

Pulls away with pain

4

No response

1

Moans

2

Abnormal flexion

3

None

1

Abnormal flexion

2

No response

1

Source: Borgialli, D. A., Mahajan, P., Hoyle, J. D., Jr., Powell, E. C., Nadel, F. M., Tunik, M. G., Foerster, A., Dong, L., Miskin, M., Dayan, P. S., Holmes, J. F., & Kuppermann, N. (2016). Performance of the pediatric Glasgow Coma Scale score in the evaluation of children with blunt head trauma. Academic Emergency Medicine, 23(8), 878–884. https://onlinelibrary.wiley.com/doi/full/10.1111/ acem.13014

ABDOMINAL EMERGENCIES (See also Chapter 12)

• • • •

A thorough history is essential; there are many causes of abdominal complaints in children. Rapidly identify children who are volume depleted with signs of dehydration. Vomiting and diarrhea can cause hypovolemic shock. Remember, children decompensate quickly! Rehydration is essential; if it is not contraindicated, and the child is able to tolerate oral fluids, give oral replacement therapy of 2 to 5 mL every 2 to 5 minutes (ENA, 2020). • Give nothing by mouth for ongoing vomiting or if the child may require surgery. • Monitor the  number, frequency, appearance, and odor of any abnormal bowel movements. • Rapidly establish vascular access; if IV access is unlikely or unsuccessful, consider early intraosseous access. ID:c0004-ti0060

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CHAPTER 4 Pediatric Considerations

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38 PART II Essentials in Emergency Nursing

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ENDOCRINE EMERGENCIES (See also Chapter 13)

• • • • • • • •

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OBSTETRIC EMERGENCIES (See also Chapter 14) ID:c0004-p0765

• Always consider the possibility of pregnancy for any female who is physiologically capable of becoming pregnant; girls under the age of 12 years can sometimes conceive. • At a minimum, pregnant females can consent to care for the pregnancy, and in some jurisdictions, they are considered emancipated. Know the legal requirements as well as the facility policies and procedures. ID:c0004-ti0070

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GYNECOLOGIC EMERGENCIES (See also Chapter 15)

• In most jurisdictions, persons under the legal age of consent can seek treatment for sexually transmitted infections. Know the legal requirements as well as the facility policies and procedures. • Consider the possibility of child abuse in the presence of a sexually transmitted infection. ID:c0004-ti0075

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MALE REPRODUCTIVE EMERGENCIES (See also Chapter 16) ID:c0004-p0785

• In most jurisdictions, persons under the legal age of consent can seek treatment for sexually transmitted infections. Know the legal requirements for consent to treat as well as the facility policies and procedures. • Testicular torsion is most common in 12 to 18 years of age (Shenot, 2021); this emergency requires rapid intervention! • Consider the possibility of a penile hair tourniquet in inconsolable infants. • Consider the possibility of child abuse in the presence of a sexually transmitted infection. ID:c0004-ti0080

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OCULAR EMERGENCIES (See also Chapter 17) ID:c0004-p0805

• • • •

Chemical exposure to the eye is an emergency and requires immediate and continuous irrigation. Consider the possibility of maltreatment in the presence of trauma or retinal hemorrhage in an infant. Conjunctivitis is very common in children and highly contagious; emphasize the importance of handwashing. A perforated globe is an emergency. Patch the affected eye with a hard shield taking care to not put pressure on the eye and patch the unaffected eye to limit consensual movement. If an object is still impaled, stabilize the object and cover the unaffected eye to prevent eye movement. Unless contraindicated, keep the head of the bed elevated 30°. • Refer to Table 4.6: Tips for a Pediatric Eye Exam. ID:c0004-ti0085

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CHAPTER 4 Pediatric Considerations

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Table 4.6: Tips for a Pediatric Eye Exam ID:c0004-p2110

STEP

ACTION

1

Distract the child with a flashlight/pen light, wand with sparkles, or a colorful toy around your stethoscope.

2

If eye drops are needed, place the drops with the eyes closed into the inner canthus.

3

Encourage the child to blink three times. The eye drop should roll into the eye.

These tips make an eye exam much more effective than prying the lids open to examine the eyes as children can be very strong!

DENTAL, EAR, NOSE, THROAT, AND FACIAL EMERGENCIES (See also Chapter 18)

• Anticipate airway compromise with any injury to the face or neck. • Drooling inconsistent with age is a red flag for possible airway compromise; do not insert anything into the mouth. Allow the child to maintain a position of comfort, avoid agitating the child and immediately obtain physician presence at the bedside. High-risk presentations associated with possible or actual airway compromise include epiglottitis, tonsillitis, retropharyngeal abscess, peritonsillar abscess, croup, and foreign body aspiration. DO NOT perform a blind finger sweep if a foreign body aspiration or occlusion is suspected. • Consider the possibility of a foreign body in the ear or nose; a foreign body in the nose can dislodge and cause an airway obstruction. • An avulsed permanent tooth should be reimplanted as soon as possible to increase the likelihood of success. Gently cleanse the tooth by only touching the enamel and not the roots or periodontal ligaments. Then place ID:c0004-ti0090

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the tooth in normal saline or a commercial product designed for this purpose. An avulsed permanent tooth is a time-sensitive condition and must be reimplanted within 60 minutes. • Dental infections can cause significant swelling and airway occlusion or progress to systemic infection or endocarditis if left untreated. • Ear infections are common; do not irrigate or place anything in the ear if there is a perforated tympanic membrane. • For epistaxis, hold direct continuous pressure and lean the patient forward unless contraindicated. ID:c0004-p0855

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MUSCULOSKELETAL EMERGENCIES (See also Chapter 19) ID:c0004-p0865

• Severity of fractures range from mild to life-threatening (e.g., pelvic fracture with hemorrhage). • Assess all injured extremities (distal to the injury site) for neurovascular status. Consider compartment syndrome that can cause irreversible damage within 4 to 6 hours. Assess the 6 “Ps”: pain, pallor, pulselessness, paraesthesia, paralysis, and poikilothermia. Pain, especially when out of proportion to the complaint or refractory to pain medication, is the earliest sign of compartment syndrome (Harding, 2019). Frequently reassess. • Frequently reassess any injured extremity for early recognition of neurovascular compromise. • When applying a splint, always include the joint above and below the injury. • Musculoskeletal conditions unique to children include nursemaid’s elbow (subluxation of the radial head), osteogenesis imperfecta (genetic disorder resulting in extremely fragile bones), and slipped capital femoral epiphysis (the ball of the femur slips off and moves backward; most common in teens and preteens). • Consider child maltreatment in musculoskeletal injuries in which the history is not consistent with developmental age of injury or in the presence of spiral fractures. Remember, bones are more pliable in the neonate and infant and require a significant force to cause a fracture. See Figure 4.1: Types of Fractures. • Hemorrhage control is critical with an amputated limb or digit; monitor for signs of hypovolemic shock (tachycardia, tachypnea, pallor, delayed capillary refill, altered mental status, cool pale skin, hypotension). Consider and prepare for surgical reimplantation. ID:c0004-ti0095

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42 PART II Essentials in Emergency Nursing

Transverse

Impacted

Oblique

Spiral

Results from angulation force or direct trauma.

Results from severe trauma causing fracture ends to jam together.

Results from twisting force.

Results from twisting force with firmly planted foot.

Figure 4.1: Types of Fractures ID:c0004-p9311

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Greenstick

Avulsion

Comminuted

Compressed

Results from compression force; usually occurs in children younger than 10 years of age.

Results from muscle mass contracting forcefully, causing bone fragment to tear off at insertion.

Results from severe direct trauma; has more than two fragments.

Results from severe force to top of head or os calcis or acceleration/ deceleration injury.

Figure 4.1: Types of Fractures (Continued) ID:c0004-p9310

CHAPTER 4 Pediatric Considerations

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44 PART II Essentials in Emergency Nursing

• Severe musculoskeletal injuries (especially crush injuries) can cause rhabdomyolysis; monitor urine output closely for myoglobinuria. ID:c0004-p0905

INFECTIOUS AND COMMUNICABLE DISEASE EMERGENCIES (See also Chapter 20)

• Rapidly determine if the child has symptoms consistent with a communicable disease and immediately initiate the appropriate isolation precautions. • Screen for sepsis. • Utilize a reliable resource (e.g., Centers for Disease Control and Prevention) to determine what diseases are and are not reportable to governmental agencies; mandatory reporting may vary from jurisdiction to jurisdiction. • Fever in an immunosuppressed child is an emergency; initiate protective isolation immediately! Inquire about the child’s immunization status. • See Table 4.4: Pediatric Infectious Respiratory Emergencies in the Respiratory Emergencies section. ID:c0004-ti0100

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HEMATOLOGIC AND ONCOLOGIC EMERGENCIES (See also Chapter 21) ID:c0004-p0930

• Initiate protective isolation for the immunocompromised. Fever is an emergency! • The sequelae of sickle cell disease affect every body system; maintain a high index of suspicion for splenic sequestration or splenic rupture with acute upper abdominal pain. Children with sickle cell disease are immunocompromised due to being functionally asplenic or because of a prior splenectomy. • Screen for sepsis. • Closely monitor the complete blood count and electrolytes. • Implement appropriate protective interventions (e.g., limit the number of vascular access attempts) for children with bleeding disorders and/or coagulopathies. • Prevent hypothermia. ID:c0004-ti0105

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• For children with central venous access, including imbedded ports, consider the possibility of bacteremia. • Children with sickle cell disease and splenic sequestration receive blood transfusions in smaller amounts (5 mL/ kg) and more slowly, because during sequestration, blood can be leaked from the spleen and cause circulatory overload. • Anticipate administration of clotting factors for children with hemophilia or von Willebrand disease. ID:c0004-p0965

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TOXICOLOGY EMERGENCIES (See also Chapter 22) ID:c0004-p0975

• Ingestions are common in children; always consider this possibility especially in younger, mobile children. • Ask the guardian or accompanying adult if any antidotes were given prior to arrival. • Children can have a coexisting medical condition (e.g., viral infection) and have ingested a substance. Therefore, if a child is unresponsive to interventions that should have caused improvement, consider a coexisting ingestion. • Treat the patient and not the drug! Immediately assess the airway, breathing, circulation, and disability and provide supportive care while another professional notifies poison control. • Have the phone number of the Poison Control center readily available. • Children can rapidly deteriorate especially if cardiac or antidepressant medications are ingested. • Closely monitor ventilations and initiate cardiac monitoring and seizure precautions. • Consider a button battery ingestion; if lodged in the esophagus can cause serious burns in 2 hours. • Do not use gastric lavage, cathartics, or emetics for treatment; evidence does not show better outcomes. ID:c0004-ti0110

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BITE AND STING EMERGENCIES (See also Chapter 23) ID:c0004-p1020

• Children can receive less venom than adults yet have catastrophic effects. Initiate cardiac monitoring. • For pit viper envenomation, elevate the affected limb only after antivenom has been initiated. • Monitor for angioedema during antivenom administration. ID:c0004-ti0115

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46 PART II Essentials in Emergency Nursing

• Anticipate the need for airway and ventilatory support with grade III or IV scorpion envenomation. Monitor the child for hypersalivation, difficulty swallowing, nystagmus, and asymmetrical rapid eye movement, slurred speech, altered mental status, ataxia, and/or muscle jerking or twitching. ID:c0004-p1040

BEHAVIORAL HEALTH EMERGENCIES (See also Chapter 24)

• Initiate suicide/danger-to-self/danger-to-others screening per facility policy. For a positive screening, implement facility policy/protocols including, but not limited to, the following: notifying security and the charge nurse/supervisor, placing the patient under direct and continuous observation by a staff member, ensure the environment is safe by removing all personal and room items that could potentially be harmful to the patient, and maintain safety for the child, staff, and others. • Maintain a nonjudgmental attitude and open communication. Set clear boundaries and when appropriate to the developmental stage and circumstances, contract with the child not to harm self. • Provide choices when possible. • Obtain a thorough history: Many medical conditions may mimic acute behavioral health presentations! Anticipate diagnostics to rule out a medical condition; do not assume the issue is behavioral health. • Maintain a calm environment regardless of the child’s behavior; do not escalate the situation! • Multiple psychiatric conditions can coexist. ID:c0004-ti0120

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SEXUAL ASSAULT AND INTIMATE PARTNER VIOLENCE, CHILD MALTREATMENT, AND HUMAN TRAFFICKING ( See also Chapters 25 and 26) ID:c0004-ti0140

• Refer to Box 4.1: Human Trafficking Risk Factors.

SPECIAL CONSIDERATIONS ID:c0004-p1275

Child Maltreatment • Screen all children for maltreatment. Be familiar with your jurisdictional mandates for reporting suspected abuse. • Ask open-ended questions and make every effort to appear nonjudgmental. • Carefully document anything told to you by the caregiver; use direct quotes when possible. • Suspicious for abuse: TEN-4 FACES P; bruising or injury to the torso, ears, or neck in children under the age of 4, frenulum, auricular area, cheek, eyes, scleral, pattered bruising (Hinton, 2020). Any bruising in infants under 4 months of age (Hinton & Trop, 2020). • Red flags for abuse include, but are not limited to, petechiae on the face, circular burns consistent with a cigarette tip, circumferential water burns without splash marks and clear lines of demarcation, bruises or injuries that are in recognizable shapes or patterns and/or various stages of healing, adult-sized human bites marks, delay in seeking care, and injury inconsistent with history or developmental stage. • Children should be completely undressed to thoroughly assess for child abuse. • Consider if the story is consistent with the injury or injuries. • Evaluate if there are other children living in the home who may be at risk. • Any suspicion of child abuse should prompt consideration of intimate partner violence in the home (Gordon, 2016). ID:c0004-ti0135

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48 PART II Essentials in Emergency Nursing

Box 4.1: Human Trafficking Risk Factors ID:c0004-p2160

• • • • • • • • •

Child welfare system involvement Chronic medical conditions left untreated Depression or low self-esteem Disabilities Fear of law enforcement Fear of person in charge of them Fear of harm to their family Homeless youth Involvement in a natural or manmade disaster

• • • • • • • •

Lack of financial resources Lack of social circle Language barrier LGBTQ individuals Mental health issues Psychological instability Recent relocation Substance use

TRAUMA EMERGENCIES (See also Chapter 27)

• Be familiar with facility trauma activation criteria and transfer processes (including EMTALA requirements in the United States) for injured children! • Always consider the possibility of child maltreatment when assessing injured children. • Shock is not defined by blood pressure. • Tachycardia is an early sign of shock, and hypotension is a late sign of shock. A child can lose 30% of circulating blood volume before hypotension occurs. ID:c0004-ti0125

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• Early recognition of shock is critical. Children usually have strong compensatory mechanisms; however, when they decompensate, they do so quickly. • Minimally acceptable systolic blood pressure: ■ Newborn to 1 month is 60 mmHg ■ 1 month to 1 year is 70 mmHg ■ Greater than 1 year of age is a systolic of 70 mmHg + (2 × the patient’s age in years). • Rapidly consider intraosseous (IO) vascular access if unable or unlikely to obtain IV access. • IV/IO fluid bolus of warmed isotonic crystalloids solution: ■ Neonates and children at risk for heart failure may receive 10 mL/kg ■ Children may receive 20 mL/kg ■ Packed red blood cells are 10 mL/kg (ENA, 2020b). • Children are at risk for pulmonary contusion without underlying rib fractures (ACS, 2018). • Prevent hypothermia, keep the child warm! • Spinal cord injury without radiographic abnormality (SCIWORA) is more common in children under 8 years of age due to hypermobility of the spine and lax ligaments. • See Table 4.5: Pediatric Glasgow Coma Scale for Children Less than 18 Months. ID:c0004-p1095

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CHAPTER 4 Pediatric Considerations

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BURN EMERGENCIES (See also Chapter 28)

• Consider the possibility of child maltreatment. • Children have thinner skin and are more susceptible to injury. • Normal urine output in children: ■ Neonates and infants 2 mL/kg/hr ■ Toddler 1.5 mL/kg/hr ■ Older child 1 mL/kg/hr ■ Adolescent 0.5 mL/kg/hr • Anticipate a transfer to a burn center. • See Figure 4.2: Rule of Palms and Figure 4.3: Burn Table for Infants and Children. • Refer to Chapter 28, Burn Emergencies, Figure 28.2: Parkland Burn Resuscitation Formula. ID:c0004-ti0130

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18% (back) 1% Tip: to estimate scattered burns, patient’s hand (including fingers) = 1% total body surface area

9%

Subtract 1% from the head area for each year over age 1

18%

18% 9%

Add 1/2% to each leg for each year 14% over age 1

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Figure 4.2: Rule of Palms

18% (back) 9% 14%

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Figure 4.3: Burn Table for Infants and Children ID:c0004-p1315

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NOTES ID:c0004-ti0145

5

O L D E R A D U LT C O N S I D E R AT I O N S

Dawn Friedly Gray, Anna Sivo Montejano, Lynn Sayre Visser, Amanda Rose, Andrea Perry, and Erik Angle (See also Chapters 8-28)

RED FLAGS • • • •

Apathy Change in mental status Change in physical function Dyspnea—increased respiratory rate may be the only sign of distress

• • • •

Fatigue History of falls Polypharmacy Self-neglect

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QUICK ASSESSMENT—OLDER ADULT A–B–C–D–E of the Older Adult • Airway: The tongue is the most common obstruction (also consider dentures); kyphosis/c-spine alignment makes airway ventilations difficult. • Breathing: Age-related changes lead to increased work of breathing and a decrease in reserve, so they decompensate more quickly. Be sure to know preexisting underlying lung conditions that mimic respiratory conditions. • Circulation: Beta-blockers can mask an increase in heart rate; stress reaction requires an increase frequency of vital signs; dysrhythmias may be normal. • Disability: Can be difficult to assess; pupil assessment may be difficult due to cataracts and macular degeneration; assess for new cognitive impairment and new onset dysphagia. • Expose/Environment: Poor historians; decreased bone density may increase the risk for hidden injuries. Be vigilant when assessing! Reduced ability to perspire; decreased subcutaneous fat produces an increased risk for thermoregulation challenges (hypothermia/hyperthermia), may not become febrile despite an infectious process.

VITAL SIGN TIPS • Vital sign changes are late signs; baseline vital signs are often altered due to preexisting conditions and medications. • Hypoperfusion is often overlooked; lab tests help identify changes (lactate, electrolytes). • Overall decreased physical reserve; will decompensate before a vital sign change is evident.

OLDER ADULT TRIAGE PEARLS Initial Assessment

• Consider anatomic and physiologic differences that may affect hematology and/or oncology presentations. • Older adults often underreport their symptoms because they fear their independence will be taken away. • In general, some do not want tests performed (e.g., consider socioeconomic status limiting access to care, concern that additional findings may change their level of independence). • Pain can be challenging to assess as it’s often difficult for the older adult to localize. • After speaking to the patient, consider using family to help identify changes in patient behavior or demonstration of pain and determine the patient’s baseline cognitive and physical function. • Consider the effect of comorbidities and polypharmacy. • Alcohol intake/abuse is fairly common. • Older adults are at high-risk for dehydration (e.g., decreased thirst response, physical limitations).

Triage Considerations

• Increased risk for under-triage; consider comorbidities, medications, and physiological changes which occur with aging. • Present with vague symptoms (e.g., tired, weak, not eating, achiness). • An atypical presentation is typical; if missed, this can lead to a misdiagnosis (e.g., complaint of confusion or weakness can be an acute myocardial infarction or sepsis). • Minimize distractions as it may take longer to triage the older adult due to a potentially lengthy past medical history, multiple medications, and so on. • Falls are the most common injury; assess if the patient takes blood thinners as this leads to a higher risk for bleeding. CHAPTER 5 Older Adult Considerations

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• Depression is not a normal aging presentation; find the underlying cause. • Recognize dementia and delirium are often superimposed on each other. • Ask about activities of daily living (ADLs) and how illness, injury, or pain impacts the ADLs. This may provide insight into the severity of the condition. Recognizing the patient’s desire to maintain independence may influence their response. • Have an increased awareness of a possible weight change; for example, weight gain may be an early sign of heart failure and weight loss could be from dehydration or malnutrition (Touhy & Jett, 2018). • Be aware of polypharmacy as this could cause the presenting symptoms. • Lack of hygiene and/or depression may raise concern for financial and/or emotional abuse. Watch for subtle clues. • Caregiver stress can be common when older adults live with family members. Assess how both the caregiver and patient are coping.

Communication

• Speak slowly, be simple and direct, and clearly ask one question at a time. For the older adult, processing what is asked takes time. • Asking closed-ended questions will help focus on key information. • Be aware of communication barriers (e.g., language, culture, hearing issues). • Do not refer to the patient as “honey” or “sweetie” as this can be considered disrespectful or condescending. • Obtain permission to speak with their family; assess the status of social support. • Ask permission from the patient if they need assistance removing clothing or personal items.

KEY TIPS FOR OLDER ADULT EMERGENCIES RESPIRATORY EMERGENCIES (See also Chapter 9)

• The potential causes of apnea in an older adult can be endless. Start with considering the history and then progress to other potential circumstances. Consider acute myocardial infarction and previous falls (e.g., pulmonary contusion). • The differential includes chronic obstructive pulmonary disease (COPD), emphysema, pneumonia, pulmonary embolus, COVID, and flu. • Dental prosthetic aspiration and other risks exist due to polypharmacy and alcohol use. • Decreased cilia with aging make it more difficult to mobilize secretions creating an increased risk for pneumonia. • Changes in epiglottis and loss of protective reflexes increase the risk for aspiration and upper airway collapse (Murano & Ravi, 2020). • ACE inhibitors can be a common cause of angioedema (unexplained facial, tongue, and neck swelling) that can lead to difficulty breathing. Remember, this can occur even if the patient has been taking the medication for a long time. • Excessive use of some medications, such as sleeping aids, can cause respiratory depression. • An atypical presentation is common. • Older adults tend to minimize their symptoms. Be sure to obtain a complete history at triage. • Many experienced nurses state that when a patient says “I feel like I am going to die” there is usually something significant occurring clinically. Act fast and search for the cause. • Respiratory complaints can often be cardiac in nature (e.g., shortness of breath may be caused by palpitations). • “Dyspnea” may be the only presenting symptom for females experiencing an acute myocardial infarction (AMI). Have a low suspicion for dyspnea being an incidental complaint.

CHAPTER 5 Older Adult Considerations

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CARDIAC EMERGENCIES (See also Chapter 10)

• An atypical presentation is common. • Older adults tend to minimize their symptoms. Be sure to obtain a complete history. • Dyspnea, fatigue, or weakness may be the only presenting sign or symptom for females experiencing an AMI. Do not minimize this complaint. • Many older adults have palpitations; determining if something is “new” or “different” is important. Hormonal changes in older women can cause palpitations. • Older adults may present with only a complaint of syncope (no chest pain) and end up diagnosed with an AMI.

NEUROLOGIC EMERGENCIES (See also Chapter 11)

• Think of the causes for altered mental status, including neurologic (e.g., stroke, head trauma), metabolic (e.g., hypoxia, hypoglycemia), infection (e.g., urosepsis, pneumonia), and/or alcohol use among others. • Early signs of altered mental status include a change in focus and attention, restlessness or agitation, visual/ motor dysfunction, and sleep/wake cycle interference. • Assess for recent falls, medication changes or potential overdose, trauma, and/or dehydration. Acute or chronic subdural hematomas may occur from a minor trauma that occurred a while ago. • This population has more brain atrophy, thus there is more room to swell. Symptoms may appear at a slower rate than in pediatrics or younger adults. • Headaches in older adults are often life-threatening. Think possible stroke, giant cell arteritis, acute angle closure glaucoma, encephalitis, and/or meningitis. Migraines are less common and lessen in frequency with age. • Consider potential causes for a seizure, including stroke, intracranial mass, metabolic imbalances, alcohol withdrawal, trauma, or central nervous system infections. • Patients with dementia are at an increased risk for delirium.

• Common causes of changes in mental status and precursors to delirium include medications, hypoxia, infection, and dehydration. Knowing the patient’s baseline medical and functional status is critical. • A behavior change is often the first sign of a urinary tract infection in older adults. • Refer to Box 5.1: Mnemonic for the Causes of Delirium and Table 5.1: Dementia Versus Delirium for additional information. Box 5.1: Mnemonic for the Causes of Delirium DELIRIUM Dementia Electrolyte imbalances Lung, liver, heart, kidney, brain Infection Rx drugs Injury, pain, stress Unfamiliar environment Metabolic

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Table 5.1: Dementia Versus Delirium DEMENTIA

DELIRIUM

Slower onset

Acute illness

Change in brain tissue

Usually the result of another condition—infection, dehydration, medication related

Irreversible

Reversible

Affects memory

Associated with increased agitation, confusion, and inattention

Usually not oriented

Frequently oriented

Not curable

Treatment often cures disease

ABDOMINAL EMERGENCIES (See also Chapter 12)

• Older adults often wait longer to seek medical treatment so they may be acutely ill even if they do not appear so. Think sepsis and metabolic alkalosis. • Rarely does the older adult present with classic findings of an acute abdomen, and they are at an increased risk for a ruptured appendix. Abdominal pain can be caused by constipation, mesenteric ischemia, malignancy, or abdominal aortic aneurysm, among others. • Identifying the diagnosis is often difficult due to changes in immune function, decreased sensation (e.g., neuropathy), underlying conditions (e.g., diabetes, renal dysfunction), and medication use (e.g., recent antibiotics).

• If the patient presents with diarrhea, recent use of antibiotics within the last 8 weeks, recent hospitalization or surgery, or a horse barn odor, there should be an increased suspicion for C. difficile. Isolate per policy. • Assess for the use of antiplatelets, anticoagulants, and nonsteroidal anti-inflammatory drugs (NSAIDs). Various coagulation studies may be ordered to assess elevated levels, which may require the administration of a reversal therapy (e.g., an elevated international normalized ratio [INR] level may require vitamin K administration). • Older patients can suffer from spontaneous osteoporotic compression fractures; in the patient with a complaint of loss of bowel or bladder control, consider the possibility of cauda equine syndrome.

ENDOCRINE EMERGENCIES (See also Chapter 13)

• Consider alterations in the clearance rate of hormonal therapies (e.g., testosterone, estrogen). • Elderly patients are at a higher risk of medication induced hypoglycemic events. • Hypothyroidism can be difficult to manage and contributes to cardiac arrhythmias and cognitive impairment; consider drawing thyroid stimulating hormone (TSH). • Age-related glucocorticoid and aldosterone changes are common in the elderly and predispose patients to cardiac and metabolic dysfunction and osteopathy.

GYNECOLOGIC EMERGENCIES (See also Chapter 15)

• A chief complaint of rectal bleeding may actually be postmenopausal bleeding; assess where the bleeding is coming from. • Rectal or uterine prolapse can sometimes be easily resolved but may require emergent attention/surgery. • Typical urinary tract infection (UTI) signs and symptoms are rare. For example, an older adult may only present with a change in mentation or a change in urine quality. • Think of elder maltreatment with signs of sexually transmitted infections (STI) or when there is vaginal bleeding caused by trauma. CHAPTER 5 Older Adult Considerations

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MALE REPRODUCTIVE EMERGENCIES (See also Chapter 16)

• For a presentation of altered mental status, consider the potential for urosepsis and anticipate a septic workup. • Urinary retention is the highest risk for those over 70 years of age and with a history of benign prostate hyperplasia or medication use (e.g., tricyclic antidepressants, antihistamines, decongestants). Be aware of the potential for renal failure and/or sepsis. • For sudden groin pain, think abdominal aortic aneurysm until ruled out. In older males, testicular torsion is rare, but consider inguinal hernia, kidney stone, or prostatitis. • Inquire about medication use for sexual dysfunction and consider the potential interactions with cardiac medications and antiretrovirals. • Infection, trauma, or Fournier’s scrotal gangrene (pain out of proportion to the clinical assessment of the scrotum, genitalia, or rectum) are common causes of pain in men. Have an increased level of concern in immunocompromised patients.

OCULAR EMERGENCIES (See also Chapter 17)

• Establish the patient’s baseline vision before seeking care. Be alert for acute angle closure glaucoma; this condition can present as eye pain, headache, or a fixed midpoint pupil. • Consider the possibility of an injury caused by a fall or maltreatment. There is an increased risk of a poor outcome when taking anticoagulants. Assess for a hyphema.

DENTAL, EAR, NOSE, THROAT, AND FACIAL EMERGENCIES (See also Chapter 18)

• Look for asymmetry of facial features to help identify facial trauma; have a heightened awareness/suspicion for elder maltreatment and a neurologic event.

• Small batteries from a hearing aid can cause a burn through the esophagus, causing mediastinitis. • Look for airway compromise with facial and nasal fractures. • Increased irritability or difficulty arousing (e.g., unable to or does not respond to verbal or tactile stimulation) can signify head trauma. • Keep the patient calm, as anxiety can escalate to agitation. Minimize alarms to decrease overstimulation. • For swelling to one side of the face, consider shingles. • A sore throat, as evidenced by hoarseness, can be a sign or symptom of a thoracic aneurysm or a symptom of a transient ischemic attack or stroke. • Dentition is essential to help maintain good nutritional status. Use a multidisciplinary approach to achieve the best outcomes for dental injuries or avulsions.

MUSCULOSKELETAL EMERGENCIES (See also Chapter 19)

• Elderly patients are at high-risk for fractures due to osteoporosis. • Ask how the injury has impacted activities of daily living (ADL). This will help determine the severity of the injury. • Consider maltreatment when looking at the mechanism of injury. Does the story match the injury? Look for bruising in different stages of healing.

INFECTIOUS AND COMMUNICABLE DISEASE EMERGENCIES (See also Chapter 20)

• Prompt detection can be challenging because signs and symptoms, such as fever, are often absent. • Obtaining a history of exposure to disease it may be difficult. Use visitors to help attain history and exposure risk. • Consider the origin/susceptibility of disease from the patient’s living situation (e.g., nursing homes, assisted living, community shelters, jail). CHAPTER 5 Older Adult Considerations

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HEMATOLOGIC AND ONCOLOGIC EMERGENCIES (See also Chapter 21)

• Hypoperfusion issues and anemia can present as respiratory and neurologic symptoms. • Sepsis may be difficult to detect because older adults often have subtle symptoms in the face of infection and have an altered compensatory mechanism. Assess for a neutropenic fever in immunocompromised patients and implement reverse isolation per policy. • High risk for dehydration; consider the impact on hematologic and oncologic emergencies. • High risk for respiratory complications due to decreased chest wall compliance, vital capacity, and functioning alveoli.

TOXICOLOGY EMERGENCIES (See also Chapter 22)

• Often, these patients are prescribed multiple long-term medications and other prescription medications. • Aging factors may contribute to the older adult accidentally or intentionally misusing medications. • Some medications can cause nausea, vomiting, and diarrhea leading to dehydration, increasing serum drug levels, as well as the level of toxicity. Assess for signs and symptoms of an overdose.

BITE AND STING EMERGENCIES (See also Chapter 23)

• Decreased sensation can mask bites on the feet and lower legs. Assess completely. • Wounds are slower to heal and more susceptible to infection. • Monitor for side effects of antivenom treatment, especially in those with existing coagulopathies.

BEHAVIORAL HEALTH EMERGENCIES (See also Chapter 24) • • • •

Depression is not a normal sign of aging. Screen for suicide risk and assess if firearms are available at home before discharging a depressed older adult. Always rule out a metabolic issue before treating it as a psychiatric concern. Ask about access to mental health services and encourage appropriate resources.

TRAUMA EMERGENCIES (See also Chapter 27)

• Older adults have less reserve, so they will decompensate more quickly. Remember, medications and comorbidities can mask early symptoms of physiologic stress. • Increased risk of falls is common with age. More fragile bones and osteoporosis increase the chance of fractures. Assess for foot injuries that may not be readily apparent or painful. • Multiple rib fractures from blunt trauma place the patient at high risk for pulmonary contusion, pneumothorax, and aspiration. Be aware that the onset of symptoms is often delayed. • Assess for signs of maltreatment.

BURN EMERGENCIES (See also Chapter 28)

• Wound healing is more complex due to other age-related health issues. A significant infection may not occur until days later. • A higher risk of mortality exists with the presence of an underlying disease. • Screen for sepsis criteria. • Fluid balance needs to be monitored closely due to the risk of fluid overload and cardiac concerns. • Consider the possibility of carbon monoxide poisoning during the colder months.

SPECIAL CONSIDERATIONS Adult Maltreatment Always consider maltreatment and financial abuse when assessing the older adult. • Ask who helps with the activities of daily living (ADL), such as bathing and shopping, and the needs are being met?

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66 PART II Essentials in Emergency Nursing

• • • • •

Ask the patient if they feel safe at home. Body language may provide clues about their feelings of safety. Consider cultural influences and traditions that may mimic signs of abuse (e.g., cupping, coining and so on). Skin integrity/turgor can provide clues to the overall nutritional status. Assess for dehydration and malnutrition. Clothing (odor), hygiene, nutritional status, and overall presentation can provide clues to abuse. Unexplained medical conditions (e.g., bruises/injuries, fractures, genital pain, bleeding, infection, and/or skin excoriation) should be investigated thoroughly. • Failure to obtain medications or necessary care can be a sign of maltreatment. • Notify appropriate agencies for reporting purposes per applicable laws. • Patients older than 60 can be involved in intimate partner violence (Zink et al., 2004).

NOTES            

6

WA I T I N G R O O M I S S U E S

Shelley Cohen and Lynn Sayre Visser The waiting room is one of the highest liability areas in any acute care setting. Ongoing monitoring of patients, even after the initial triage, is vital to observe for illness or injury progression and to be able to intervene in a timely manner as needed.

PATIENTS WHO SHOULD NOT BE IN THE WAITING ROOM Safety and Security Issues • • • •

Inmates from jail/prison or under the custody of law enforcement Suicidal patients or others of high concern for harm to self Aggressive patients Any patient whose personal safety is at risk (e.g., suspected child maltreatment, intimate partner violence, or human trafficking) • Unaccompanied minors or an unaccompanied patient with a mental status change

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Exposure Issues (Consider Pandemics and Other Patient Surges That Limit Space) • Patients who can potentially expose others to their illness (e.g., active tuberculosis, suspected meningitis) • Immunocompromised patients (can be exposed to other illnesses) • Patients in an extremely poor state of personal hygiene or neglect

Miscellaneous (Consider NOT Placing in Waiting Room)

• Person with severe psychological impact (e.g., death of a loved one or other significant loss) • Person in a motor vehicle accident who was in the same compartment in which another occupant died • Patient with significant vital sign abnormality accompanied by any perfusion changes (e.g., dizziness, lethargy, weakness)

PATIENT REASSESSMENTS • Consider initial triage level to determine reassessment priorities. • Follow facility policies and procedures related to reassessment frequencies. • Never change the initial triage acuity level decision. If reassessment findings determine the patient should have a change in triage acuity level, this level should be documented as a subsequent triage decision leaving the initial triage acuity level unchanged.

EXTENDED WAIT TIMES Pandemic situations and patient surges can prolong wait times. The triage nurse should notify the team leader and security of any potential for violence. Be alert to a patient or family member demonstrating any of the following: • Loud and offensive language • Pacing, slamming chairs or other items • Overt anger/discontent • Verbal abuse of staff or others in the waiting area

Staff Talking Points for Patients Waiting

• “I understand it is frustrating and concerning to have to wait to be seen. Please know we are working as fast as possible to get people back to see the medical provider. Please let us know if your condition changes while you are waiting; we will gladly reassess you.” • “During this pandemic there are so many ill patients. We certainly appreciate everyone’s understanding and patience. Please know you will be seen as soon as possible.” • “I realize you are thirsty; however, our doctors recommend nothing to eat or drink as it may delay important tests you may need.” • Avoid using the words “I apologize” as this implies you did something wrong. Instead, explain the status of the department with compassion and sincerity. Try to incorporate the words “I understand” within your response. • For healthcare systems where testing such as labs and x-rays are initiated at triage, use statements like “Yes, it does seem crowded today, doesn’t it? Since you already have had your labs drawn and x-rays taken, we are hopeful that your care will move faster once the medical provider sees you.”

CHAPTER 6 Waiting Room Issues

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PRECAUTIONS: PREVENTING THE SPREAD OF GERMS The staff member who is the first point of contact upon the patient’s arrival must be familiar with the Centers for Disease Control and Prevention recommendations and should initiate them. As new diseases arise, the most up-todate information can be accessed at www.cdc.org.

Types of Isolation Precautions and Action (Nonpandemic) Contact • Patient action: Ear-loop procedure masks or behind-the-head tie surgical masks help to contain respiratory secretions. Standard procedure masks are adequate (N95 or above not indicated), sit 3 ft from others if coughing. Cover mouth/nose with a tissue. Dispose of tissue in trash containers. Cover open wounds with dressings. • Staff action: Diligent hand hygiene per guidelines, and offer masks to patients judiciously. Use disposable or dedicated patient-care equipment, and a gown and gloves for all contact with the patient. • Examples: Chickenpox/shingles, impetigo, lice, methicillin-resistant Staphylococcus aureus (MRSA), scabies, smallpox Droplet • Patient action: Mask the patient until placed in a negative pressure room with high-efficiency particulate air (HEPA) filter. • Staff action: Wear ear-loop procedure masks or behind-the-head tie surgical masks and initiate standard precautions. Note: An N95 mask is recommended when caring for a COVID-19 patient. Use a gown and gloves for all interactions. Initiate placing the patient in a negative pressure room or a room with a portable HEPA filter. • Examples: Group A streptococcus, influenza, measles (Rubeola), meningitis, mumps, norovirus, coronavirus, rubella (German measles), whooping cough

Airborne • Patient action: Mask required until placed in a negative pressure room with HEPA filter. • Staff action: Initiate placing the patient in a negative pressure room or a room with a portable HEPA filter; initiate standard precautions including gown, gloves, respirator like N95, N99, N100, or powered air purifying respirator (PAPR) • Examples: Chicken pox/shingles, tuberculosis, smallpox Note: A private room is typically required for the conditions discussed. Refer to www.cdc.org for further information.

CHAPTER 6 Waiting Room Issues

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7

L E GA L I S S U E S

Lynn Sayre Visser and Shelley Cohen

CONCEPTS AND DEFINITIONS Emergency Medical Treatment and Active Labor Act (EMTALA): A federal law to ensure that any individual presenting to an ED requesting care for emergency services receives a medical screening exam (MSE) to determine if they have a legally defined emergency medical condition (EMC). If it is determined that there is an EMC, necessary stabilizing treatment must be provided and/or an appropriate transfer to another hospital regardless of the ability to pay. Medical Screening Exam (MSE): Anything and everything necessary to determine whether or not the patient has a legally defined EMC. A qualified medical professional completes the MSE. Note: Triage in itself does not replace the MSE! Emergency Medical Condition (EMC): Any presentation with acute symptoms of sufficient severity such that, if medical care were not provided, the patient’s health, including the health of an unborn child, would be at risk for serious dysfunction of bodily organs, impairment of bodily functions, or death. Symptoms of sufficient severity also include pain and psychiatric illness (Centers for Medicare and Medicaid Services, 2021). Left Without Being Seen (LWBS): Patients who leave after triage but before seeing a provider. Against Medical Advice (AMA): Patients who have been advised of the risks associated with leaving against the medical provider’s advice but choose to leave despite those risks.

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MINIMIZING RISK AT TRIAGE Triage is “risky business,” requiring the nurse to minimize this risk. To avoid triage pitfalls and potential litigation, consider the following:

Assessment

• Never use a first-come, first-served mentality . . . the last patient may be the sickest. • Prioritize the “what” (the complaint and associated signs and symptoms) rather than the “who.” • Avoid focusing on the red herring/distracting body part (e.g., there may be an obvious fracture, but the patient is visibly short of breath). • Perform a quick triage assessment with a pertinent history every time. • Inquire about (and document) the patient’s care before arrival (e.g., analgesics, antiemetics); for example, sepsis can be easily missed without knowledge of the prior treatment (analgesics were given at home to reduce the fever so the patient presents afebrile). • Think of the worst-case scenario! • A patient who does not visibly show pain does not mean the patient does not have pain; possibly the patient’s culture believes not to show pain, the patient is routinely stoic, and so forth. • Always use critical thinking (avoid the cookbook approach). • Visualize the area of complaint or concern when possible.

Nurse Behaviors

• Stay sharp with your clinical knowledge and continue learning so you can rapidly and accurately recognize life-threatening injuries and illnesses, including those with atypical presentations. Failure to do so will cause a delay in treatment. CHAPTER 7 Legal Issues

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• Be familiar with the triage acuity or scoring system utilized at your facility; assign the acuity level based on the criteria. • Focus treatment needs on the patient’s condition, not the status of the department (e.g., peer pressure). • Quickly communicate with the charge nurse/provider when a patient presents with a life-threatening condition. • Recognize that age and gender biases subconsciously exist (e.g., children can have a stroke or heart failure); be aware of your personal biases and avoid bringing them into your triage decision-making. • Maintain an open mind to avoid tunnel vision. • Avoid delaying the MSE to gather payment or demographic details. • Be familiar with EMTALA; current EMTALA rules dictate that patients should not be triaged out of the department prior to the MSE. This does not apply to EMTALA addenda related to pandemics. • Frequent users of the ED should not be ignored; they too can have a serious medical condition such as acute appendicitis. • Listen to the patient’s self-diagnosis but think beyond the patient’s comments (avoid being too focused on only what the patient thinks is wrong). • Recognize that all patients returning within 72 hours are at risk for serious conditions. • Immediately identify patients who are at risk of falling. • Recognize that individuals with mental illness who are under the influence of substances, including alcohol, are high-risk patients. • Be knowledgeable in current laws pertaining to your geographical area regarding when a minor can seek care without consent of a parent/guardian as well as the definition of an emancipated minor. • Appropriately reassess patients utilizing your facility policies and procedures.

Documentation • • • • •

Document exactly what the patient says in the subjective statement. Document exactly what the nurse observes in the objective statement. Document any communication regarding the patient or situation. Document any verbal orders or instructions by leaders or medical providers. Document any actions, interventions, and the patient’s disposition.

MINORS: KNOW THE LAWS The triage nurse must be aware of applicable laws regarding minors who present without parents or guardians who are seeking care for themselves, as well as for minors who refuse the treatment or care requested by their parents or guardians. Some jurisdictions allow minors to seek care for specific issues without parental consent, such as pregnancy, contraception, sexually transmitted infections, and substance abuse. Emancipation rules and laws also differ from one region to another. The triage nurse must be knowledgeable about the definition of an emancipated minor and know the local laws and rules related to the care of a minor. YOU ARE THE DETECTIVE! Use critical thinking to connect the dots between the patient’s story and your clinical observations and assessment. Document your findings!

CHAPTER 7 Legal Issues

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PATIENT LEAVING WITHOUT TREATMENT Before the Patient Leaves Before the patient leaves consider the following: • Notify a medical provider to determine the patient’s mental capacity. • Discuss additional examination and testing needed to rule out an EMC; this should ideally be completed by the medical provider. • Discuss risks and benefits of the patient leaving without treatment or AMA; these risks should preferably be completed by the medical provider. • Whenever possible, have the patient sign appropriate forms for refusing further evaluation and treatment. • Follow your organization’s policy regarding terms and definitions related to patients who leave the department other than through a routine discharge process.

Documentation When the Patient Leaves Without Treatment Documentation should include: • The date and time. • A detailed description of the examination/treatment refused. • A statement regarding the patient’s condition upon leaving the facility. • Everything you did to encourage the patient to stay. • Notification of the supervisor/charge nurse per facility policies and procedures. • Your signature and preferably a second signature/witness if a patient refuses to sign the AMA paperwork. Note: These are suggestions. Following facility policies and procedures is always suggested.

REPORTABLE CONDITIONS AND EVENTS Conditions that are commonly reportable in most states include the following: • Abuse of a vulnerable adult • Assault with weapons • Child abuse • Elder abuse • Gunshot wounds • Homicide • Human trafficking, victim of • Injury from explosives • Injury, illness, or death from a medical device • Sexual assault/rape • Sexually transmitted infections • Some communicable diseases (e.g., tuberculosis) • Stab wounds • Suicide Note: This list is not all-inclusive. Follow your jurisdictional mandates, facility policies and procedures, and those of governing bodies.

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REPORT TO RISK MANAGEMENT • • • •

Any adverse event in waiting room Person threatening to sue Person threatening to harm patients, staff, or building Arrival of unexpected media

Note: This list is not all-inclusive. Follow your facility policies and procedures.

Part III: High-Risk Presentations by Body System

8

INTRODUCTION TO H I G H - R I S K P R E S E N TAT I O N S Lynn Sayre Visser

INTRODUCTION TO CHAPTERS 8 to 28 The first two chapters in this book create the foundation for the body system chapters that follow. For departments using a dual or multi-RN triage system, ideally the first nurse the patient encounters should perform the rapid triage assessment and determine if the patient requires immediate intervention. The questions listed in bold refer to common questions to ask during the rapid triage assessment; they are merely prompts to identify patients with immediate treatment needs. You do not need to ask all of the questions listed in the rapid triage assessment section every time. Sometimes you may ask only one or two questions and then determine the need for immediate intervention. At other times, you may need to continue with questions that may not be in bold that are more commonly covered during a comprehensive triage assessment. When making your triage decision, always gather enough information to support and document the triage acuity level or index score assigned. You may be thinking, “I don’t work in a two-part triage system that uses both a rapid and comprehensive triage assessment process.” Then think of the rapid triage assessment (goal of less than 60–90 seconds) as the primary

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assessment and the comprehensive triage assessment (goal of less than 2–5 minutes) as the secondary assessment. Additional information is gathered during the comprehensive triage assessment. At times the comprehensive triage assessment will immediately follow the rapid triage assessment, while at other times, the comprehensive triage assessment may occur much later (sometimes by the bedside nurse). Education through a formalized triage training course can more clearly outline this process.

THE A-B-C-D-E ASSESSMENT: A REVIEW During the across-the-room and rapid triage assessment, observe for A-B-C-D-E abnormalities that could indicate the patient requires immediate intervention.

Assessment

• Airway—Obstruction (tongue, teeth, blood, emesis, foreign body), swelling, abnormal airway sounds (grunting, stridor, wheezing); unable to speak/cry **Tip: If the patient is talking normally, a severe airway issue is unlikely. If the patient is talking, the airway is open. • Breathing—Work of breathing (labored, accessory muscle use, nasal flaring, retractions), rate (slow/fast), rhythm (irregular), depth (deep/shallow), positioning (tripod), chest rise and fall (unequal), speech patterns (number of words able to speak), tracheal position (deviated) **Tip: If the patient is speaking in full sentences, breathing is likely sufficient. • Circulation—Pulse rate (slow, fast), quality (bounding, weak, absent), capillary refill (delay >2 seconds), skin color (cyanosis, pallor, mottling) and condition (moist, diaphoretic, turgor, tenting), bleeding (absent, uncontrolled) **Tip: If a pulse is present and capillary refill is 2 seconds), mottling, cool extremities • Depression (severe), irrational, irritability, combative • Hemiplegia • Hyperglycemia or hypoglycemia

• Hypertension or hypotension • Hyperthermia and hypothermia • Increased work of breathing, retractions, and accessory muscle use • Loss of consciousness • Palpitations • Polyuria, polydipsia, polyphagia • Seizures, severe tremors • Skin flushed/diaphoretic • Sunken eyes • Tachycardia with signs of poor perfusion

TRIAGE CONSIDERATIONS Worst-case scenarios: The following should be considered as a potential for high acuity: Addisonian crisis, Cushing’s disease/syndrome, diabetes insipidus, diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic state (HHS), hypoglycemia, myxedema crisis, syndrome of inappropriate antidiuretic hormone (SIADH), and thyroid storm. • Utilize all your senses; your sense of smell may identify an invaluable sign (e.g., fruity smell on breath). • Inquire if the patient had similar symptoms in the past and the outcome at that time. • If there is any suspicion of an underlying infectious process, initiate isolation precautions. • Administer medications to treat symptoms in accordance with facility protocols or standing orders. • Patients with diabetic ketoacidosis/hyperosmolar hyperglycemic state may have signs and symptoms of a urinary tract or upper respiratory infection. These conditions may be the precipitating factor. CHAPTER 13 Endocrine Emergencies

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KEY TIPS • Complete the following when triaging all patients but be cognizant of when this is completed during the triage process: Treatment prior to arrival, provokes/palliates; quality; region/radiation; severity/associated symptoms; timing/temporal relations (PQRST), past medical history, drug and alcohol use, medications, allergies, immunization status, a full set of vital signs, O2 saturation, provide supplemental O2 if needed, and a capillary blood glucose if indicated. • An endocrine condition often results from another cause (e.g., infection, trauma, recent surgery); focus on identifying and treating the underlying condition. • Careful monitoring of intake and output is essential for many of these conditions; collect this data early in the treatment process. • Consider seizure precautions and the benefits of a calm, quiet environment. • Think electrolyte imbalances. • Anticipate orders that may include: Labs: CBC, chemistry and thyroid panel, serum antidiuretic hormone (ADH) and osmolality, urinalysis, pregnancy test, arterial blood gas (ABG), refer to Table 13.1: Common Lab Values Seen in Endocrine Emergencies; Diagnostics: Chest x-ray, EKG; Medications: IV fluids and medications specific to the endocrine issue.

POLYURIA, POLYDIPSIA, AND POLYPHAGIA Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver ASSESSMENT Baseline objective assessment

INTERVENTIONS General Interventions

• How long have the signs and symptoms been present? • Any seizure-like activity? Syncopal episode, dizziness, and /or weakness? • Ounces of water you drink in 24 hours? How often do you urinate? Quantity? Nocturia? • Any symptoms of an infection? Recent fever? • Any urinary symptoms (e.g., dysuria, urinary frequency, urgency, hematuria)? • Weight loss? Fatigue? Headache? Weakness? • A-B-C-D-E; intervene immediately for any serious concerns • Assess level of consciousness and for Kussmaul respirations (rapid and deep) • Assess for hemodynamic instability (tachycardia, hypotension, cool, pale skin, altered mental status) • Signs and symptoms of dehydration (e.g., tachycardia, hypotension, dry mucous membranes, altered mental status), or fruity odor to breath • Screen for sepsis; if criteria met, act! • Consider orthostatic vital signs • EKG per facility protocol and prepare for seizure precautions • Urinalysis and/or pregnancy test if indicated CHAPTER 13 Endocrine Emergencies

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SKIN HYPERPIGMENTATION, BRUISING, UNUSUAL FAT DEPOSITS, EXPOTHALMOS, AND NECK SWELLING Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• How long have you noticed this change in your body? Any other changes you have noticed? • Seizure activity? Any muscle weakness? Leg cramps? Tetany? • Numbness to the face, fingers, or toes? • Recent bruises? Bruise easily without taking blood thinners? • Nausea, vomiting, or constipation? • Excessive hair growth to face/body?

ASSESSMENT Baseline objective assessment

• • • •

INTERVENTIONS General interventions

• • • •

A-B-C-D-E; intervene immediately for any serious concerns Agitation, restlessness, confusion, drowsiness, or lethargy; flushed, hot, dry skin Fruity odor on breath, polydipsia or polyuria Skin discolorations (hyperpigmentation) to the face, buccal mucosa, hands, elbows, knees, and in “creases,” such as on the palm of the hands • Unusual fat deposits, such as a moon face or buffalo hump EKG per facility protocol Prepare for seizure precautions Urinalysis and/or pregnancy test if indicated Keep patient safe; the patient may be a fall risk

WORST-CASE SCENARIOS • Addisonian Crisis: Signs and symptoms include tachycardia, hypotension, fever, nausea, vomiting, abdominal pain, severe weakness/fatigue, altered mental status, and/or seizures; ED Care: Capillary blood glucose, CBC, chemistry panel, serum cortisol, plasma adrenocorticotropic hormone (ACTH), urinalysis, ABG; EKG, x-ray, CT, MRI; IV fluids, corticosteroids, may require hormone replacement; Note: The patient may have diffuse hyperpigmentation of the skin seen on the hands, elbows, and knees. • Cushing’s Disease/Syndrome: Signs and symptoms include tachycardia, hypertension, weight gain, weakness, fatigue, and/or sleep disturbance; ED Care: Focus on treating what caused the disease/syndrome and treat the associated signs and symptoms; Note: The patient may have unusual fatty deposits (e.g., moon face, buffalo hump), hyperpigmentation, purple striae, and/or hirsutism (an increase in body or facial hair). • Diabetes Insipidus: Signs and symptoms include polyuria, polydipsia, tachycardia, hypotension, dizziness, weight loss, fatigue, dry mucous membranes, poor skin turgor, and/or weak pulses; ED Care: CBC, chemistry panel, serum osmolality, urinalysis (osmolality and specific gravity); desmopressin; Note: Patients can urinate from 5 to 20 L/day. • Diabetic Ketoacidosis (DKA): Signs and symptoms include tachycardia, hypotension, Kussmaul respirations (rapid, deep breathing), volume depletion (e.g., dry mucous membranes, poor mucous membranes), polyuria, polydipsia, polyphagia, nausea, vomiting, fruity odor on breath, abdominal pain, and/or acute mental status changes; ED Care: Capillary blood glucose, CBC, chemistry panel, lactate, serum osmolality, urinalysis (check for glucose, ketones, and infection), blood culture if indicated, ABG; chest x-ray, EKG, CT; IV fluid replacement, IV insulin followed by an insulin drip; Note: Monitor for signs and symptoms of hypoglycemia and hyperkalemia during insulin administration. CHAPTER 13 Endocrine Emergencies

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• Hyperosmolar Hyperglycemic State (HHS): Signs and symptoms include tachycardia, hypotension, altered mental status, profound dehydration (e.g., dry skin, poor skin turgor, dry mucous membranes, dry tongue), and/or seizures; ED Care: Capillary blood glucose, CBC, chemistry panel, urinalysis, blood culture if indicated, ABG; chest x-ray, EKG, CT; IV fluid replacement, IV insulin followed by an insulin drip, potassium replacement (if indicated), cardiac monitor, intake and output; Note: HHS is most commonly seen in type 2 diabetics. • Hypoglycemia: Signs and symptoms include weakness, dizziness, headache, irritability, diaphoretic, dry mouth, altered mental status, and/or loss of consciousness; ED Care: Check the capillary blood glucose and if it is low, anticipate oral carbohydrates, glucagon IM if IV access is unavailable, or an injectable if the patient is semiconscious or unconscious; Note: Hypoglycemia is the most common cause of altered mental status in a person with diabetes. • Myxedema Crisis: Signs and symptoms include tachycardia, hypotension, hypothermia, respiratory depression, and altered mental status; ED Care: Maintain airway; capillary blood glucose, CBC, chemistry and thyroid panel, cultures (blood, urine, sputum if indicated), urinalysis; EKG; provide warm blankets, continuous cardiac monitoring, vascular access; glucose, corticosteroids; Note: The most common precipitating factor for a patient in myxedema coma is a pulmonary infection (Morton & Fontaine, 2018). A patient may experience slurred speech and hoarseness due to the thickening of the laryngeal and pharyngeal mucous membranes causing the tongue to become thickened (Morton & Fontaine, 2018).

ID:c0013-p0720

• Syndrome of Inappropriate Antidiuretic Hormone (SIADH): Signs and symptoms include irregular respirations, tachycardia, hypertension, oliguria, headache, altered mental status, abdominal pain, muscle cramps, irritability, nausea, vomiting, diarrhea, and/or seizures; ED Care: CBC, chemistry panel, serum osmolality, urinalysis (osmolality and specific gravity); fluid restriction; electrolyte replacement, diuretic; Note: Some causes of SIADH are head injury, malignant tumors, infection, or stroke. • Thyroid Storm: Signs and symptoms include restlessness, agitation, tremors, hyperthermia, altered mental status, and/or coma; ED Care: CBC, chemistry and thyroid panel, urinalysis, cultures for a source of infection; x-ray if indicated; beta blocker, antithyroid agent, antipyretic, antibiotic if an infection; Note: The older adult may present with an atypical presentation exhibiting only one symptom, such as weakness, depression, heart failure, or atrial fibrillation (Morton & Fontaine, 2018).

CHAPTER 13 Endocrine Emergencies

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RESOURCES Table 13.1: Common Lab Values Seen in Endocrine Emergencies *ELECTROLYTE IMBALANCE

**SIGNS AND SYMPTOMS

SEEN IN THE FOLLOWING ENDOCRINE EMERGENCIES

Sodium 145 mEq/L HIGH

Flushed skin, thirst, weakness, twitching, agitation, restlessness, lethargy, confusion, seizures, coma

Cushing’s syndrome, diabetes insipidus

Potassium 5.0 mEq/L HIGH

Irritability, muscle weakness, paresthesia, nausea, diarrhea, abdominal cramping, EKG changes, irregular and/or decrease pulse rate, hypotension, cardiac arrest

Addisonian crisis

ID:c0013-p4154

*ELECTROLYTE IMBALANCE

SEEN IN THE FOLLOWING ENDOCRINE EMERGENCIES

**SIGNS AND SYMPTOMS

Calcium 10.2 mg/dL HIGH

Anorexia, nausea, vomiting, constipation, abdominal pain, confusion, muscle weakness, decreased deep tendon reflex, hypertension, EKG changes, arrhythmias, stupor, coma, cardiac arrest

Thyroid storm

Glucose 110 mg/dL HIGH

Flushed, hot, dry skin, polydipsia, polyuria, fruity odor on breath, hypotensive, tachypnea, restless, drowsiness, lethargic, unconscious

Cushing’s syndrome, DKA, HHS, thyroid storm

*Normal electrolyte values: sodium 135–145 mEq/L; potassium 3.5–5.0 mEq/L; calcium 8.6–10.2 mg/dL; glucose 70–110 mg/dL. **Signs and symptoms may vary from patient to patient. DKA, diabetic ketoacidosis; HHS, hyperosmolar hyperglycemia syndrome; SIADH, syndrome of inappropriate antidiuretic hormone. CHAPTER 13 Endocrine Emergencies

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14

OBSTETRIC EMERGENCIES

Teri Campbell and Deb Jeffries (See also Chapter 4, Pediatric Considerations; Chapter 12, Abdominal Emergencies; Chapter 15, Gynecologic Emergencies; Chapter 25, Sexual Assault and Intimate Partner Violence; Chapter 26, Human Trafficking; and Chapter 27, Trauma Emergencies)

CHIEF COMPLAINTS • • • • • •

Abdominal, back, and/or pelvic pain Absence of fetal movement Bleeding or passing of clots from the vagina Difficulty breathing/shortness of breath Headache/blurred vision Leaking or gush of fluid from the vagina

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• Miscarriage • Special considerations: Imminent or precipitous delivery (urge to push) • Seizure • Vomiting

RED FLAGS • • • • • • • •

Abdominal, back, or pelvic pain or cramping Absent or decreased fetal movement Bleeding or clots from vagina Epigastric pain unrelieved by antacids Fetal heart rate 160 beats per minute Gush or leaking of fluid from vagina Intractable vomiting Imminent delivery: Crowning, perineal bulging, actively bearing down, or urge to push

• • • • • • •

Maternal hypertension Proteinuria Protruding fetal parts Prolapsed cord Suspected or known intimate partner violence Trauma Visual changes

CHAPTER 14 Obstetric Emergencies

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TRIAGE CONSIDERATIONS Worst-case scenarios: The following should be considered as a potential for high acuity: Abruptio placentae, eclampsia, cardiomyopathy, fetal demise, HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome, placenta previa with active bleeding, postpartum complications, premature rupture of membranes, prolapsed cord, and uterine rupture • After 20 to 24 weeks, gestation both mother and fetus must be considered in care-related decisions. • The medical screening exam in the United States includes both the mother and fetus. • If delivery is imminent, consider transporting the maternal and neonatal patient after delivery and stabilization. • Confirm estimated date of confinement (EDC) using early ultrasound, last menstrual period, or with a pregnancy wheel or pregnancy app. • Maternal hypotension causes maternal shunting of intravascular volume away from the placenta and uterus resulting in decreased uterine and placenta perfusion. • Normal fetal heart tones (FHTs) are 110 to 160 beats per minute. Check for FHTs according to facility policy. • Consider preterm labor if the mother presents with back pain, pelvic or abdominal cramping, or the maternal sensation that the baby is “balling up on the inside.” • Dehydration is a common cause of preterm contractions. • The risk of intimate partner violence increases during pregnancy. Screen all women and maintain a high index of suspicion for abuse. • Back pain may be the only symptom of active labor. • A pregnant teenager may be considered an emancipated minor and allowed to consent for treatment. Know the legal requirements for consent to treat in your local jurisdiction. • Maintain a high index of concern during the postpartum period (also known as the fourth trimester) for complications such as excessive bleeding or signs of pre-eclampsia/eclampsia.

KEY TIPS • Always correlate the FHTs with the mother’s pulse; if the beats per minute are the same, it is more likely the mother’s heartbeat is being heard and not the fetus. • Pregnancy related vital sign changes: Respiratory rate increases, however, an increase in work of breathing is abnormal; heart rate increases by 15 to 20 beats per minute over maternal baseline and blood pressure decreases. A maternal blood pressure higher than 140/90 is pathologic at any time during pregnancy. • Fundal height is assessed by measuring in centimeters from the symphysis pubis to the top of the fundus and usually correlates to gestational age; 32 centimeters = 32 weeks’ gestation. • The fundal height is usually at the umbilicus at 20 to 24 weeks, gestation. • The earliest sign of maternal instability is fetal tachycardia as blood is shunted away from the uterus. • Signs of maternal hemodynamic instability include cool skin, delayed capillary refill, altered mental status, and/ or decreased urinary output. Hypotension is a late sign. • Maternal fever may be associated with a urinary tract infection or sepsis. • Fetal movement is the primary indicator of fetal well-being. • Anticipate orders that may include: Labs: CBC, chemistry panel, human chorionic gonadotropin (HCG; urine and/or serum), type and crossmatch; Diagnostics: Abdominal ultrasound, assessment of fetus via a non-stress test; Medications: Magnesium sulfate, antipyretics, antiemetics, analgesics, antihypertensives; Other: Doppler FHTs

CHAPTER 14 Obstetric Emergencies

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SPECIAL CONSIDERATIONS: IMMINENT OR PRECIPITOUS DELIVERY Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

ASSESSMENT Baseline objective assessment

• Date of last menstrual cycle, EDC? • Gravida/para (TPAL: term, preterm, abortions/miscarriages, now living), single or multiple gestation? • Have you received prenatal care? How many weeks were you when it started, and how often have you gone? • Leaking or gush of fluid from the vagina? How long ago? Color and odor? • Urge to push? • Bleeding from vagina? • Use of any drugs or substances in the past 4 hours? • A-B-C-D-E; intervene immediately for any serious concerns • Immediately assess for perineal bulging, crowning, and protrusion of body parts from the vagina • FHTs

INTERVENTIONS General interventions

• Immediately notify labor and delivery and neonatal intensive care unit (NICU) staff if available and alert anesthesia • Anticipate transfer to labor and delivery or another facility with NICU and highrisk obstetric services if labor and delivery is not available at the facility; think Emergency Medical Treatment and Active Labor Act (EMTALA) • Anticipate delivery and immediately obtain a precipitous delivery tray/kit, neonatal supplies, and an infant warmer if no delivery tray is available; the minimum necessary equipment includes cord clamps, scissors, towels, and a bulb suction (ENA, 2020). • If hemodynamically unstable, place the mother on her left side otherwise place the mother in the position of comfort (e.g., on all fours or in a squatting position) ■ Breech delivery: Position the mother side-lying or on all-fours which allows the fetus to be delivered without being touched or pulled. The most experienced clinician should lead the delivery. ■ Prolapsed cord: Position the mother on her left side, bed in Trendelenburg or on all-fours. With a gloved hand, insert two fingers into the vagina and gently push up on the presenting fetal part. DO NOT manipulate, palpate, or attempt to reinsert the umbilical cord. Cover the exposed umbilical cord with damp, warm gauze. (continued )

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SPECIAL CONSIDERATIONS: IMMINENT OR PRECIPITOUS DELIVERY (continued) ID:c0014-ti0015

INTERVENTIONS General interventions (continued)

• Supplemental oxygen if indicated and vascular access • Support the head as the shoulders are delivered and the rest will quickly follow • If you need to clear the airway, suction the mouth before the nose; remember big hole before little hole, or one mouth before the two nares • After delivery, clamp the cord in two places at least 6 inches from the umbilicus (ENA, 2020) • Anticipate delivery of the placenta, which typically occurs 5 to 10 minutes after delivery of the fetus; signs of spontaneous placental separation include the maternal patient feeling an urge to push, a small gush of blood, and lengthening of the umbilical cord; have the maternal patient push while you apply gentle traction to the umbilical cord while delivering the placenta; if there is any resistance, stop pulling (ENA, 2020); follow facility policy on disposition of the placenta • Monitor the mother for excessive bleeding and postpartum hemorrhage • See NEONATAL CARE POST-DELIVERY for immediate care of the neonate and Table 14.1: APGAR Score in the Resources section

NEONATAL CARE POST-DELIVERY • Dry, warm, and stimulate the neonate; ensure any wet towels/blankets are changed • Place in a sniffing position using a shoulder roll

• The neonate may remain with the mother if actively crying with a heart rate above 100 beats per minute, breathing adequately, has adequate muscle tone, and is term; place skin-to-skin • If the neonate is not actively crying, has gasping respirations, or is apneic, the heart rate must be auscultated within 30 seconds of life; if the heart rate is less than 100 beats per minute, begin positive pressure ventilation (PPV) with 21% FiO2 ■ If the heart rate is less than 60 beats per minute despite adequate chest rise and mask seal with PPV, begin chest compressions at a rate of 120 events per minute; this is 90 chest compressions and 30 ventilations per minute with a rhythm of one-and two-and three (compressions) breaths ■ If heart rate remains less than 60 beats per minute despite adequate PPV and chest compressions, epinephrine should be administered at a dose of 0.01 mg/kg (0.1 mL/kg); consider intubation and possible causes such as hypovolemia or pneumothorax ■ Follow neonatal resuscitation program (NRP) guidelines. • If the heart rate is greater than 100 beats per minute but there is persistent cyanosis or labored breathing, consider supplemental oxygen and/or continuous positive airway pressure (CPAP); if supplemental oxygen is required, titrate to the lowest possible level to maintain the targeted SpO2 and consider cardiac monitoring • Place pulse oximeter on the neonate’s right wrist; preductal measurements at 1 minute of age is 60% to 65%, 3 minutes of age is 70% to 75%, 5 minutes of age is 80% to 85%, and 10 minutes of age is 85% to 95% • Obtain APGAR scores at 1 minute, 5 minutes, 10 minutes; see Table 14.1: APGAR Score • Document the time of delivery and placenta delivery • Ensure matching identification bands are placed on the mother and the neonate; this is always an essential step but with a higher sense of urgency if the mother and neonate must be separated • Ensure neonate is kept warm to prevent hypothermia • Monitor blood glucose frequently • Do not stress about APGAR scoring when performing care after a delivery. All aspects of the APGAR scoring will be observed during the assessment process. CHAPTER 14 Obstetric Emergencies

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Table 14.1: APGAR Score BREATHING 0 Not breathing

1 Slow irregular

2 Crying

HEART RATE 0 No heartbeat

1 100

MUSCLE TONE 0 Floppy

1 Some tone

2 Active movement

REFLEX/GRIMACE 0 No response

1 Facial grimace only

2 Pulls away, cries, coughs, or sneezes

SKIN COLOR 0 Pale blue

1 Body pink, hands and feet blue

2 Entire body is pink

Assessment intervals: 1 minute, 5 minutes, 10 minutes; APGAR 7 or greater is considered very good (ENA, 2020)

ABDOMINAL, BACK, AND/OR PELVIC PAIN Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• Onset, location, and duration of pain? Is the pain constant or intermittent? Any urge to push? • Date of last menstrual cycle, EDC? • Gravida/para (TPAL: term, preterm, abortions/miscarriages, now living), single or multiple gestation? Previous ectopic pregnancy? • Leaking or spontaneous gush of fluid from the vagina? Onset, color, odor? • Vaginal bleeding or clots? Onset, color (bright or dark red), number of pads used per hour? • Any trauma (consider the possibility of intimate partner violence; see Chapter 25, Sexual Assault and Intimate Partner Violence)? • When did the baby last move? Is the amount of movement the same as usual or less? • Prenatal care? Any complications? Any complications with previous pregnancies? • Any fever? COVID symptoms/exposure? Vaccination status? • Painful or frequent urination? (continued )

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ABDOMINAL, BACK, AND/OR PELVIC PAIN (continued) ID:c0014-ti0030

ASSESSMENT Baseline objective assessment

• A-B-C-D-E; intervene immediately for any serious concerns • Imminent delivery: crowning, perineal bulging, actively bearing down, or urge to push • Time contractions if indicated; the duration of the contraction is from the beginning of the contraction to the beginning of the next contraction with the strength of the contraction assessed by palpating the uterus • Obtain FHTs • Sepsis screening; if criteria met, act! • Intimate partner violence screening

INTERVENTIONS General interventions

• Position the mother ideally in the left lateral position or right lateral position to increase uterine perfusion; if the patient is hemodynamically unstable and secured to a long backboard, displace the uterus manually • Vascular access • Notify labor and delivery staff of patient presence and according to facility policy; anticipate transfer to the appropriate level care if obstetric services/NICU is not available

ABSENCE OF FETAL MOVEMENT Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

ASSESSMENT Baseline objective assessment

• When did you last feel the baby move? Is the amount of movement the same as usual or less? • Any pain? Onset, location, and duration of pain. Is the pain constant or intermittent? • Date of last menstrual cycle, EDC? • Gravida/para (TPAL), single or multiple gestation? • Leaking or spontaneous gush of fluid from the vagina? Onset, color, odor? • Any bleeding or clots from the vagina? Onset, color (bright or dark red), number of pads used over the last hour? • Any trauma (consider the possibility of intimate partner violence?) • Prenatal care? Any complications? Any complications with previous pregnancies? • Fever? COVID symptoms/exposure? Vaccination status? • Painful or frequent urination? • • • •

A-B-C-D-E; intervene immediately for any serious concerns Obtain FHTs if applicable Sepsis screening; if criteria met, act! Intimate partner violence screening (continued ) CHAPTER 14 Obstetric Emergencies

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ABSENCE OF FETAL MOVEMENT (continued) ID:c0014-ti0040

INTERVENTIONS General interventions

• Notify labor and delivery staff of patient presence according to facility policy based on the weeks of gestation • Turn the patient to the left lateral position or the right lateral position; unless contraindicated, provide a sugary drink as this will stimulate fetal movement

BLEEDING/PASSING CLOTS FROM VAGINA Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• Onset of vaginal bleeding, color (bright or dark red), number of pads used over last hour? • Any abdominal, back, or pelvic pain? Onset, location, and duration of pain? Is the pain constant or intermittent? • Date of last menstrual cycle, EDC? • Gravida/para (TPAL), single or multiple gestation? • When did you last feel the baby move? Is the amount of movement the same as usual or less? • Any lightheadedness or dizziness? • Any trauma (consider possibility of intimate partner violence)? • Prior uterine surgery or uterine abnormalities?

ASSESSMENT Baseline objective assessment

INTERVENTIONS General interventions

• A-B-C-D-E; Intervene immediately for any serious concerns • Assess for hemodynamic instability (e.g., tachycardia, hypotension, cool, pale skin, altered mental status) • Monitor FHTs; fetal tachycardia is the earliest sign of maternal instability • Quantify blood loss by weighing pads/towels • Place the patient in the left lateral position or right lateral position or manually displace the uterus to increase uterine perfusion • Vascular access; obtain 2 large caliber IVs; if unable or unlikely to obtain vascular access and the patient is hemodynamically unstable consider intraosseous (IO) access • Anticipate the need for balanced blood replacement: emergent blood administration or massive transfusion protocol • Anticipate the need for administration of tranexamic acid (TXA) if indicated • Notify labor and delivery staff of patient presence and according to facility policy; anticipate transfer to an appropriate level care if obstetric services/NICU not available • Give nothing by mouth

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HEADACHE/BLURRED VISION Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver ASSESSMENT Baseline objective assessment

INTERVENTIONS General interventions

• Onset, duration, and location of the headache? Constant or intermittent? Visual changes? • Epigastric pain or heartburn? • Weakness or numbness to extremities? • Nausea or vomiting? • Date of last menstrual cycle? EDC? • Gravida/para (TPAL), single or multiple gestation? • Swelling to legs or feet? Sudden swelling to the face? Sudden weight gain? Fever? • • • • • • •

A-B-C-D-E; intervene immediately for any serious concerns Face, arms, speech, timing (FAST) exam (consider the possibility of a stroke) Glasgow Coma Scale Pupils, size and reaction FHTs Deep tendon reflexes Hypertension with epigastric pain or heartburn (indicates pre-eclampsia)

• Vascular access if indicated

MISCARRIAGE Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• Any vaginal bleeding? Number of pads used over the last hour? Clots? • Passed any tissue vaginally (if so, save the tissue for laboratory evaluation)? • Abdominal, back, or pelvic pain? Onset, location, duration of pain? Constant or intermittent? • Date of last menstrual cycle? EDC? • Gravida/para (TPAL), single or multiple gestation? • Any trauma (consider possibility of intimate partner violence)? Lightheadedness or dizziness?

ASSESSMENT Baseline objective assessment

• A-B-C-D-E; intervene immediately for any serious concerns • Closely monitor for signs of shock: tachycardia, cool, pale, clammy skin, altered mental status, decreased urine output • Quantify blood loss by weighing pads/towels

INTERVENTIONS General interventions

• Save any tissue passed vaginally for laboratory evaluation • Vascular access if indicated and give nothing by mouth • Provide psychosocial support as this can be a devastating experience

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SEIZURE Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver ASSESSMENT Baseline objective assessment INTERVENTIONS General interventions

• • • • •

Onset and duration of seizure? Were all extremities involved? Incontinence? Injuries sustained? Past medical history of seizures*? Headache? Onset and duration? Any elevation of blood pressure during pregnancy? Sudden onset of edema? Epigastric pain/heartburn? Decreased urinary output?

• A-B-C-D-E; intervene immediately for any serious concerns • Glasgow Coma Scale • FHTs, pupil size and reaction, deep tendon reflexes • • • • •

Place mother on left side Cardiac and pulse oximetry monitoring Vascular access Monitor blood pressure frequently and anticipate the administration of magnesium sulfate Notify labor and delivery staff for continuous fetal monitoring (if available)

* If no past history of seizures, seizures in pregnancy after 20 weeks are considered eclampsia until proven otherwise.

VOMITING Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver ASSESSMENT Baseline objective assessment

INTERVENTIONS General interventions

• • • • •

Onset, duration, and frequency of vomiting? Able to take any oral fluids without vomiting? Any abdominal cramping or pain? Fetal movement? Does anything decrease the vomiting? Urine output? Color and odor?

• A-B-C-D-E; intervene immediately for any serious concerns • Signs of dehydration (e.g., tachycardia, hypotension, dry mucous membranes, decreased urine output, and/or altered mental status; remember hypotension is a late sign!) • FHTs • Vascular access and notify labor and delivery for continuous fetal monitoring if indicated • Capillary blood glucose if indicated per policy/protocol

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WORST-CASE SCENARIOS • Abruptio Placentae: Signs and symptoms include dark red painful vaginal bleeding with localized abdominal and/or back pain; pain is usually disproportionate to the amount of bleeding visualized; it is possible that an abruptio occurs without vaginal bleeding; it is common for an abruptio to precipitate contractions/preterm labor—contractions worsen the abruption and bleeding; ED Care: Management of hemorrhage with balanced blood replacement, and if necessary, massive transfusion protocol (MTP); magnesium sulfate may be indicated to control labor; notify labor and delivery staff and request continuous fetal monitoring; anticipate a possible cesarean section and hysterectomy for uncontrolled hemorrhage; Note: Abruptio placentae is the premature separation of the placenta from the uterine wall. Disseminated intravascular coagulation (DIC) is common with large abruptions with hemorrhage. Risk factors include hypertension, multiple gestations, cocaine use, trauma, or possibly idiopathic. • Breech Fetal Presentation: Signs and symptoms include the buttock or feet as the presenting part; ED Care: If delivery is imminent, alert the physician; anticipate the need for an emergency cesarean section; alert the labor and delivery team (if available); Note: A breech presentation is when the head is not the presenting part. If a vaginal delivery is imminent, remember that breech deliveries are “hands-off” deliveries; see the Chief Complaint/ Special Considerations: Imminent or Precipitous Delivery in this chapter. • Cardiomyopathy: Signs and symptoms include shortness of breath, chest discomfort, palpitations, arrhythmias, fluid retention, and/or signs of heart failure; ED Care: Treatment is supportive and determined by symptoms and the degree of heart failure or end organ failure; anticipate an echocardiogram and management by a cardiologist. (ACOG, 2019); Note: Peri- or postpartum cardiomyopathy causes left ventricular dysfunction with an ejection fraction of less than 45% in women without previously diagnosed cardiac disease and is typically diagnosed in the last month of pregnancy or in the first few months after delivery.

• Eclampsia: Signs and symptoms include seizures in addition to the signs and symptoms of pre-eclampsia; ED Care: Oxygen, vascular access; administration of magnesium sulfate, benzodiazepines may be necessary to treat the seizure; anticipate the need for an emergency cesarean section, and alert the labor and delivery team (if available); monitor deep tendon reflexes and postictal states; Note: Eclampsia involves pre-eclampsia along with seizures associated with pregnancy and is considered an immediate threat to the life of both the mother and fetus (ENA, 2020). If the postictal state persists after 1 hour, consider the possibility of an intracranial bleed and anticipate a head CT scan. • Ectopic Pregnancy: Signs and symptoms include missed or irregular menses, colicky/crampy abdominal or pelvic pain, and/or vaginal bleeding or spotting; if the pregnancy advances far enough to rupture, there may be pain referred to the left shoulder known as Kehr’s sign; ED Care: Give nothing by mouth, vascular access; obtain an immediate obstetrical consultation and prepare for emergency surgery; monitor closely for signs or symptoms of hypovolemic shock due to hemorrhage; Note: An ectopic pregnancy is a pregnancy that occurs outside of the uterus. A recent menstrual cycle does not rule out pregnancy; maintain a high index of suspicion for pregnancy for any female able to conceive. • Fetal Demise: Signs and symptoms include the absence of fetal movement and FHTs and may occur at any stage of the pregnancy; ED Care: No specific treatment is necessary; an induction of labor is usually conducted as a scheduled procedure; provide psychosocial support to the mother and the family; Note: Mementos such as a lock of hair, photos, or the blanket used to wrap the baby may help with the grieving process. Even if the family does not want the items, they may want them at a later time. Encourage the family to hold the baby and point out beautiful features such as “your baby has your fingers.” • Hemolysis, Elevated Liver Enzymes, and Low Platelets (HELLP) Syndrome: Signs and symptoms include epigastric or right upper quadrant abdominal pain; ED Care: Vascular access, oxygen, management of CHAPTER 14 Obstetric Emergencies

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hemorrhage, supportive care; notify labor and delivery staff and request continuous fetal monitoring; anticipate a possible emergency cesarean section; Note: HELLP syndrome is associated with pre-eclampsia causing hemolysis, elevated liver enzymes, and low platelets resulting in multiorgan damage and bleeding disorders (disseminated intravascular coagulation). It is more common in multigravida women and is life-threatening. Although more common prior to delivery, HELLP syndrome can also occur during the postpartum period (ENA, 2020). • Hyperemesis Gravidarum: Signs and symptoms include a constellation of symptoms which typically resolve by the end of the first trimester including frequent vomiting, weight loss, headaches, extreme fatigue, and/or dehydration; ED Care: IV fluids, antiemetics, hyperalimentation; Note: The American College of Obstetrics and Gynecology (ACOG, 2018) has the “Nausea and Vomiting of Pregnancy” guidelines for the care of patients which includes other medications and interventions (Jennings & Mahdy, 2022). REMEMBER: Dehydration in pregnancy can lead to preterm labor. • Placenta Previa: Signs and symptoms include bright red, painless vaginal bleeding, cramping, and possibly contractions; the bleeding may irritate the uterus causing uterine irritability/cramping which may cause increased bleeding; ED Care: Management of hemorrhage with balanced blood replacement and if necessary MTP; magnesium sulfate may be indicated to control labor; notify labor and delivery staff and request continuous fetal monitoring; Note: Placenta previa is the complete or partial covering of the internal cervical os by the placenta. Digital pelvic exams are contraindicated as they may worsen the bleeding. Cervical assessment is completed by a sterile speculum exam. • Postpartum Complications: Signs and symptoms include, but are not limited to, retained products of conception, hemorrhage, pre-eclampsia or eclampsia, amniotic embolism, deep vein thrombosis, endometritis, sepsis, postpartum thyroiditis, cardiomyopathy, pulmonary embolism, and/or stroke; ED Care: Treatment is

determined by the specific disease process; Note: Sometimes postpartum complications are referred to as the fourth trimester; this is a period of physiologic vulnerability and extends from birth to 12 weeks post-delivery. It is of the utmost importance for the team to maintain a high index of suspicion for postpartum complications! • Pre-eclampsia: Signs and symptoms include gestational hypertension (blood pressure greater than 140/90) with proteinuria, signs of organ dysfunction including renal and hepatic changes; other symptoms include headache, visual changes, edema, hyperreflexia, and epigastric pain; ED Care: Supportive management although magnesium sulfate may be indicated to deter the development of eclampsia; Note: Pre-eclampsia may precipitate the development of HELLP syndrome. • Premature Rupture of Membranes: Signs and symptoms include leakage or a sudden gush of fluid from the vagina; ED Care: There is no treatment and preterm labor is a common complication; if there is a gross rupture of the membranes the fetus should be delivered within 48 hours; Note: Preterm is the rupture of membranes before the onset of labor and premature is the rupture before 37 weeks’ gestation. There is a high risk of infection; assess for signs of maternal sepsis. • Prolapsed Cord: See Special Considerations: Imminent or Precipitous Delivery at the beginning of the chapter • Trauma Emergencies: See Chapter 27 • Uterine Rupture: Signs and symptoms include severe abdominal pain; ED Care: Supportive, management of hemorrhage, and immediate surgical intervention; Note: This occurs because of dehiscence of a previous uterine scar or a tearing of the uterine wall; consider the possibility of uterine rupture in trauma especially with rapid deceleration forces. This is a surgical emergency! CHAPTER 14 Obstetric Emergencies

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G Y N E C O LO G I C E M E R G E N C I E S

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Lynn Sayre Visser and Anna Sivo Montejano (See also Chapter 4, Pediatric Considerations; Chapter 5, Older Adult Considerations; Chapter 12, Abdominal Emergencies; Chapter 14, Obstetric Emergencies; and Chapter 25, Sexual Assault and Intimate Partner Violence) ID:c0015-p0005

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CHIEF COMPLAINTS • Pelvic pain/lower abdominal pain

• Vaginal bleeding

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RED FLAGS • Abdominal pain (severe) within 48 hours after delivery • Abdomen rigid and accompanied by severe pain • Bruising around the umbilicus (Cullen’s sign) • Foreign object retained (signs and symptoms of sepsis or obstruction) ID:c0015-p0025

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• Menstrual cycle delayed >2 weeks, severe pain, and possibility of pregnancy • Pain (severe) that awakens a person from sleep, intractable or severe • Rebound tenderness in abdomen ID:c0015-p0050

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• Retained products of conception, partial or complete (suspicion of) • Sexual assault • Shoulder pain (Kehr’s sign) with abdominal or pelvic pain • Syncope ID:c0015-p0065

• Trauma to the vagina (or rectum) from foreign object • Vaginal hemorrhage, uncontrolled (saturating 12 tampons/day or 8 pads/day is considered excessive bleeding; Jordon, 2020, p. 288) ID:c0015-p0085

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TRIAGE CONSIDERATIONS Worst-case scenarios: The following should be considered as a potential for high-acuity: Ectopic pregnancy, ovarian torsion, pelvic inflammatory disease, sexual assault (see Chapter 25), sexually transmitted infection, and toxic shock syndrome • Delay of treatment of an ectopic pregnancy or ovarian torsion can cause permanent injury or loss of ovary. Time is ovary! • Think potential high-risk presentation if the patient is pregnant; often an ectopic pregnancy needs to be ruled out. • Shoulder pain with abdominal or pelvic pain, think perforation and free air. • Do not assume a young female is not pregnant; anticipate the need for a pregnancy test in pre- and post-menarcheal women and obtain an obstetric history. • Avoid making assumptions when it comes to a person’s sexual orientation and practices (ACOG, 2021). Ask the patient what pronouns they prefer to use. Refer to www.acog.com “Healthcare for Transgender and Gender Diverse Individuals” to better understand the terminology. • A thorough history is essential as there are many etiologies for gynecologic emergencies. • Consider the possibility of abuse and/or sexual assault. ID:c0015-p0095

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• Screen for sexually transmitted infections; these can lead to infertility if undiagnosed and untreated. • Screen for sepsis if there is a known infection or suspicion of an infection. • Refer to Chapter 12 and Figure 15.1: Lower Abdominal Diagnostic Considerations Based on Anatomy of the Abdomen for more common gynecologic diagnoses. ID:c0015-p0140

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KEY TIPS • Complete the following when triaging all patients, but be cognizant of when this is completed during the triage process: Treatment prior to arrival, provokes/palliates, quality, region/radiation, severity/associated symptoms, timing/temporal relations (PQRST), past medical history, drug and alcohol use, medications, allergies, immunization status, a full set of vital signs, O2 saturation, provide supplemental O2 if needed, and a capillary blood glucose if indicated. • For abdominal pain with a positive pregnancy test, anticipate the need for surgical intervention. • If a patient has vaginal bleeding, a catheterized urine specimen will likely be needed. • Some contraceptives, such as intrauterine devices (IUDs), can cause pain even when a person is not currently sexually active. • Anticipate orders that may include: Labs: CBC, chemistry panel, urinalysis/pregnancy test, gonorrhea/ chlamydia, type and screen/crossmatch, Rh blood type; Diagnostics: Pelvic exam, abdominal or transvaginal ultrasound; Medications: Analgesics, antiemetics, antimetabolites. ID:c0015-p0155

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PELVIC PAIN/LOWER ABDOMINAL PAIN ID:c0015-ti0015

Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes ID:c0015-ti0020

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

ASSESSMENT Baseline objective assessment

• Location of pain? Unilateral or bilateral? Duration? Description (sharp, dull, achy)? Does it radiate? Intermittent or constant? Progressively worsening? Awakened from sleep? • Recent fever? How high? For how many days? Prior treatment (e.g., analgesics given)? • Date of last menstrual cycle? Possibility of pregnancy (if yes, see Chapter 14)? Estimated date of confinement (EDC)? Expecting one baby or multiple? • Vaginal bleeding or spotting? Quantity of tampons or pads saturated per hour? • Syncope? Shoulder pain (Kehr’s sign)? Pain anywhere else? • Trauma? Recent injury? • Nausea, vomiting, and/or diarrhea? For how long? • Recent use of tampons (e.g., retained) or other foreign objects placed in the pelvic area? • Vaginal discharge and/or foul-smelling odor? • Any urinary symptoms (e.g., dysuria, frequency, urgency, hematuria)? • Previous ovarian torsion/cysts, pelvic inflammatory disease, or fertility treatments? • Sexually active? Sexually transmitted infections? Method of contraceptives? • A-B-C-D-E; intervene immediately for any serious concerns • Screen for sepsis; if criteria met, act! • Inspect and palpate the abdomen (e.g., rebound tenderness, voluntary/involuntary guarding) (continued ) CHAPTER 15 Gynecologic Emergencies

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PELVIC PAIN/LOWER ABDOMINAL PAIN (continued ) ID:c0015-ti0015

INTERVENTIONS General interventions

• Nothing by mouth until surgical intervention is ruled out • Anticipate the need for a urinalysis/pregnancy test and/or serum pregnancy test per policy • Anticipate a pelvic exam, specimens may be needed (e.g., sexually transmitted infection screening, such as chlamydia, gonorrhea, trichomoniasis) and/or wet mount • Anticipate the need for an ultrasound and/or surgical intervention

VAGINAL BLEEDING ID:c0015-ti0025

Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes ID:c0015-ti0030

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• Vaginal bleeding/spotting? • Date of last menstrual cycle? Possibility of pregnancy? Estimated date of confinement? Expecting one baby or multiple? • Is this amount of bleeding normal during menses? Quantity of pads saturated per hour (≥1 maxi pad/hour = concern)? • Abdominal pain?

• For pregnancy: Frequency and duration of contractions? How far apart are the contractions? • Syncope, dizziness, and/or weakness? • Trauma? Abuse? • Swelling and pain to the perineal/vaginal area? • C-section or vaginal delivery? ASSESSMENT Baseline objective assessment

• A-B-C-D-E; intervene immediately for any serious concerns • Screen for sepsis; if criteria met, act! • Assess for imminent delivery (e.g., crowning, bulging membranes, patient bearing down, presenting fetal parts); see Chapter 14, Obstetric Emergencies • Signs of shock; hypovolemia or sepsis may occur if retained products of conception • Abdominal and fundal assessment

INTERVENTIONS General interventions

• Give nothing by mouth until surgical intervention is ruled out • Anticipate a pelvic exam and possibly an ultrasound • Anticipate fundal massage and/or vaginal packing, possible blood transfusion; anticipate potential surgical intervention if fundal massage/packing does not control bleeding • Consider the need for emotional support and resources concerning pregnancy loss for women with miscarriage

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WORST-CASE SCENARIOS • Ectopic Pregnancy: Signs and symptoms include the classic triad of pain (unilateral pelvic pain), amenorrhea, vaginal bleeding; shoulder pain (typically referred pain is a high probability for a ruptured ectopic pregnancy); ED Care: Pregnancy test, Rh factor, type and screen; ultrasound; pelvic exam, vascular access; methotrexate administration or surgical intervention; Note: Watch for hypovolemic shock. ID:c0015-ti0035

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• Ovarian Torsion: Signs and symptoms include a sudden onset of sharp, unilateral lower abdominal pain; at times, the pain may initially be vague and then steadily worsen becoming more constant and localized; pain may radiate to the pelvic region or flank and be accompanied by a fever, nausea, and/or vomiting; ED Care: Nothing by mouth, CBC, chemistry panel, pregnancy test, type and screen with crossmatch as indicated; ultrasound and occasionally MRI; vascular access; analgesics, antiemetics, IV fluid or blood products as indicated; anticipate rapid surgical intervention; Note: Pain is due to ischemia. Time is ovary! If left untreated, ovarian torsion can rupture and potentially lead to infertility, hemorrhage, and infection. ID:c0015-p0560

• Pelvic Inflammatory Disease (PID): Signs and symptoms include lower abdominal pain, pain with movement, rebound tenderness, fever, vaginal bleeding or discharge with foul odor, abnormal menstrual bleeding, pain with intercourse, dysuria, nausea, and/or vomiting; ED Care: Nothing by mouth, pelvic exam; vaginal cultures (e.g., chlamydia, gonorrhea), CBC, urinalysis, pregnancy test; ultrasound, CT or MRI; analgesics, antibiotics; surgical intervention when diagnosis unclear; Note: Commonly identified when observing the patient ambulating with what is known as the “PID shuffle.”

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• Sexually Transmitted Infection (STI): Signs and symptoms vary depending on the type of STI; dysuria, vaginal discharge, bleeding, fever, asymptomatic (gonorrhea), itching (chlamydia), painful vesicles (herpes), sores to the mouth (primary syphilis), rash to palms of hands, and/or soles of feet (secondary syphilis); ED Care: Pelvic exam, vaginal cultures (e.g., chlamydia, gonorrhea), CBC, urinalysis with testing for gonorrhea/chlamydia, pregnancy test; urethral, rectal, or throat swab for STIs; antibiotics or antiviral therapy; Note: In some jurisdictions, STIs may be reportable to the health department; be familiar with local reporting criteria. If child abuse, sexual abuse, intimate partner violence, or human trafficking is suspected, see Chapter 4, Pediatric Considerations; Chapter 25, Sexual Assault and Intimate Partner Violence; and Chapter 26, Human Trafficking. Involve additional agencies and support (e.g., social services) for assistance as indicated. ID:c0015-p0570

• Toxic Shock Syndrome: Signs and symptoms include a sudden onset of a fever up to 102°, chills, headaches, sunburn-appearing rash with skin peeling off in sheets, malaise, and/or decreased blood pressure; ED Care: Initiate contact isolation; CBC, chemistry and coagulation panel, blood cultures, urinalysis, pregnancy test, pelvic exam with cultures and the removal of a foreign object(s); Note: Some individuals at risk include those with recent tampon use, diaphragm use, surgical wounds, and history of recent childbirth or abortion. ID:c0015-p0575

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RESOURCES ID:c0015-ti0040

RLQ • Appendicitis • Inguinal hernia • Ovarian torsion, cyst • PID, ovarian abscess • Ruptured ectopic pregnancy • Salpingitis

LLQ • Diverticulitis • Inguinal hernia • Ovarian torsion, cyst • PID, ovarian abscess • Ruptured ectopic pregnancy • Salpingitis

Diffuse Acute gastroenteritis, Constipation, DKA, IBS, Intestinal obstruction, Peritonitis, SCC Figure 15.1: Lower Abdominal Diagnostic Considerations Based on Anatomy of the Abdomen DKA, diabetic ketoacidosis; IBS, irritable bowel syndrome; LLQ, left lower quadrant; PID, pelvic inflammatory disease; RLQ, right lower quadrant; SCC, squamous cell carcinoma.

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MALE REPRODUCTIVE EMERGENCIES

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Lynn Sayre Visser and Anna Sivo Montejano (See also Chapter 4, Pediatric Considerations; Chapter 5, Older Adult Considerations; Chapter 12, Abdominal Emergencies; Chapter 20, Infectious and Communicable Disease Emergencies; Chapter 25, Sexual Assault and Intimate Partner Violence; and Chapter 27, Trauma Emergencies) ID:c0016-p0005

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CHIEF COMPLAINTS • Difficulty urinating • Pain or penile discharge ID:c0016-ti0010

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• Urinary catheter problems ID:c0016-p0025

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184 PART III High-Risk Presentations by Body System

RED FLAGS ID:c0016-p0030

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Abdominal pain (severe) with fever Catheter not draining (symptomatic) Constrictive penile ring(s) Difficulty/inability to void (symptomatic) Flank pain, severe Foreign body to the penis Foreskin retracted for a prolonged period of time Hemorrhaging, uncontrolled

• Necrosis or cellulitis to the penis, scrotum, or perineal area • Pelvic/abdominal pain, sudden onset, intractable or severe • Priapism • Rigid abdomen • Testicular or scrotal pain, sudden onset, intractable or severe • Traumatic injury ID:c0016-p0075

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TRIAGE CONSIDERATIONS Worst-case scenarios: The following should be considered as a potential for high acuity: Epididymitis, Fournier’s gangrene, fractured penis, incarcerated inguinal hernia, priapism, and testicular torsion • Consider the risk of ischemia to the penis/testicles. Time is testicle and possibly infertility! • Goal is to identify acute penis/scrotum conditions to prevent future fertility/erectile difficulties. • Screen for sepsis criteria particularly if the patient is febrile. • For cloudy urine or foul-smelling urine, consider urosepsis. • Necrosis or cellulitis to the penis, scrotum, or perineal area, think necrotizing fasciitis or Fournier’s gangrene. • Any trauma to the genitalia is considered an emergency until proven otherwise. ID:c0016-p00300

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KEY TIPS • Pain to male genitalia is often referred to surrounding areas and the abdomen. • Urethral pain when a kidney stone is passing can cause pain radiating to the testicle. • In an uncircumcised male, a foreskin that is retracted and cannot be pulled forward (with tenderness/ swelling to glans) is a urologic emergency; necrosis may occur if blood flow is impaired. • Urinary retention can be neurologic (spinal cord injury, multiple sclerosis, or diabetes) or mechanical (due to urethral stricture, prostatic hyperplasia, or meatal stenosis). Untreated urinary issues may lead to renal failure. Knowing why the patient has a urinary catheter can help determine the cause of the problem. • Correlate the symptoms with the story to rule out sexual abuse; remember if there is a “suspicion” of abuse present, healthcare professionals are mandated reporters. See Chapter 4,  Pediatric Considerations; Chapter 5, Older Adult Considerations; and Chapter 25, Sexual Assault and Intimate Partner Violence as indicated. • The Prehn’s sign can help differentiate testicular torsion from epididymitis. When elevating the testicle, pain increases with testicular torsion and decreases with epididymitis. Prehn’s sign is not definitive. • On rare occasions, swelling of the testicles can be caused by mumps. • Anticipate orders that may include: Labs: CBC, chemistry panel, urinalysis, urine culture, urethral swabs, cultures; Diagnostics: Ultrasound, CT, MRI; Medications: Antipyretics, antibiotics; Other: Urology consult. ID:c0016-p0145

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CHAPTER 16 Male Reproductive Emergencies

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186 PART III High-Risk Presentations by Body System

DIFFICULTY URINATING ID:c0016-ti0015

Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes ID:c0016-ti0020

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• • • • • • • • • • • •

Time of the last void? Hematuria or passing clots? Back pain? Fever? How high? For how many days? Prior treatment (e.g., antipyretics given)? Recent hospital discharge or post-op with indwelling catheter recently removed? Currently taking blood thinners? When was the urethral catheter replaced? Recent constipation (possibly causing an obstruction)? Penile discharge (what color)? Swelling or discoloration of the scrotum? Penile ring(s), penile/scrotal piercing(s), or foreign body present? Acute or chronic problem? History of bladder or prostate problems, obstruction, kidney stone, or urinary tract infections? Recent surgery to prostate/bladder?

ASSESSMENT Baseline objective assessment

• • • •

A-B-C-D-E; intervene immediately for any serious concerns Screen for sepsis; if criteria met, act! Inspect and palpate the abdomen (e.g., tenderness, firmness, rigidity) Test for costovertebral angle tenderness

INTERVENTIONS General interventions

• Anticipate urinalysis (void/straight catheter) • Bladder scan and/or ultrasound as indicated • Cold compress and elevation for trauma or ecchymosis

PAIN OR PENILE DISCHARGE ID:c0016-ti0025

Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes ID:c0016-ti0030

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• What happened? Injury/trauma? Location of pain? • Prolonged erection? Scrotal swelling, discoloration (e.g., redness, ecchymosis), or fever? • How high was the fever? For how many days? Prior treatment (e.g., antipyretics given)? • Penile ring(s), penile/scrotal piercing(s), or foreign body? • Use of medication that causes an erection? • Penile discharge? What is the color? Recent surgery to prostate, bladder, or genitalia? • Abdominal pain, nausea, and/or vomiting? • Does gently elevating the scrotum cause a decrease or an increase in pain (Prehn’s sign)? • Sexually active? History of sexually transmitted infections or exposure to them? (continued )

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PAIN OR PENILE DISCHARGE (continued ) ID:c0016-ti0025

ASSESSMENT Baseline objective assessment INTERVENTIONS General interventions

• • • •

A-B-C-D-E; intervene immediately for any serious concerns Screen for sepsis; if criteria met, act! Inspect and palpate surrounding tissue/area for infection/abscess/penile discharge Swelling or discoloration of the scrotum (e.g., redness)

• Anticipate pain management, culture for penile discharge, urinalysis with possible culture and sensitivity (C&S), and/or ultrasound

URINARY CATHETER PROBLEMS ID:c0016-ti0035

Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes ID:c0016-ti0040

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• Length of time the catheter has been in place and why (e.g., post-op, urinary retention)? • When was the last time the catheter was changed? Is it draining (amount, color, clots)? • If blocked, duration of time, presence of blood or clots in the urine? • Taking blood thinners? • Associated (severe) pain? If so, where? • Fever? How high? For how many days? Prior treatment (e.g., antipyretics given)? • Penile discharge (what color)? Swelling or discoloration of the scrotum? • Attempts to irrigate the catheter? Any issues with prior catheter insertion(s) or required a specialist to insert? • Constipation? Last bowel movement? • Recent surgery to prostate/bladder? • History of bladder or prostate problems, obstruction, kidney stones, or urinary tract infections? (continued )

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URINARY CATHETER PROBLEMS (continued ) ID:c0016-ti0035

ASSESSMENT Baseline objective assessment INTERVENTIONS General interventions

• • • •

A-B-C-D-E; intervene immediately for any serious concerns Screen for sepsis criteria; if criteria met, act! Assess the abdomen for distension and pain Visualize urine characteristics in catheter tubing

• Anticipate a bladder scan and urinalysis • C&S if indicated • If bloody drainage or clots, anticipate an order for a triple lumen indwelling catheter per policies

WORST-CASE SCENARIOS • Epididymitis: Signs and symptoms include fever, discharge, gradual scrotal pain and/or swelling alleviated with elevation; ED Care: Apply a cold compress to groin area if suspected, gonorrhea and chlamydia culture, urinalysis; antibiotics; Note: Recent placement of an indwelling catheter or a scope into the urethra for diagnostic testing can lead to untreated chronic infections or an abscess that can cause epididymitis; the onset is typically over 24 to 48 hours. ID:c0016-ti0045

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• Fournier’s Gangrene: Signs and symptoms include scrotal and anal swelling, redness, moderate to severe pain, crepitus, fever, malaise, and/or odor from affected tissue; ED Care: Ultrasound, x-ray, and/or CT scan; vascular access, IV antibiotics; surgical debridement; Note: Occurs from an infection near the genitals and can be caused by prolonged exposure to soiled clothing or disposable undergarment in an incontinent person. ID:c0016-p0720

• Fractured Penis: Signs and symptoms include penile ecchymosis and/or inability of the penis to become fully erect after audibly hearing a pop; ED Care: Ultrasound or MRI, surgical management; Note: Occurs from forceful bending of the penis following intercourse or aggressive masturbation; urethral injury may also occur. ID:c0016-p0725

• Incarcerated Inguinal Hernia: Signs and symptoms include fever, severe pain, swelling/bulge in groin area, redness, nausea, and/or vomiting; ED Care: Give nothing by mouth; ultrasound, CT, or MRI; CBC, blood cultures; anticipate provider to place the patient in Trendelenburg position and attempt to gently massage hernia back into place; if unsuccessful, anticipate surgical intervention; Note: Occurs after testicular trauma with development of scrotal mass; may lead to bowel obstruction if not treated rapidly.

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• Priapism: Signs and symptoms include prolonged erection not related to sexual arousal, rigid penile shaft with the tip of the penis soft, and/or worsening pain over time; ED Care: Cold compresses, urology consult, corporal blood gas, ultrasound, needle aspiration, intracavernosal phenylephrine for erection 36 hours (Bivalacqua et al., 2021); may be caused by medications, blood disorders (e.g., sickle cell anemia), metabolic disorders, and spinal cord injury among others. ID:c0016-p0735

• Testicular Torsion: Signs and symptoms include sudden onset, severe pain to testicle; could also be a gradual onset with lower abdominal pain, scrotal swelling and/or redness, and may awaken the patient from sleep (less common presentation); pain may radiate to the testicle or groin; no relief with testicular elevation; ED Care: Pain management, cold compresses to the testicle, ultrasound, anticipate an attempt at manual torsion reduction and/ or surgical intervention within 4 hours to save the viability of the testicle; Note: Time is testicle! ID:c0016-p0740

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17

OCULAR EMERGENCIES

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Lynn Sayre Visser and Andrea Perry (See also Chapter 4, Pediatric Considerations; Chapter 5, Older Adult Considerations; Chapter 11, Neurologic Emergencies; Chapter 20, Infectious and Communicable Disease Emergencies; Chapter 27, Trauma Emergencies; and Chapter 28, Burn Emergencies) ID:c0017-p0005

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CHIEF COMPLAINTS ID:c0017-ti0010

• Chemical exposure/burn to eye(s) • Foreign body • Infection, eye(s) ID:c0017-p0015

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• Pain, eye(s) • Trauma (isolated eye injury) • Vision loss (total, partial, or segmental) ID:c0017-p0030

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RED FLAGS ID:c0017-p0045

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Blood in the colored part of the eye Burns: Chemical or steam exposure/burns to eye(s) Clear jelly-like substance or drainage Color perception impaired from normal (e.g., seeing red) Extraocular movement impaired Pain to the eye(s): Severe or persistent Periorbital edema and unable to visualize pupil Proptosis (eye protrusion)

• Pupils: Asymmetrical and/or nonreactive, diminished pupillary response, and/or misalignment of eyes • Trauma to eye(s) from penetrating object or blunt force • Vision loss (total, partial, or segmental) • Vision: Sudden onset of a change, seeing the visual field as a curtain or veil, presence of peripheral floaters, halos around light, or difficulty distinguishing light ID:c0017-p0090

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TRIAGE CONSIDERATIONS Worst-case scenarios: The following should be considered as a potential for high acuity: Acute angle closure glaucoma, central retinal artery occlusion, chemical exposure/burn, endophthalmitis, ischemic optic neuropathy, open/ruptured globe, orbital cellulitis, orbital fracture, penetrating object to the eye, retinal detachment, retrobulbar hematoma, third nerve palsy, and trauma to the eye(s) • Consider the need for spinal motion restriction and other trauma interventions (see Chapter 27, Trauma Emergencies) as indicated. • Permanent loss of vision is the highest concern. Remember: Time is vision, and immediate intervention is critical. • Consider a stroke with transient vision loss, and implement appropriate action per policy. • Any chemical burn to the eye(s) mandates immediate continuous irrigation. • In the case of a proven or suspected penetrating eye injury, irrigation of the eye is contraindicated as this might cause damage to the intraocular tissues. ID:c0017-p0110

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CHAPTER 17 Ocular Emergencies

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194 PART III High-Risk Presentations by Body System

• Abnormal pupil(s) size or reaction may indicate a serious situation! • Remove contact lenses as warranted. Do not forcefully try to remove them; seek specialist help as necessary. • Perform a visual acuity exam when indicated but do not delay treatment of chemical burns to obtain the visual acuity. Refer to Table 17.1: Types of Visual Acuity Tests. ID:c0017-p0145

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KEY TIPS • Complete the following when triaging all patients, but be cognizant of when this is completed during the triage process: Treatment prior to arrival, provokes/palliates, quality, region/radiation, severity/associated symptoms timing/ temporal relations (PQRST), past medical history, drug and alcohol use, medications, allergies, immunization status, a full set of vital signs, O2 saturation, provide supplemental O2 if needed, and a capillary blood glucose if indicated. • For chemical exposure, remember that alkali substances are worse than acids, causing liquefaction necrosis; therefore, the agent can penetrate deeper into the eye tissues which is why it is critical to omit the visual acuity exam. Acids cause coagulation of proteins in the eye tissue, thus preventing deeper penetration of the agent. • Refer to http://www.msds.com/ or the material safety data sheet (MSDS) at your facility to direct further treatment. • Anticipate a likely emergency ophthalmology referral as treatment can be time sensitive. • Pain relief with topical analgesia is often associated with more benign disease processes. • Decreased vision with signs and symptoms of infection to both upper and lower lid; think orbital cellulitis and potential for meningitis! • Individuals who are significantly farsighted (thick glasses/contact lenses) are at a higher risk for acute angle closure glaucoma. • Anticipate orders that may include: Labs: CBC, chemistry panel, sexually transmitted infection (STI) panel; Diagnostics: Visual acuity, slit lamp evaluation, fluorescein stain examination, patching eye(s) as indicated; ultrasound (retinal detachment), CT (orbital floor fracture), x-ray, MRI; Medications: Anesthetic, antibiotics, analgesics, and/or antiemetics; Other: Ophthalmology consult ID:c0017-p0160

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CHEMICAL EXPOSURE/BURN TO EYE(S) ID:c0017-ti0015

Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes ID:c0017-ti0020

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver ASSESSMENT Baseline objective assessment

• • • • • • • •

Type of substance (e.g., cleaning, pool, or hair products)? Concentration of the substance? Length of exposure? Vision loss? Sudden or gradual? Constant or intermittent? Unilateral or bilateral? Partial or complete vision loss? Treatment/eye irrigated prior to arrival? Wearing safety glasses? Sensitivity to light? Headache, nausea, and/or vomiting?

• A-B-C-D-E; intervene immediately for any serious concerns • Do not delay immediate interventions (e.g., eye irrigation) to perform a visual acuity exam or complete triage • Pupils including corneal opacification or redness to the sclera • Pupils for equal size, roundness/reactivity to light, accommodation • Swelling around eye(s), skin color, and temperature • Skin breakdown in areas surrounding the eye(s) • Crusting or discharge present; color of drainage (continued )

CHAPTER 17 Ocular Emergencies

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196 PART III High-Risk Presentations by Body System

CHEMICAL EXPOSURE/BURN TO EYE(S) (continued ) ID:c0017-ti0015

INTERVENTIONS General interventions

• Remove contact lenses if able or seek assistance; instruct the patient not to rub eyes • Immediate irrigation of the eye(s) with copious amounts of water or normal saline; DO NOT let irritant run from one eye into the other during irrigation (see Table 17.2: Tips for Inserting a Morgan Lens) • Refer to Table 17.3: Types of Chemical Burns and Associated Treatment for Eyes; interventions vary based on the type of agent that caused the exposure • Delegate someone to obtain information on the substance from employer/family/local resources • Refer to http://www.msds.com/ or the MSDS at your facility to direct further treatment

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FOREIGN BODY ID:c0017-ti0025

Rapid Triage Assessment goal is 60 to 90 seconds ; Comprehensive Triage Assessment goal is 2 to 5 minutes ID:c0017-ti0030

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver ASSESSMENT Baseline objective assessment

• • • •

Mechanism of injury (e.g., blunt/penetrating trauma)? Time of incident? Penetrating object (e.g., knife, gun pellets)? Size? Loss of consciousness (see Chapter 27, Trauma Emergencies)? Vision loss? Sudden or gradual? Constant or intermittent? Unilateral or bilateral? Partial or complete vision loss? • Seeing peripheral floaters or red hue? • Other injuries? • Wearing safety glasses? Contacts? • A-B-C-D-E; intervene immediately for any serious concerns • Pupils: Look for a change in appearance (fluid leakage, bulging eye, blood in anterior chamber, teardrop-appearing pupil deviating toward the side of injury, decreased extraocular movements) • Discharge from eye(s), color, consistency • Pupils for equal size, roundness/reactivity to light, accommodation • Visual acuity • Periorbital edema, ecchymosis, and/or deformity (continued )

CHAPTER 17 Ocular Emergencies

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198 PART III High-Risk Presentations by Body System

FOREIGN BODY (continued ) ID:c0017-ti0025

INTERVENTIONS General interventions

• Consider head/neck injury and the need for spinal motion restriction • Stabilize impaled objects and do not remove them; apply a patch to the contralateral eye to limit movement • Instruct patient not to rub the eye(s) • DO NOT place anything in the eye (including eye drops) if you suspect an open/ ruptured globe

INFECTION, EYE(S) ID:c0017-ti0035

Rapid Triage Assessment goal is 60 to 90 seconds ; Comprehensive Triage Assessment goal is 2 to 5 minutes ID:c0017-ti0040

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

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Injury? Mechanism? Onset and duration of symptoms? Fever? How high? For how many days? Prior treatment (e.g., antipyretics given)? Stiff neck and/or headache? Vision loss (partial or complete)? Sudden or gradual? Constant or intermittent? Unilateral or bilateral?

ASSESSMENT Baseline objective assessment

INTERVENTIONS General interventions

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A-B-C-D-E; intervene immediately for any serious concerns Screen for sepsis; if criteria met, act! Proptosis (eye bulging) Discharge from eye(s), color, consistency Pupils for equal size, roundness/reactivity to light, accommodation Toxic appearance, swelling to cheek or face, shiny red or purple eyelid Visual acuity (an impaired visual acuity from baseline is a late finding)

• Consider isolation if concerned about exposure (e.g., meningitis); if drainage noted, consider placing a dressing • Remove contacts as indicated • Anticipate the need for diagnostics such as sinus x-rays • Anticipate the need for lab tests (e.g., CBC, chemistry panel, blood cultures), obtain an ocular culture as indicated, and/or medications (e.g., analgesics, antibiotics)

CHAPTER 17 Ocular Emergencies

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200 PART III High-Risk Presentations by Body System

PAIN, EYE(S) ID:c0017-ti0045

Rapid Triage Assessment goal is 60 to 90 seconds ; Comprehensive Triage Assessment goal is 2 to 5 minutes ID:c0017-p0735

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

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Mechanism of injury (blunt or penetrating trauma)? Type and size of the object? Time of incident? Loss of consciousness (see Chapter 27, Trauma Emergencies)? Pain with a sudden or gradual onset? Vision loss (partial or complete)? Sudden or gradual? Constant or intermittent? Unilateral or bilateral? Decreased peripheral vision? Halo’s around lights? Fever? How high? For how many days? Prior treatment (e.g., antipyretics given)? Headache, nausea, and/or vomiting? Wearing safety glasses (if applicable)?

ASSESSMENT Baseline objective assessment

INTERVENTIONS General interventions

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A-B-C-D-E; intervene immediately for any serious concerns Visualize the eye (blood present, eye reddened, foggy appearance to cornea) Discharge from eye(s), color, consistency Pupils for equal size, roundness/reactivity to light, accommodation Swelling around eye(s), skin color, and temperature Periorbital edema, deformity, skin color, and temperature Skin breakdown in areas surrounding the eye(s) Crusting or discharge present; color of drainage Visual acuity

• Anticipate the need to rapidly decrease intraocular pressure • Shielding eye(s) if applicable • Anticipate orders which may include analgesics and eye drops to decrease intraocular pressure

CHAPTER 17 Ocular Emergencies

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202 PART III High-Risk Presentations by Body System

TRAUMA (ISOLATED EYE INJURY) ID:c0017-ti0050

Rapid Triage Assessment goal is 60 to 90 seconds ; Comprehensive Triage Assessment goal is 2 to 5 minutes ID:c0017-ti0055

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver ASSESSMENT Baseline objective assessment

• • • •

Mechanism of injury (blunt or penetrating trauma)? Type and size of the object? Time of incident? Loss of consciousness (see Chapter 27, Trauma Emergencies)? Vision loss sudden or gradual? Constant or intermittent? Unilateral or bilateral? Partial or complete vision loss? Pain? • Fever? How high? For how many days? Prior treatment (e.g., antipyretics given)? • Wearing safety glasses? • A-B-C-D-E; intervene immediately for any serious concerns • Visualize and palpate head/neck • Pupils; assess for blood in the anterior chamber or conjunctival hemorrhage, ocular movement, and pupillary response • Pupils for equal size, roundness/reactivity to light, accommodation • Discharge from eye(s), color, consistency • Periorbital edema, ecchymosis, and/or deformity • Visual acuity

INTERVENTIONS General interventions

• Initiate spinal motion restriction if indicated; when not indicated, elevate the head of bed to keep blood pooling inferiorly • Remove contact lenses • Shielding eye(s) if applicable • Nothing by mouth if surgical intervention anticipated

CHAPTER 17 Ocular Emergencies

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204 PART III High-Risk Presentations by Body System

VISION LOSS (TOTAL, PARTIAL, OR SEGMENTAL) ID:c0017-ti0060

Rapid Triage Assessment goal is 60 to 90 seconds ; Comprehensive Triage Assessment goal is 2 to 5 minutes ID:c0017-ti0065

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• Mechanism of injury (blunt or penetrating trauma)? • Type and size of the object? Time of incident? • Loss of consciousness or head/neck trauma (see Chapter 27, Trauma Emergencies)? • Vision loss (partial or complete)? Sudden or gradual? Constant or intermittent? Unilateral or bilateral? Length of time the vision loss occurred (see Chapter 11, Neurologic Emergencies)? • Seeing flashing lights? Peripheral floaters? Halo’s around lights or the appearance of a curtain? • Chemical exposure to eye(s) (See Chemical Exposure/Burn complaint earlier in this chapter)? • Pain? Constant or intermittent? • Headache, nausea, and/or vomiting? • Sensitivity to light? • Use contacts or glasses?

ASSESSMENT Baseline objective assessment

INTERVENTIONS General interventions

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A-B-C-D-E; intervene immediately for any serious concerns Any neurologic deficits Pupils (note any restriction of eye movement) Proptosis (eye protrusion) Discharge from eye(s), color, consistency Pupils for equal size, roundness/reactivity to light, accommodation Periorbital edema, skin color, temperature Redness or tearing Shielding eye(s) from light or to limit consensual movement Visual acuity

• Remove contact lenses or glasses when indicated • Nothing by mouth if surgical intervention anticipated • Anticipate the need for a CT if indicated

CHAPTER 17 Ocular Emergencies

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206 PART III High-Risk Presentations by Body System

WORST-CASE SCENARIOS • Acute Angle Closure Glaucoma: Signs and symptoms include a sudden and severe onset; unilateral pain, halos around lights, headache, nausea, onset after entering a dark room, and/or may notice change in appearance to eye or redness; ED Care: Place supine, anticipate a tonometer, an antiemetic, and medications to decrease intraocular pressure; Note: Individuals who are significantly farsighted (thick glasses/contact lenses) are at a higher risk for acute angle closure glaucoma. ID:c0017-ti0070

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• Central Retinal Artery Occlusion: Signs and symptoms include painless, unilateral vision loss, vision may be transient if occlusion is mobile in the vessel, and/or pupil may be dilated with decreased pupillary reaction; ED Care: If recent onset, anticipate orders for medications that decrease intraocular pressure; Note: Retinal perfusion needs to be rapidly re-established; irreversible vision loss can occur within 90 minutes of the occlusion (Sims & Ting, 2017). ID:c0017-p1265

• Chemical Exposure/Burn: Signs and symptoms include pain, redness, tearing, vision change, and/or corneal opacification; ED Care: Initiate immediate irrigation of the eye(s) with copious amounts of water or normal saline; anticipate analgesics and tetanus; Note: Any burn of significance to the eye(s) will be a high triage acuity. Remember, alkaline is worse than acidic substances and may cause liquefaction necrosis. DO NOT DELAY treatment to obtain a visual acuity exam. ID:c0017-p1270

• Endophthalmitis: Signs and symptoms include eye pain progressively worsening after an injury or injection to the eye or after eye surgery/procedures, pus or discharge, redness, vision loss or changes, and/or eyelids puffy or swollen; ED Care: Anticipate an aqueous/vitreous tap, ophthalmic antibiotics, and antifungals; Note: Onset may occur a few days after an eye procedure or surgery (e.g., cataracts). An infection that starts in another part of the body may also lead to endophthalmitis. ID:c0017-p1275

• Hyphema: Signs and symptoms include sudden decreased vision, possible floaters or red hue to vision, and/or blood in the anterior chamber of eye often caused by blunt trauma; ED Care: Elevate the head of the bed to keep blood within the eye pooling inferiorly if c-spine is NOT needed; if c-spine is indicated, place the patient in reverse Trendelenburg; for blunt trauma, patch the eye with an eye shield; anticipate analgesics and tetanus; Note: Prolonged increased intraocular pressure from the hyphema can result in permanent optic nerve damage. ID:c0017-p1280

• Ischemic Optic Neuropathy: Signs and symptoms include painless vision loss in one or both eyes, onset may be sudden or over days, headache, and/or muscle aches; ED Care: Type dependent involves controlling risk factors (blood pressure, diabetes) in arteritic cases or corticosteroids in nonarteritic cases; Note: In some situations, rapid treatment protects the unaffected eye. ID:c0017-p1285

• Open/Ruptured Globe: Signs and symptoms include teardrop-appearing pupil deviating toward the side of injury, sudden loss of vision, eye pain, blurry vision, and/or possibly visible vitreous humor; ED Care: Patch the unaffected eye to limit consensual eye movement; anticipate analgesics and tetanus; Note: High-speed projectiles can also cause open/ruptured globe. DO NOT instill any substance or medication into the eye if you suspect an open/ruptured globe. ID:c0017-p1290

• Orbital Cellulitis: Signs and symptoms include vision changes, ocular movement impaired and painful, eyelid pain, swelling around the eye and to the lid, proptosis, fever, and/or malaise; ED Care: Anticipate antibiotics, antipyretics, and analgesics; Note: Think potential for meningitis! Screen for sepsis. Orbital cellulitis can progress rapidly. Complications may also include optic nerve damage and loss of vision, hearing loss, or a blood clot that develops at the base of the brain known as cavernous sinus thrombosis. ID:c0017-p1295

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208 PART III High-Risk Presentations by Body System

• Orbital Fracture: Signs and symptoms include pain, decreased extraocular movements if muscle entrapment, crepitus, periorbital edema, ecchymosis, and/or deformity; ED Care: Ice pack; x-ray; anticipate antibiotics and tetanus; Note: Frequently monitor for entrapped extraocular muscles. ID:c0017-p1300

• Penetrating Object to Eye(s): Signs and symptoms include a change in vision and appearance to the eye (blood present, irregular pupil shape) and/or fluid leaking from the eye; ED Care: Stabilize any impaled objects in place and do not remove; cover both eyes to avoid consensual movement; anticipate analgesics and tetanus; Note: Eyedrops are contraindicated in globe penetration. ID:c0017-p1305

• Retinal Detachment: Signs and symptoms include the appearance of “floaters” (dark spots) or squiggly lines in the visual field, flashes of light in one or both eyes, and/or a dark shadow or “curtain” in the field of vision; ED Care: Bed rest and give nothing by mouth; if associated with eye trauma, protect the globe with an eye shield and anticipate the possibility of a surgical repair; Note: Delayed recognition and treatment can lead to an increased detachment resulting in permanent vision loss. • Retrobulbar Hematoma: Signs and symptoms include pain, pressure, blurred vision or loss of vision, decreased visual acuity, nausea, vomiting, severe headache, periorbital ecchymosis, and/or eyelids tense/edematous; ED Care: Visual acuity, ophthalmic exam including intraocular pressures; anticipate analgesics and antiemetics, possibly steroids or beta-blockers; CT scan, ophthalmology consult (definitive treatment is a lateral orbital canthotomy or cantholysis to decompress the orbit) and an Ear/Nose/Throat consult for an orbital fracture; Note: Retrobulbar hematoma most commonly occurs with trauma. Orbital compartment syndrome can lead to complete vision loss if not treated promptly; the treatment goal is 60 years old • Bleeding, uncontrolled or patient on an anticoagulant • Capillary refill >2 seconds or pulseless extremity • Color and/or temperature change to extremity • Crush injury • Degloving injury

• High-pressure injury (e.g., paint gun) • History inconsistent with injury, or high velocity trauma/impact • Joint deformity with severe pain • Loss of bowel or bladder function • Neurovascular compromise • Open fracture • Pain out of proportion to the injury • Paralysis • Penetrating injury (significant force)

TRIAGE CONSIDERATIONS Worst-case scenarios: The following should be considered as a potential for high acuity: Spinal cord injury (SCI) leading to paralysis or weakness, cauda equina syndrome, compartment syndrome, and crush injury

Spinal Cord Considerations

• Always consider an SCI with neck and back pain. If traumatic, place the patient in spinal motion restriction. • Loss or altered sensation to extremities may indicate trauma (think spinal involvement and refer to Chapter 27). • A chronic condition does not mean the patient is not ill or injured. Avoid judgment regarding chronic issues. CHAPTER 19 Musculoskeletal Emergencies

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Amputation/Limb Deformity Considerations

• An amputation can be a distracting injury; consider other injuries if there was a blast or high impact/pressure mechanism. • Visualize the joint above and below the area of injury and compare it to the uninjured side. • If neurovascular compromise or severe pain, act fast! • Consider compartment syndrome with a crush injury. • Consider rhabdomyolysis with a crush injury, overexertion (e.g., exercise), trauma, and so forth. • Consider deep vein thrombosis or arterial occlusion with pulselessness or discoloration. • Think of the possibility of compartment syndrome in patients with trauma to the extremity and pain out of proportion to their injury. A patient with both a radial and ulnar fracture that presents days after the injury is at high-risk for compartment syndrome with irreversible damage occurring within 4 to 6 hours after onset.

Wound and Treatment Considerations • • • • • •

Think increased risk of infection if open wounds are present. An obvious or suspected open fracture is a high-risk for infection. Cover an open fracture with a moist sterile dressing (e.g., normal saline, sterile water). Ice, elevate, and immobilize in the position of comfort, unless compartment syndrome is suspected. Give nothing by mouth if anticipating the need for conscious sedation or surgical intervention. Provide comfort measures, including distraction.

KEY TIPS • Complete the following when triaging all patients but be cognizant of when this is completed during the triage process: Treatment prior to arrival, provokes/palliates, quality, region/radiation, severity/associated symptoms timing/temporal relations (PQRST), past medical history, drug and alcohol use, medications, allergies, immunization status, a full set of vital signs, O2 saturation, provide supplemental O2 if needed, and a capillary blood glucose if indicated. • Do not be distracted by visual disturbances (e.g., open fractures, gross bleeding). Investigate further. • Think about the potential for other injuries. Do not assume a minor complaint is all that is present. • Consider the mechanism of injury and the possibility of maltreatment of children or/older adults or intimate partner violence. Is the story consistent with the injuries? Assess bruising in different stages of healing. Be mindful of defensive wounds and suspicious locations of bruising. Report as required by the law. Ensure the safety of the patient. • Think about the potential for neurologic, cardiac, abdominal/chest, behavioral health, trauma involvement, and vasculature compromise. • With back pain, think about the possibility of cardiac involvement, acute coronary syndrome (ACS), or aortic dissection. • Consider bleeding with a pressure dressing as a high-risk for complications. • For amputations, time is critical for successful reattachment; an amputation is considered a potential threat to life or limb. Amputated parts should never be placed directly onto ice. • Think about a possible arterial bleed, as this causes faster blood loss and deterioration. • Oil-based paint can cause ischemia followed by possible amputation. Emergency debridement and intervention are required. Common substances injected into the hand include paint, hydraulic fluid, and grease. CHAPTER 19 Musculoskeletal Emergencies

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• • • •

An amputation after a high-pressure injection has been reported in 30% to 40% of cases (Hadeed et al., 2021). Patients with crush injuries of the limb are at high-risk for an ischemic limb if not treated promptly. Stabilize the joint above and below the injury when splinting. When applying any compression wrap, splint, or traction device, check extremity for color, warmth, sensation, and pulses before and after applying the device. • Damage to the epiphysis (growth plate) can result in impaired limb growth. • Anticipate orders that may include: Labs: CBC, coagulation panel (if indicated), blood cultures prior to antibiotics; Diagnostics: CT scan, computed tomography angiography (CTA) scan, ultrasound, x-ray, Doppler; Medications: Analgesics, antibiotics, tetanus injection as per policy; Other: Physician consults (e.g., orthopedic, vascular, and/or trauma surgeons).

AMPUTATION (PARTIAL OR COMPLETE) Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• • • • •

What was amputated? How did it occur (mechanism of injury)? Location of the amputated part (currently with the patient or elsewhere)? Length of time the part has been amputated (obtain time of the incident)? Other injuries (do not focus solely on the amputated part)? Last meal?

ASSESSMENT Baseline objective assessment

• A-B-C-D-E; intervene immediately for any serious concerns • Examine for partial or total amputation • Signs of uncontrolled bleeding; if tourniquet or pressure dressing is in place prior to arrival, inquire about “how long” applied, and assess for perfusion of the extremity • Assess for hemodynamic instability (e.g., tachycardia, hypotension, cool, pale skin, altered mental status)

INTERVENTIONS General interventions

• Consider C-A-B-C if there is excessive hemorrhage • Apply direct pressure followed by a pressure dressing if bleeding profusely; utilize a tourniquet as a last resort; if a tourniquet is used, write the time and location it was applied in a visible location (e.g., patient forehead) • Never place an amputated part directly onto ice or in ice water; rinse off debris and place the amputated part in a moistened sterile gauze, place into a container, then immerse the container directly on ice or in ice water; be sure to label the container with the patient name and date of birth. • Remove jewelry and restrictive clothing from the affected extremity • Splint above and below the joint for stabilization and assess for neurovascular status following the splint application • Give nothing by mouth until the need for surgical intervention is ruled out • Monitor blood loss and anticipate lab work (e.g., CBC, if surgery is required) • Anticipate an x-ray, analgesics, antibiotics, and possibly tetanus prophylaxis

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BACK PAIN Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• • • • • •

Acute onset (higher level of concern) versus chronic (lower level of concern)? Pain radiates to the chest, jaw, neck, and/or arm? Neurological deficits to extremities? Loss of bowel or bladder control? Pain radiating to or numbness to the rectal/pelvic/groin area? Pain rapidly increasing in severity? Associated with numbness, weakness, and/or altered sensations? • Recent fever? How high? For how many days? Prior treatment (e.g., antipyretic given)? • Weakness to legs worsening with time?

ASSESSMENT Baseline objective assessment

• A-B-C-D-E; intervene immediately for any serious concerns • Assess the motor and neurovascular function of the upper and lower extremities

INTERVENTIONS General interventions

• Consider a STAT EKG for high-risk patients with back pain (e.g., female, elderly, diabetics, substance abusers); blood pressure in both arms for cardiac concerns • Monitor and document the extent of neurologic deficit in the context of back pain • X-ray, CT, or MRI may be indicated • Anticipate the need for analgesics

BLEEDING, UNCONTROLLED Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver ASSESSMENT Baseline objective assessment

• What occurred? • Mechanism of injury (consider trauma criteria and refer to Chapter 27, Trauma Emergencies, if indicated)? • Taking blood thinners? Do you have a history of a blood disorder? • Duration of bleeding? • Attempt to harm self? • When did you last eat/drink (in case surgical/vascular consultation is needed)? Last meal? • A-B-C-D-E; intervene immediately for any serious concerns • Visualize the area where the patient reports bleeding • Pulsatile bleeding (think arterial bleed); if a tourniquet or pressure dressing is in place prior to arrival, inquire about “how long” ago it was applied • Assess for perfusion of the extremity • Palpate pulse(s): Pulses weak or absent • Assess for hemodynamic instability (e.g., tachycardia, hypotension, cool, pale skin, altered mental status) (continued)

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BLEEDING, UNCONTROLLED (continued) ID:c0019-ti0050

INTERVENTIONS General interventions

• If the bleeding is from an extremity, elevate above the level of the heart • Apply direct pressure followed by a pressure dressing if bleeding profusely; utilize a tourniquet as a last resort; if a tourniquet is used, write the time and location it was applied in a visible location (e.g., patient forehead) • Remove jewelry and restrictive clothing from the affected extremity • Rest, ice, compression, elevation (RICE) if an extremity is involved • Evaluate the need for prophylactic tetanus • Give nothing by mouth until the need for surgical intervention is ruled out • Anticipate the need for analgesics and follow-up blood work (CBC, chemistry and coagulopathy panel, type and screen)

CRUSH INJURY TO EXTREMITY Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver ASSESSMENT Baseline objective assessment

INTERVENTIONS General interventions

• What occurred? • Mechanism of injury (consider trauma criteria and refer to Chapter 27, Trauma Emergencies, if indicated)? • Neurovascular compromise to extremity? • Duration of time extremity was crushed? What was the extremity crushed by? • When was your last meal (surgical consult for emergent fasciotomy)? • A-B-C-D-E; intervene immediately for any serious concerns • Palpate distal pulse of the affected extremity: Pulse weak or absent (consider the use of a Doppler) • Assess the extent of motor abilities (e.g., wiggle fingers/toes, joint involvement?) • Evaluate the 6 Ps (pain, pulseless, pallor, paresthesia, paralysis, poikilothermia) • • • •

Remove jewelry and restrictive clothing from the affected extremity Give nothing by mouth until the need for surgical intervention is ruled out Evaluate the need for prophylactic tetanus Ice and analgesics per policy; splint above and below the joint for stabilization

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DISLOCATION/FRACTURE, SUSPECTED Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• • • •

Mechanism of injury? When did this occur? Does the patient have repetitive dislocation of this joint (assess recurrence)? Last meal?

ASSESSMENT Baseline objective assessment

• • • • • • • •

A-B-C-D-E; intervene immediately for any serious concerns Visualize the area of injury Palpate pulse of the affected extremity: Pulse weak or absent Obvious deformity or dangling extremity Neurologic deficits in the affected extremity Severe pain Presence of open wound(s) or bone protrusion 6 Ps (pain, pulseless, pallor, paresthesia, paralysis, poikilothermia)

INTERVENTIONS General interventions

• Remove jewelry and restrictive clothing from the affected extremity • Give nothing by mouth until the need for conscious sedation or surgical intervention is ruled out • Stabilize joint in a position of comfort above and below joint (assess neurovascular status post application) • Advocate for analgesics as needed • Rest and cool compress • Evaluate the need for tetanus

HIGH-PRESSURE INJURY Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• • • • • •

Location of injury (e.g., upper or lower extremity)? Time of the injury? How did the injury occur? Tools or machines involved? Chemical in the injector (e.g., paint, grease)? Pressure magnitude of the injection tool if available? How close to the blast was the patient (consider trauma criteria and refer to Chapter 27, Trauma Emergencies, if indicated)? • Number of wounds present? • Last meal? (continued) CHAPTER 19 Musculoskeletal Emergencies

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HIGH-PRESSURE INJURY (continued) ID:c0019-ti0080

ASSESSMENT Baseline objective assessment

INTERVENTIONS General interventions

• A-B-C-D-E; intervene immediately for any serious concerns • Visualize area of injury; check pulse of affected extremity • Evaluate the forearm, elbow, upper arm, and axilla to assess the proximal extent of the injury (Hadeed et al., 2021) • Pain out of proportion to injury (think compartment syndrome) • High risk for infection, swelling, tissue injury (reference compartment syndrome protocols) • 6 Ps (pain, pallor, paresthesia, paralysis, pulselessness, poikilothermia) • • • • •

Anticipate immediate surgical intervention (fasciotomy) to preserve nerves Remove jewelry and restrictive clothing from the affected extremity Give nothing by mouth until the need for surgical intervention is ruled out Elevate extremity; avoid ice or compression dressings Anticipate the need for labs (e.g., CBC, chemistry panel), analgesics, antibiotic(s), and x-rays per protocol • Evaluate the need for prophylactic tetanus

LOSS OF FUNCTION/SENSATION/TEMPERATURE REGULATION TO EXTREMITY Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• When was the last time seen/felt normal (if no obvious injury, think possible stroke)? • Is there a difference in limb temperature? Movement? Appearance? Pulse? Referred pain (e.g., lower back pain could indicate vascular occlusion at the bifurcation causing lower limb function loss)? • Last meal?

ASSESSMENT Baseline objective assessment

• A-B-C-D-E; intervene immediately for any serious concerns • Visualize the extremity of concern • Perform a quick neurologic assessment to evaluate for stroke (FAST—facial droop, arm weakness, speech difficulties, time); refer to Chapter 11, Neurologic Emergencies if indicated • If injury, palpate pulses distal to the injury; pulses weak or absent, assess circulation, movement, and sensation of extremity • Compare extremity of concern to opposite extremity • Extent of sensation loss; how far up or down the extremity is their loss of sensation • 6 Ps (pain, pulseless, pallor, paresthesia, paralysis, poikilothermia)

INTERVENTIONS General interventions

• Remove jewelry and restrictive clothing from the affected extremity • Give nothing by mouth until the need for surgical intervention or concern for a stroke is ruled out CHAPTER 19 Musculoskeletal Emergencies

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NECK PAIN/INJURY Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• Mechanism of injury (consider trauma criteria and refer to Chapter 27, Trauma Emergencies, if indicated)? • Loss of consciousness? • Weakness, numbness/tingling to extremities? • Muscle spasms? • Last meal?

ASSESSMENT Baseline objective assessment

• A-B-C-D-E; intervene immediately for any serious concerns • Cervical tenderness with palpation (be aware of breathing compromise postcervical injury • Assess for neurologic deficits • Frequent neurologic assessments per policy

INTERVENTIONS General interventions

• Initiate c-spine immobilization if indicated by trauma mechanism and/or complaints • Give nothing by mouth until the need for surgical intervention is ruled out

PAIN, SEVERE WITH DEFORMITY, NUMBNESS, ABNORMAL MOVEMENT, AND/OR COLOR Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• • • •

Mechanism of injury? Loss of consciousness? Duration? Sudden or gradual onset? Neck or back pain, weakness, numbness/tingling to extremities? Last meal?

ASSESSMENT Baseline objective assessment

• • • • • •

A-B-C-D-E; intervene immediately for any serious concerns Utilize critical thinking as to when to initiate c-spine immobilization Visualize area(s) of concern and assess for neurologic deficits Compare extremity of concern to opposite extremity Extent of sensory loss; how far up or down extremity has change in sensation 6 Ps (pain, pulseless, pallor, paresthesia, paralysis, poikilothermia)

INTERVENTIONS General interventions

• Give nothing by mouth until the need for surgical intervention is ruled out

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WORST-CASE SCENARIOS • Spinal Cord Injury: Signs and symptoms include extreme back pain or neck pressure, weakness, paralysis to any body part, numbness, tingling or loss of sensation, loss of bladder/bowel control, and potentially respiratory complications; ED Care: Spinal immobilization, maintain A-B-C-D, possible surgical intervention; CBC, electrolytes, coagulation panel, type and screen/crossmatch, urinalysis, pregnancy test if indicated; CT scan (head, spine) or MRI, spinal x-rays; Note: Quick medical treatment is critical to minimize poor outcome. • Cauda Equina Syndrome: Signs and symptoms include lower back pain, decreased perineal sensation, altered bladder function, bowel incontinence due to loss of anal tone, and/or sexual dysfunction; ED Care: MRI, CT scan, myelogram, emergent surgical intervention may be required; Note: Surgery should be performed within 48 hours of sudden onset of symptoms otherwise there can be an increased risk of permanent dysfunction (Long et al., 2020). • Compartment Syndrome: Signs and symptoms include deep throbbing pain out of proportion to the original injury, not relieved with narcotics; evaluate the 6 Ps (pain, pulseless, pallor, paresthesia, paralysis, poikilothermia) of the extremity; ED Care: Compartmental fasciotomy; Note: Irreversible tissue damage can occur in 4 to 6 hours.

Part IV: Special Issues in Emergency Care

20

I N F E C T I O U S A N D C O M M U N I CA B L E DISEASE EMERGENCIES

Andrea Perry (See also Chapter 4, Pediatric Considerations; Chapter 5, Older Adult Considerations; Chapter 9, Respiratory Emergencies; Chapter 11, Neurologic Emergencies; Chapter 12, Abdominal Emergencies; and Chapter 23, Bite and Sting Emergencies)

CHIEF COMPLAINTS • Fever • Rash with fever  

• Rash, rapidly progressing

RED FLAGS • • • •

Change in baseline mentation Cough with fever Drooling, stridor, or throat swelling (new onset) Edema to the face or tongue

• • • •

Petechiae/purpura with or without fever Rash, rapidly progressing Rash with fever, stiff neck, and/or severe headache Sepsis criteria met 241

242 PART IV Special Issues in Emergency Care

TRIAGE CONSIDERATIONS Worst-case scenarios: The following should be considered as a potential for high acuity: COVID-19, diphtheria, hemorrhagic fever, measles, meningitis, pertussis, and tuberculosis • Your responsibility is to rapidly identify and isolate those with contagious, transmittable, and/or life-threatening diseases and prevent secondary exposure to patients, visitors, and staff. Consider who else may have been exposed, requiring isolation and assessment! • Many common complaints can be related to infectious processes, including, but not limited to, changes in mentation, fatigue/malaise, headache, nausea, vomiting, diarrhea, and/or sore throat. Always consider infection as a possibility. • Always inquire about recent travel out of the region or country and assess vaccination status. • Notify necessary hospital personnel and clinical charge nurse of a patient with a potentially infectious disease. • Screen for sepsis and act accordingly (see Chapter 3, Screening Tools and Checklists, for criteria). • Shingles are frequently seen and not usually a reason for alarm. Remember there is a localized zoster and a disseminated zoster; while localized zosters only require standard precautions, disseminated zosters (where the rash is present in more than one location) require airborne and contact precautions. • For pediatric infectious respiratory emergencies, refer to Chapter 4, Pediatric Considerations.

KEY TIPS • Complete the following when triaging all patients but be cognizant of when this is completed during the triage process: Treatment prior to arrival, provokes/palliates, quality, region/radiation, severity/associated symptoms timing/temporal relations (PQRST), past medical history, drug and alcohol use, medications, allergies, immunization status, a full set of vital signs, O2 saturation, provide supplemental O2 if needed, and a capillary blood glucose if indicated. • Always refer to the Centers for Disease Control and Prevention (CDC) guidelines or appropriate agency for treatment guideline updates. • For patients with a suspected contagious condition, maintain a list of staff who came in contact with that patient in the event staff require prophylactic or acute treatment for the condition. • Anticipate orders that may include: Labs: CBC, chemistry panel, COVID-19, flu, respiratory syncytial virus (RSV) in pediatrics, hepatitis, HIV, Clostridioides difficile (C. diff), methicillin-resistant Staphylococcus aureus (MRSA), blood/ sputum/stool cultures, urinalysis, sexually transmitted infection (STI) panel; Diagnostics: Chest x-ray to rule out tuberculosis, a lumbar puncture to rule out meningitis; Medications: Antibiotics, antivirals, and/or analgesics.

CHAPTER 20 Infectious and Communicable Disease Emergencies

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244 PART IV Special Issues in Emergency Care

FEVER Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

ASSESSMENT Baseline objective assessment

• Recent fever? How high? For how many days? Prior treatment (e.g., antipyretics given)? • Productive cough? Color? • Experiencing night sweats? Recent weight loss? • Immunosuppressed? • Compromised living conditions with close contact with others (e.g., homeless shelter)? • What’s the vaccination status? • Recent exposure to a sick person? • Positive tuberculosis skin test in the past? • Has the fever responded to antipyretics (if given)? • Fatigue? • • • •

A-B-C-D-E; intervene immediately for any serious concerns Screen for sepsis; if criteria met, act! Diaphoretic, cool, or clammy Full set of vital signs and O2 saturation per policy/protocols

INTERVENTIONS General interventions

• Isolate the patient; place a surgical mask until rooming can occur • Place a mask on anyone in close contact with a suspected infectious patient; keep precautions in place until deemed noninfectious • Provide tissues and educate the patient to cover nose/mouth when sneezing/coughing • Educate the patient on hand hygiene

RASH, RAPIDLY PROGRESSING Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• Duration of rash? How rapidly is the rash progressing? • Recent fever? How high? For how many days? Prior treatment (e.g., antipyretics given)? • Shortness of breath or chest pain or tightness? • Severe swelling to lips/tongue/face/eyes? • Any flu-like symptoms? • Viral/bacterial diseases? (continued )

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RASH, RAPIDLY PROGRESSING (continued ) ASSESSMENT Baseline objective assessment

INTERVENTIONS General interventions

• A-B-C-D-E; intervene immediately for any serious concerns • Assess the rash (macules, papules, vesicles, sloughing of skin/peeling off in sheets, etc.) • Presence of rash (petechiae/purpura) • Presence of subcutaneous air • Screen for sepsis; if criteria met, act! • Initiate isolation precautions per CDC guidelines; see Table 20.1: Isolation Precaution Guidelines for additional information

RASH WITH FEVER Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• How long has the rash been present? How fast is it progressing? • Recent fever? How high? For how many days? Prior treatment (e.g., antipyretics given)? • What started first, the rash or the fever? • Shortness of breath or chest pain/chest tightness? • Severe swelling to lips/tongue/face/eyes? • What's the vaccination status? • Progression pattern of rash (e.g., began on the head and moving down body)? • Photophobia? • Recent travel (both in and out of the country)? • Bitten by a tick? • Been in any wooded areas? • Menstruating? Tampon use? • Recent blood transfusion or surgery? • Immunocompromised (e.g., cancer history)? (continued )

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RASH WITH FEVER (continued ) ASSESSMENT Baseline objective assessment

• A-B-C-D-E; intervene immediately for any serious concerns • Screen for sepsis; if criteria met, act! • Signs of dehydration (e.g., tachycardia, hypotension, dry mucous membranes, decreased urinary output, altered mental status) • Presence and appearance of the rash (e.g., petechiae, purpura, bullseye) • Assess if the patient is able to place chin to chest (nuchal rigidity)

INTERVENTIONS General interventions

• EKG per facility protocol • Initiate droplet precautions if meningitis is suspected and place the patient in a private room • Initiate isolation precautions as indicated • Place patient in a private room

WORST-CASE SCENARIOS • COVID-19: Signs and symptoms include fever/chills, cough, shortness of breath/difficulty breathing, fatigue, muscle/body aches, headache, loss of taste or smell, sore throat, congestion/runny nose, nausea, vomiting, and/ or diarrhea; symptoms often more severe in unvaccinated patients and/or patients with underlying comorbidities; ED Care: Constantly evolving; mild cases may require no treatment, supportive treatment, or monoclonal

antibodies; severe cases may require supplemental oxygen, noninvasive ventilation, or intubation, extracorporeal membrane oxygenation (ECMO); antivirals, steroids; Note: The focus is on oxygenation and supportive therapy. • Diphtheria: Signs and symptoms include sore throat, difficulty swallowing or breathing, fever, chills, headache, nausea, malaise, and/or gray membrane covering pharynx/larynx; ED Care: Droplet precautions, maintain airway; CBC, chemistry panel, throat culture, cardiac and liver enzymes; vascular access; chest x-ray; diphtheria antitoxin, erythromycin or penicillin G, antitussives, antipyretics; Note: Diphtheria is highly contagious and can result in widespread organ damage including thrombocytopenia, acute tubular necrosis, and ascending paralysis similar to Guillain-Barre. Obtain a throat culture and treat close contacts. • Hemorrhagic Fever (e.g., Ebola, Lassa, Marburg): Signs and symptoms include high fever, vomiting and diarrhea, shortness of breath, headache, myalgias, and/or hemorrhaging as thrombocytopenia and organ failure progress; ED Care: Personal protective equipment (PPE) that covers all skin and mucous membranes; CBC, chemistry and coagulation panel, arterial blood gas (ABG), blood cultures; vascular access; chest x-ray; IV fluids, electrolytes, analgesics, antipyretics; supportive therapy. • Measles: Signs and symptoms include fever, rash, cough, and Koplik spots; can develop complications such as pneumonia and encephalitis; ED Care: Airborne precautions; viral cultures, IgM antibodies, central venous catheter (CVC), urinalysis; vascular access; chest x-ray; anticipate lumbar puncture if suspect encephalitis; acetaminophen, measles, mumps, rubella (MMR), immune globulin if high risk for severe illness or complication. • Meningitis: Signs and symptoms include sudden onset headache, photophobia, fever, chills, vomiting, altered mental status, seizures, petechial rash, and/or meningeal irritation (Kernig’s sign, Brudzinski sign); ED Care: Droplet precautions; CBC, chemistry and coagulation panel, blood cultures, cerebrospinal fluid (CSF) studies;

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ID:c0020-p0695 ID:c0020-p0908 ID:c0020-p0700 ID:c0020-p0705

250 PART IV Special Issues in Emergency Care

vascular access; CT head and manage increased intracranial pressure; antibiotics, antiemetics, antipyretics, benzodiazepines, diuretics for intracranial pressure (ICP); Note: Meningitis can be bacterial, viral, or fungal. Viral meningitis is usually mild and short-lived, while bacterial meningitis is often severe and life-threatening. If bacterial meningitis is identified, individuals with recent close contact with the patient should be identified and treated. Up to one-third of pediatric survivors are left with some permanent neurologic dysfunction. • Pertussis: Signs and symptoms include the catarrhal stage that lasts up to 2 weeks with conjunctivitis, fever, chills, rhinorrhea/sneezing, fatigue, and/or dry cough; the paroxysmal stage lasts 4 to 6 weeks in children and up to 3 months in adults with a severe cough, apnea, hypoxia, and vomiting following the coughing episode; the convalescent stage lasts 1 to 2 weeks during which the cough gradually decreases; ED Care: Droplet precautions; maintain airway; nasopharyngeal culture, CBC, urinalysis; vascular access; supplemental O2; minimize/prevent crying or excitement (exacerbates cough); antibiotics (e.g., erythromycin), antipyretics, IV fluids; Note: Pertussis is highly contagious and can result in pneumonia, atelectasis, pneumothorax, seizure, and/or encephalitis. Prophylactic treatment of close contacts is recommended. • Tuberculosis: Signs and symptoms include a prolonged productive cough, fever/chills, night sweats, fatigue, weight loss/anorexia, and/or hemoptysis; latent tuberculosis is asymptomatic and nontransmissible; active tuberculosis is when the patient is symptomatic and contagious; ED Care: Airborne precautions; tuberculin skin test, tuberculosis (TB) blood test, liver panel, sputum for acid-fast bacillus (AFB), and culture; chest x-ray; vascular access; isoniazid (INH), rifampin, ethambutol, pyrazinamide; Note: The patient will require special discharge instructions/follow-up care to ensure isolation and continued access to the appropriate drug regimen.

RESOURCES Table 20.1: Isolation Precaution Guidelines DISEASE

POTENTIAL PATHOGEN

PRECAUTIONS

Diarrhea

Escherichia coli, Shigella, hepatitis A, norovirus, rotavirus, C. difficile

Contact

Meningitis

Neisseria meningitides

Droplet for first 24 hours of antibiotics

Enterovirus

Contact

Mycobacterium tuberculosis

Airborne

N. meningitides

Droplet for first 24 hours of antibiotics

Hemorrhagic virus (e.g., Ebola, Lassa fever)

Droplet, contact, full coverage of skin and mucous membranes

Rash, generalized: vesicular

Varicella zoster, herpes simplex, smallpox

Airborne plus contact

Rash, generalized: Maculopapular with cough, coryza, fever

Rubeola (measles)

Airborne

Rash, generalized: petechial/ecchymotic with fever

(continued ) CHAPTER 20 Infectious and Communicable Disease Emergencies

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Table 20.1: Isolation Precaution Guidelines (continued ) DISEASE

POTENTIAL PATHOGEN

PRECAUTIONS

Respiratory infection: cough, fever, headache, GI symptoms, loss of taste and smell, fatigue, body aches, shortness of breath

COVID-19 (multiple variants)

Recommendations vary; transmission rates are greatly reduced with standard, contact, and droplet precautions with eye protection are used, with N95s reserved for aerosol generating procedures; gown, gloves, respirator (e.g., N95, PAPR, face shield) are recommended

Respiratory infection: cough, fever/upper lobe infiltrate

M. tuberculosis, respiratory viruses, Streptococcus pneumoniae, Staphylococcus aureus

Airborne + contact

Respiratory infection: infants/young children

RSV, parainfluenza, adenovirus, influenza

Contact and droplet; droplet can be discontinued when adenovirus and influenza are ruled out

Skin/wound infection

S. aureus

Contact

Centers for Disease Control and Prevention. (2015, November 5). Clinical syndromes or conditions warranting empiric transmissionbased precautions in addition to standard precautions. https://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/transmission -precautions.html.

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H E M ATO LO G I C A N D O N C O LO G I C E M E R G E N C I E S

Deb Jeffries (See also Chapter 4, Pediatric Considerations; Chapter 5, Older Adult Considerations; Chapter 9, Respiratory Emergencies; Chapter 11, Neurologic Emergencies; and Chapter 20, Infectious and Communicable Disease Emergencies)

CHIEF COMPLAINTS • • • •

Bleeding/bruising Difficulty breathing/shortness of breath Dizziness/syncope Fever

• • • •

Headache Infection Pain Weakness

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RED FLAGS • • • • • • • •

Abdominal pain Altered mental status, weakness Bleeding gums Chest pain, hypotension, or tachycardia Decreased or absent urine output Diarrhea, hematochezia Fever greater than 100.4°F Hematuria

• Intractable or severe pain: joints, extremities, abdomen • Petechiae/purpura • Severe pain, perirectal pain • Cool, clammy skin, delayed capillary refill • Tachypnea, wheezing • Vomiting, hematemesis

TRIAGE CONSIDERATIONS Worst-case scenarios: The following should be considered as a potential for high acuity: Acute chest syndrome, disseminated intravascular coagulation, febrile neutropenia, hemophilia (A&B), idiopathic thrombocytopenia, spinal cord compression, superior vena cava syndrome, tumor lysis syndrome, vaso-occlusive crisis, and Von Willebrand disease. • Anticipate immediate interventions for hemorrhage. • Initiate protective isolation for immunocompromised patients; fever is an emergency. • Screen for sepsis. Signs and symptoms of infection may be subtle due to steroids and other medications. • Oncology patients are at high risk for thromboembolic events (chemotherapy, treatments, disease itself). • Implanted ports, other vascular access devices, or drains may be a source of infection.

KEY TIPS • Complete the following when triaging all patients but be cognizant of when this is completed during the triage process: Treatment prior to arrival, provokes/palliates, quality, region/radiation, severity/associated symptoms timing/temporal relations (PQRST), past medical history, drug and alcohol use, medications, allergies, immunization status, a full set of vital signs, O2 saturation, provide supplemental O2 if needed, and a capillary blood glucose if indicated. • Avoid nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin for patients with bleeding/coagulation disorders. • Anticipate orders that may include: Labs: CBC, chemistry and coagulation panel, prothrombin time (PT), partial thromboplastin time (PTT), blood cultures, factor VIII and factor IX assay, phosphorus, urinalysis, urine, throat, wound culture; Diagnostics: Chest x-ray, EKG, CT scan, MRI; Medications: Antibiotics, anti-inflammatories, antipyretics, antineoplastics, analgesics, corticoid steroids, hydroxyurea, dexamethasone, aminocaproic acid, desmopressin, antifibrinolytics, tranexamic acid; Other: Blood and blood products

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DIFFICULTY BREATHING Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• • • • • • •

Chest pain (onset, location, intensity)? Difficulty breathing? Audible wheezing or other abnormal sounds? Fever? Cough? Productive? Nausea or vomiting? How many episodes? Pain in arms or legs? Does the pain worsen when supine? Other symptoms of a vaso-occlusive crisis?

ASSESSMENT Baseline objective assessment

• • • • • •

A-B-C-D-E; intervene immediately for any serious concerns Abnormal upper airway sounds (stridor, gurgling) Work of breathing (retractions, use of accessory muscles, abnormal positioning) Ability to speak full sentences Breath sounds Skin color, warmth

INTERVENTIONS General interventions

• • • •

Obtain vascular access Monitor pulse oximeter Cardiac monitor Consider end tidal CO2 if available

BLEEDING/BRUISING Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• • • • • •

Abnormal bruising? Bleeding from gums? Epistaxis? Blood in urine or stool (bright red or dark red, duration)? Dizziness? Weakness? Headache? Rash that is nonblanching and pinpoint? Is the menstrual cycle longer or heavier than usual? Recent blood transfusions?

ASSESSMENT Baseline objective assessment

• • • • • •

A-B-C-D-E; intervene immediately for any serious concerns Breath sounds Heart sounds, peripheral pulses (quality), mucous membranes (pale), capillary refill Orthostatic vital signs, pulse pressure Pupils Skin (petechiae, purpura, bruising)

INTERVENTIONS General interventions

• NOTE: Specific interventions are dictated by the cause of the coagulopathy • Obtain vascular access; anticipate possible need for ultrasound-guided intravenous (IV) insertion • Anticipate administration of clotting factors or blood and blood products

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DIZZINESS/SYNCOPE Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2-5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver ASSESSMENT Baseline objective assessment INTERVENTIONS General interventions

• • • • •

Loss of consciousness? For how long? Hit head? Altered mental status? Headache (location, onset)? Visual disturbance? Palpitations? Any nausea or vomiting? How many episodes? Any other injuries?

• A-B-C-D-E; intervene immediately for any serious concerns • Glasgow Coma Scale, pupils • Breath sounds, central and peripheral pulses, capillary refill • Obtain vascular access; anticipate IV fluid hydration or administration of blood and blood products as indicated • Cardiac monitor and EKG per facility protocol

FEVER Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

ASSESSMENT Baseline objective assessment

INTERVENTIONS General interventions

• Onset of fever? How high has the fever been? Has it responded to any interventions (medications, cool compresses)? • Last chemotherapy? Last radiation? • Any signs of infection (cough, sore throat, painful urination, sore mouth, gingival pain and swelling, recurrent sinusitis, skin abscesses, radiation site, central vascular access line)? Any open wounds or sores? • Pain anywhere? • Nausea, vomiting, diarrhea? How many episodes? • Dizziness? Weakness? • • • • • •

A-B-C-D-E; intervene immediately for any serious concerns Breath sounds Work of breathing Cough (harsh, hacking, moist) Peripheral pulses, skin color and temperature, skin turgor, mucous membranes Glasgow Coma Scale, pupils, nuchal rigidity

• Initiate protective isolation if indicated • Screen for sepsis; if criteria met, act! CHAPTER 21 Hematologic and Oncologic Emergencies

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HEADACHE Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver ASSESSMENT Baseline objective assessment INTERVENTIONS General interventions

• • • • • •

Onset? Constant or intermittent? Quality (sharp, dull, achy, stabbing, pounding)? Difficulty speaking? Extremity weakness? Difficulty walking? Visual disturbance? Fever? Nausea or vomiting? Precipitating event? Anything make it worse? Better? Neck pain?

• A-B-C-D-E; intervene immediately for any serious concerns • Glasgow Coma Scale, pupils, facial droop • Grip strength, palmar drift, nuchal rigidity • Initiate stroke alert if applicable per facility policy • Consider the need for isolation precautions and/or seizure precautions • Frequent neurologic assessments per facility policy; dim lights in room and limit noise

INFECTION Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver ASSESSMENT Baseline objective assessment INTERVENTIONS General interventions

• Difficulty breathing? Wheezing? • Fever? Any signs of infection? Any open wounds or sores? Source of potential infection? • Pain (location, onset, characteristics)? Headache or neck pain? • Nausea, vomiting, or diarrhea? How many episodes? • Central line port? Last accessed? • A-B-C-D-E; intervene immediately for any serious concerns • Breath and heart sounds, peripheral pulses (quality), capillary refill, skin color and temperature • Glasgow Coma Scale, pupils • Provide supplemental oxygen per facility policy • Consider vascular access • CBC, metabolic panel, coagulation studies, urine, blood and wound cultures as indicated, venous blood gases, lactate, IV fluids, antibiotics, antipyretics, analgesics

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PAIN Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• • • • •

Onset and location? Constant or intermittent? Characteristics (sharp, dull, achy)? Difficulty breathing? Nausea or vomiting? How many episodes? Difficulty walking? New onset? Change in neuropathy? Joint swelling? Fever? Able to eat and drink fluids? Able to sleep?

ASSESSMENT Baseline objective assessment

• • • •

A-B-C-D-E; intervene immediately for any serious concerns Work of breathing (retractions, use of accessory muscles, abnormal positioning) Breath sounds Skin color, warmth, swollen joints

INTERVENTIONS General interventions

• Ice or heat as appropriate to complaint • Dim lights and limit noise as appropriate to complaint • Anticipate nonsteroidal anti-inflammatory drugs (NSAIDs), steroids, opioids

WEAKNESS Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• • • • • • •

Onset and duration? Weakness all over or localized (e.g., one extremity)? Chest pain? Difficulty breathing? Fever? Blood in stool or urine? Nausea, vomiting, diarrhea? How many episodes? Anorexia or loss of appetite? Recent weight loss or gain? Last chemotherapy or radiation treatment (if pertinent)?

ASSESSMENT Baseline objective assessment

• • • •

A-B-C-D-E; intervene immediately for any serious concerns Breath sounds and heart sounds Central and peripheral pulses, skin color and temperature, capillary refill Extremity strength, ability to ambulate

INTERVENTIONS General interventions

• Obtain vascular access • Monitor pulse oximeter, cardiac monitor

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WORST-CASE SCENARIOS • Acute Chest Syndrome (ACS): Signs and symptoms include shortness of breath, chest pain, cough, fever, wheezing, rales, increased work of breathing, hypoxemia, and/or pain to arms or legs; ED Care: Oxygen, IV fluid administration, antibiotics, pain management, blood transfusions; Note: ACS occurs due to pulmonary vasculature vaso-occlusion often from bone marrow or fat emboli. In up to 78% of adults, it is related to vaso-occlusive pain episodes and is the leading cause of death in adults with sickle cell disease (Friend & Girzadas, 2021). Oxygen and IV fluids are critical treatments. • Disseminated Intravascular Coagulation (DIC): Signs and symptoms include abnormal bleeding (e.g., hematuria, hematochezia, bleeding gums), altered mental status, hypotension, oliguria (or anuria), shortness of breath, syncope, tachycardia, tachypnea, weakness, and/or bleeding from the vascular access site, phlebotomy, or injection sites; ED Care: Vascular access; Note: DIC is a process that begins with activation of the clotting cascade and mechanisms causing microthrombosis leading to the consumption of clotting factors, platelets, and fibrinogen leading to bleeding. Identify and treat underlying causes; for example, sepsis and liver disease. Closely monitor for signs of intracranial bleeding and associated neurologic deterioration. • Febrile Neutropenia: Signs and symptoms include a fever (typically without signs of obvious infection) accompanied by a low absolute neutrophil count (ANC); ED Care: Antibiotics and follow sepsis protocols as directed by hospital policy/procedure; Note: Febrile neutropenia is a fever (temperature 101.0°F or greater or 100.4°F for at least 1 hour) accompanied by an absolute neutrophil count of less than 1,500 cells/mcL. This condition is a serious cancer treatment complication and is an oncologic emergency (Punnapuzha et al., 2021). Initiate protective isolation.

• Hemophilia (A&B): Signs and symptoms include altered mental status, excessive bleeding from any site of injury, blood in stool or urine, abnormal vaginal bleeding, epistaxis, painful swollen joints, bleeding gums, and/or bleeding from the vascular access site, phlebotomy, or injection sites; ED Care: Recombinant factor VIII or factor IX, aminocaproic acid, desmopressin, tranexamic acid, fresh frozen plasma, analgesics; Note: Factor replacement therapy must be given prior to invasive procedures (e.g., lumbar puncture). Use the smallest IV catheter gauge possible and hold pressure on the site for at least 15 minutes. Monitor for signs of neurologic deterioration. • Idiopathic Thrombocytopenia: Signs and symptoms include abnormal bruising, altered mental status, blood in stool or urine, abnormal vaginal bleeding, epistaxis, bleeding gums, bleeding from the vascular access site, phlebotomy, or injection sites, hypotension, and/or oliguria (or anuria); ED Care: Corticosteroids, fresh frozen plasma, cyclosporine, IV immunoglobulin, splenectomy; Note: Causes decrease in platelet production or an increase in platelet destruction. Closely monitor for signs of intracranial bleeding and associated neurologic deterioration. • Spinal Cord Compression: Signs and symptoms include back pain, ataxia, difficulty ambulating, paraesthesia or muscle weakness of the extremities, incontinence of bowel and/or bladder; ED Care: Glucocorticosteroids, dexamethasone, pain management, emergent radiation therapy, surgery; Note: A thorough baseline neurologic assessment followed by regular reassessments is critical. Closely monitor ventilatory status, especially for tumors or compression near the cervical spine. • Superior Vena Cava Syndrome: Signs and symptoms include increased work of breathing, stridor, shortness of breath, chest pain, headache, vertigo, swelling of face or lips, venous engorgement of the face, neck, upper extremities, and/or syncope; ED Care: Anticipate airway and ventilatory support, maintain a semi-Fowlers position; Note: Be prepared for airway compromise.

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• Tumor Lysis Syndrome: Signs and symptoms include altered mental status, arrhythmias, anorexia, abdominal or flank pain, bone pain, diarrhea, edema, muscle cramps, tetany, paraesthesia, widened QRS, oliguria and/or anuria; ED Care: IV fluid hydration, allopurinol, calcium chloride or gluconate, sodium bicarbonate, medications to treat electrolyte abnormalities; monitor for cardiac arrhythmias; Note: Massive metabolic abnormalities occur because the breakdown of cancer cells causes the release of cellular contents into the bloodstream. The single most important intervention is IV fluids. • Vaso-occlusive Crisis: Signs and symptoms are dependent on the location of the ischemia and include aching bones, sudden severe abdominal pain, headache, swelling, chest, back, extremity, and/or joint pain; ED Care: Oxygen, IV fluids, analgesic medications, warm packs to painful skeletal areas; Note: Vaso-occlusive events can be precipitated by dehydration, infection, trauma, or stress to name a few examples. Avoid using cold packs on affected joints; may cause increased sickling. • von Willebrand Disease: Signs and symptoms include excessive bleeding from any site of the injury, blood in stool or urine, abnormal vaginal bleeding, epistaxis, bleeding gums, bleeding from IV, phlebotomy, or injection sites, and/or painful swollen joints; ED Care: Desmopressin, factor VIII, aminocaproic acid, tranexamic acid; Note: Avoid NSAIDs and aspirin, may be congenital or acquired from a variety of disease states.

22

TOX I C O LO G Y E M E R G E N C I E S

Andrea Perry (See also Chapter 4, Pediatric Considerations; Chapter 5, Older Adult Considerations; Chapter 11, Neurologic Emergencies; Chapter 20, Infectious and Communicable Disease Emergencies; and Chapter 24, Behavioral Health Emergencies)

CHIEF COMPLAINTS • Ingestion: Central nervous system (CNS) depressants (e.g., narcotics, benzodiazepines, alcohols, antihistamines) • Withdrawal: Alcohol  

• Ingestion: CNS stimulant (e.g., cocaine, methamphetamine, caffeine/energy drinks, pseudoephedrine) • Withdrawal: Narcotics

RED FLAGS • Altered mental status or pupillary changes • Changes in cardiac rhythm (including, but not limited to, tachycardia, bradycardia, arrhythmias, QT changes, and QRS changes) • Cyanosis • Difficulty walking/ataxia

• • • • • •

Hallucinations Hypertension/hypotension Hyperthermia Organophosphate contamination Respiratory depression Seizure 267

268 PART IV Special Issues in Emergency Care

TRIAGE CONSIDERATIONS Worst-case scenarios: The following should be considered as a potential for high acuity: acetaminophen overdose, alcohol withdrawal, cardiac medications (e.g., beta-blockers, calcium channel blockers, digoxin), organophosphate poisoning, and tricyclic antidepressant ingestion. • Your responsibility is to rapidly identify those with airway or respiratory compromise. • Contact Poison Control to assist with the identification of pills or to aid in the anticipated course of signs and symptoms and necessary treatment. • Patients who have ingested large quantities (like a balloon of cocaine) may be asymptomatic but are at high-risk for the balloon rupturing, causing a massive dose of the ingested substance to be absorbed. Rapid intervention to prevent this from happening is a must.

KEY TIPS • Complete the following when triaging all patients but be cognizant of when this is completed during the triage process: Treatment prior to arrival, provokes/palliates, quality, region/radiation, severity/associated symptoms timing/temporal relations (PQRST), past medical history, drug and alcohol use, medications, allergies, immunization status, a full set of vital signs, O2 saturation, provide supplemental O2 if needed, and a capillary blood glucose if indicated. Most poisonings occur in the home in children under 6 years old. • Interventions to stop absorption and facilitate elimination are priorities in all ingestion patients. Depending on the substance, this may require induced emesis, gastric lavage, activated charcoal, binding agents, external decontamination, dialysis, or antidote administration.

• All have a high potential for permanent, irreversible organ damage. • While ingestion is the most common route of exposure, toxins can also be inhaled or absorbed. Decontamination may be required. • Anticipate orders that may include: airway support, Labs: Urine toxicology, liver function tests, salicylate, and acetaminophen levels; Diagnostics: Chest x-ray, EKG; Medications: Antidotes, antiemetics, reversal agents, vasopressors.

INGESTION: CNS DEPRESSANTS (e.g., narcotics, benzodiazepines, alcohols, antihistamines) Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• What was ingested? Are any empty pill bottles or drug paraphernalia nearby (if witnessed or found by another person)? • How much did you take? • When was it taken? • What was it taken with (other drugs, alcohol, medication)? • Recent falls/injuries? Loss of consciousness? Neck or back pain? • Any suicidal ideation? • How did you take it (e.g., swallow, snort, inhale, inject)? • Do you take this regularly? If using alcohol, how much do you drink on a daily/weekly basis (continued ) CHAPTER 22 Toxicology Emergencies

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270 PART IV Special Issues in Emergency Care

ID:c0022-ti0015

INGESTION: CNS DEPRESSANTS (e.g., narcotics, benzodiazepines, alcohols, antihistamines) (continued) ASSESSMENT Baseline objective assessment

• • • • •

A-B-C-D-E; intervene immediately for any serious concerns Assess for airway impairment Assess for respiratory distress and/or depression Assess the level of consciousness Assess for signs of injury (e.g., bruising, lacerations) not reported by the patient

INTERVENTIONS General interventions

• • • •

Ensure patient safety Support airway and respirations as needed Anticipate vomiting; position patient to prevent aspiration Refer to Table 22.1: Toxic Alcohols for specific information related to other forms of alcohol

INGESTION: CNS STIMULANTS (e.g., cocaine, methamphetamine, caffeine/ energy drinks, pseudoephedrine) Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• • • • •

What was ingested? How much was ingested? What time was it taken? What was it taken with (other drugs, alcohol, medication)? How did you take it (swallow, snort, inhale, inject, etc.)?

ASSESSMENT Baseline objective assessment

• • • •

A-B-C-D-E; intervene immediately for any serious concerns Assess the level of consciousness Assess for danger zone vital signs Assess for signs of hypertensive emergency (e.g., headache, altered level of consciousness, chest pain; consider referring to Chapter 10, Cardiac Emergencies, and Chapter 11, Neurologic Emergencies) (continued )

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ID:c0022-ti0020

INGESTION: CNS STIMULANTS (e.g., cocaine, methamphetamine, caffeine/ energy drinks, pseudoephedrine) (continued) INTERVENTIONS General interventions

• Ensure patient and staff safety • Consider the need for decontamination if the patient was in a room where drugs were being made • Charcoal may be given, but anticipate supportive therapy based on symptoms; the patient may require anything from airway support to benzodiazepines to control psychosis and/or seizure activity • Advocate for initiating cardiac monitoring as soon as possible • Anticipate the need for support from social work/discharge planning

WITHDRAWAL: ALCOHOL Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver ASSESSMENT Baseline objective assessment INTERVENTIONS General interventions

• When was your last drink? • Experiencing any nausea/vomiting, headache, tremor, anxiety, agitation, or tactile sensations (such as itching)? • Have you experienced withdrawal and/or seizures before?

• A-B-C-D-E; intervene immediately for any serious concerns • Assess for withdrawal, including nausea/vomiting, tremor, paroxysmal sweats, anxiety, agitation, tactile/auditory/visual disturbances, headache, and/or altered mental status • Consider the need for seizure precautions • Anticipate the need for support from social work/discharge planning

CHAPTER 22 Toxicology Emergencies

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WITHDRAWAL: OPIOIDS Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver ASSESSMENT Baseline objective assessment

INTERVENTIONS General interventions

• • • •

When did you last use opioids? What did you use? Have you experienced withdrawal before? Experiencing any nausea/vomiting/diarrhea?

• A-B-C-D-E; intervene immediately for any serious concerns • Assess for symptoms of withdrawal, including tachycardia, hypertension, diaphoresis, restlessness, nausea/vomiting, diarrhea, and/or tremors • Assess the possibility of pregnancy as the patient may be experiencing complications and/or be at higher risk during withdrawal • Anticipate the need for an antiemetic • Decrease stimulation

WORST-CASE SCENARIOS Many medication and drug ingestions have a similar course of questioning and treatment. Rapid and Comprehensive Triage Assessment for All Medication/Drug Ingestions provides the standard questions, assessment, and interventions for most of these ingestions. More information related to the specific substance can be found in the substance information content that follows.

RAPID AND COMPREHENSIVE TRIAGE ASSESSMENT FOR ALL MEDICATION/DRUG INGESTIONS TRIAGE ASSESSMENT Rapid Triage Assessment

QUESTIONS What did you take? How much did you take? When did you take it? What did you take it with (e.g., alcohol, medications)?

ASSESSMENT

INTERVENTIONS

A-B-C-D-E; intervene immediately for any serious concerns

Initiate continuous observation and ensure patient safety

(continued )

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RAPID AND COMPREHENSIVE TRIAGE ASSESSMENT FOR ALL MEDICATION/DRUG INGESTIONS (continued)

ID:c0022-p0750

TRIAGE ASSESSMENT Comprehensive Triage Assessment

QUESTIONS How did you take it (swallow, snort, inject)? Do you have the bottles? Was this a medication prescribed to you? What did you think you were taking?

ASSESSMENT Full set of vital signs and O2 saturation per policies/protocol; continuous patient observation; may require an evaluation for suicidal intent

INTERVENTIONS Capillary blood glucose as indicated per policy/ protocol and initiate advanced triage protocols per policy

SUBSTANCE INFORMATION DRUG

SIGNS AND SYMPTOMS

INTERVENTIONS

Acetaminophen

Early (24–48 hours): Nausea, emesis, malaise; Later: Metabolic acidosis, right upper quadrant pain, liver injury with elevated liver function tests, jaundice, coagulopathies, sepsis

Labs include liver function tests, CBC, chemistry panel, acetaminophen level; repeat level at 4 hours post ingestion and compare with nomogram; consider charcoal orally, N-acetylcysteine orally or IV

TIPS Look for co-toxicities; acetaminophen is frequently combined with diphenhydramine or narcotics; pediatric ingestions; adult ingestions are usually intentional

(continued )

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SUBSTANCE INFORMATION (continued) ID:c0022-p0860

SIGNS AND SYMPTOMS

INTERVENTIONS

Alcohol

DRUG

Ingestion: See Table 22.1: Toxic Alcohols Withdrawal: Initially tremor, insomnia, anxiety, nausea, vomiting, headache, sympathomimetic symptoms; progresses to worsening symptoms, hallucinations, seizure, and/or delirium tremens

Labs may include liver function tests, blood alcohol, metabolic panel, finger stick glucose; consider medications including IV fluids, glucose, thiamine, benzodiazepines, dexmedetomidine (Precedex)

Initial withdrawal symptoms present 6–8 hours post last drink; following the last drink, alcoholic hallucinosis begin within 24–48 hours, seizures 12–48 hours later, and delirium tremens 2–3 days after initial symptoms

TIPS

Antidiabetic Oral Medications (Including Sulfonylureas, Meglitinides, and Biguanide)

Assess for signs of hypoglycemia including diaphoresis, decreased level of consciousness, and/or seizure

Perform fingerstick frequently; if the patient is awake and able to follow commands, give food or juice as indicated

Biguanide is unique in that it causes severe lactic acidosis, which can cause cardiovascular collapse

SIGNS AND SYMPTOMS

INTERVENTIONS

TIPS

Calcium Channel Blockers or Beta-Blockers

DRUG

Bradycardia, hypotension, weak pulses, dizziness or lightheadedness, and/or possibly an altered level of consciousness

Obtain EKG, fingerstick glucose, anticipate cardiac pacing and medications including charcoal, atropine, glucagon for betablockers, calcium chloride, or gluconate for calcium channel blockers

Calcium channel blockers cause hyperglycemia while beta-blockers cause hypoglycemia; children can be symptomatic with the ingestion of just one tablet

Digoxin

Dilated pupils, photophobia, abdominal tenderness, hypotension, dysrhythmias, and/or altered level of consciousness

Replace electrolytes, anticipate medications for dysrhythmias; digibind to manage toxicity

May result from overdose, hypokalemia, advanced heart disease, or decreased renal elimination (continued )

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SUBSTANCE INFORMATION (continued) ID:c0022-p0860

DRUG

SIGNS AND SYMPTOMS

INTERVENTIONS

TIPS

Iron

See Table 22.2: Stages of Iron Toxicity

If early enough following the ingestion, whole bowel irrigation may be required to prevent absorption; IV crystalloids to correct hypovolemia; anticipate deferoxamine infusion

Patients with gastrointestinal symptoms which resolve after a short time still require observation and supportive care; this may represent the second stage of iron toxicity rather than recovery

Opiates (Prescription or Illicit)

Central nervous system depression, respiratory depression, pinpoint pupils, altered level of consciousness, hypotension, and/or seizures (associated with meperidine, tramadol)

Airway support; anticipate naloxone administration (may require repeat administration)

Synthetic opiates may not show up on drug screens or respond to treatment the same way; monitor and treat the symptoms

INTERVENTIONS

TIPS

Organophosphate Exposure

DRUG

Hypersecretions, altered level of consciousness, hypotension, bradycardia, flaccid paralysis, seizures, and/or coma

SIGNS AND SYMPTOMS

Scene safety first, decontamination, airway support (including suction), anticipate the need for large quantities of atropine

Organophosphates cause cholinergic stimulation; remember the MUDDLES acronym which is Miosis, Urination, Defecation, Diaphoresis, Lacrimation, Excitation, Salivation

Salicylates

Early: Tinnitus, vertigo, nausea, vomiting, diarrhea, and/or tachypnea Subsequent: Altered mental status, fever, noncardiac pulmonary edema, cerebral edema, coma, and/or cardiac arrest (Runde & Nappe, 2022)

Gastric lavage, EKG, salicylate every 6 hours, compared to nomogram, correct acidosis with hyperventilation, sodium bicarbonate

Respiratory symptoms are more pronounced in adults; metabolic symptoms will be more pronounced in children; hypoglycemia may occur from increased metabolic demand

(continued )

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SUBSTANCE INFORMATION (continued) ID:c0022-p0860

DRUG

SIGNS AND SYMPTOMS

INTERVENTIONS

TIPS

Sedatives (e.g., Benzodiazepines, Barbiturates, Antihistamines)

Respiratory and cardiovascular depression and/or altered level of consciousness

Ensure patient safety, support the airway

Flumazenil is a reversal agent for benzodiazepines but is used with caution; it will cause seizures in the chronic benzodiazepine user

Stimulants (e.g., Cocaine, Methamphetamines)

Mood changes (euphoria, agitation, aggression), palpitations, chest pain, dilated pupils, seizures, tactile hallucinations, hyperthermia, and/or diaphoresis

Ensure patient and staff safety, consider benzodiazepines

If the patient has swallowed a large amount of a stimulant (such as a balloon of cocaine), whole bowel irrigation may be required

DRUG Tricyclic antidepressants (TCA) (e.g., Amitriptyline, Nortriptyline)

SIGNS AND SYMPTOMS Central nervous system depression, cardiotoxicity (hypotension, dysrhythmias), and/or metabolic acidosis

INTERVENTIONS Ensure patient safety, support airway and respirations as needed, expedite EKG and cardiac monitoring, and anticipate the need for sodium bicarbonate

TIPS TCA overdoses are usually intentional; they are cardiotoxic, neurotoxic, and anticholinergic with a high-risk of patient death; most patients die before they get to the hospital

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RESOURCES Table 22.1: Toxic Alcohols

Containing Substance Clinical Findings

Interventions

ETHANOL

METHANOL

ISOPROPANOL

ETHYLENE GLYCOL

Beverages

Windshield wiper fluid, paint remover

Rubbing alcohol, nail polish remover

Antifreeze, polishes, coolants

Nausea/vomiting, decreased level of consciousness, hypoglycemia

Nausea/vomiting, abdominal pain, decreased level of consciousness, metabolic acidosis, renal injury 6–30 hours post ingestion

Fruity breath (acetone), vomiting, hypotension

Ataxia, seizures, decreased level of consciousness, dysrhythmias, metabolic acidosis, renal injury 6–12 hours post ingestion

Lab studies including ethyl alcohol level; protect airway; thiamine and dextrose as needed

Anticipate the need for sodium bicarbonate, IV ethanol or fomepizole, dialysis

Supportive therapy; severe cases may require hemodialysis (rare)

Anticipate the need for sodium bicarbonate, IV ethanol or fomepizole, dialysis

Sources: De Laby, M., & Sturt, P. (2020). Toxicologic emergencies. In V. Sweet & A. Foley (Eds.), Sheehy’s emergency nursing: Principles and practice (6th ed., pp. 345–348). Elsevier; Sivilotti, M. L. A. (2021). Isopropyl alcohol poisoning. UpToDate  Retrieved June 1, 2022. https://www .uptodate.com/contents/isopropyl-alcohol-poisoning; Sivilotti, M. L. A. (2020). Methanol and ethylene glycol poisoning: Pharmacology, clinical manifestations, and diagnosis. UpToDate. https://www.uptodate.com/contents/methanol-and-ethylene-glycol-poisoning-pharmacologyclinical-manifestations-and-diagnosis?search=Methanol%20and%20ethylene%20glycol%20poisoning:%20Pharmacology,%20clinical%20 manifestations,%20and%20diagnosis&source=search_result&selectedTitle=1~46&usage_type=default&display_rank=1

Table 22.2: Stages of Iron Toxicity Stage 1 (0–6 hrs)

Gastrointestinal symptoms include vomiting, hematemesis, explosive diarrhea, abdominal pain; lethargy (may progress to coma); tachypnea, tachycardia, hypotension; metabolic acidosis

Stage 2 (6–48 hrs)

Latent period, the condition improves (may still have tachycardia)

Stage 3 (12–48 hrs)

Shock (hypovolemic, distributive, or cardiogenic); organ dysfunction (coagulopathy, acute kidney injury, respiratory failure); seizures; metabolic acidosis

Stage 4 (2–5 days)

Liver failure, jaundice, coma, vomiting, dehydration; hypoglycemia, and coagulopathy

Stage 5 (2–5 wks)

Abdominal scarring, causing pain, and obstruction

Sources: Liebelt, E. L. (2021). Acute iron poisoning. UpToDate.  Retrieved June 17, 2022 from https://www.uptodate.com/contents/ acute-iron-poisoning?search=iron%20toxicity&source=search_result&selectedTitle=2~146&usage_type=default&display_rank=3#H8; O’Malley, G. F., & O’Malley, R. (2022). Iron poisoning. Merck manual: Professional version. https://www.merckmanuals.com/professional/ injuries-poisoning/poisoning/iron-poisoning#v1119369

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BITE AND STING EMERGENCIES

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Erik Angle (See also Chapter 4, Pediatric Considerations; Chapter 5, Older Adult Considerations; Chapter 9, Respiratory Emergencies; Chapter 10, Cardiac Emergencies; Chapter 11, Neurologic Emergencies; Chapter 12, Abdominal Emergencies; Chapter 18, Dental, Ear, Nose, Throat, and Facial Emergencies; Chapter 20, Infectious and Communicable Disease Emergencies; Chapter 24, Behavioral Health Emergencies; and Chapter 25, Sexual Assault and Intimate Partner Violence) ID:c0023-p0005

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CHIEF COMPLAINTS ID:c0023-ti0010

• Bites: Dog, cat, non-human mammals, and human • Marine animal injuries: Jellyfish, stingrays, venomous fish, and sea urchins ID:c0023-p0015

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• Snake bites: Vipers (e.g., rattlesnakes, copperheads) and Elapids (e.g., coral snakes, cobras) • Spider bites: Black widow and brown recluse • Stings: Bee, hornet/wasp, fire ant, and scorpion ID:c0023-p0025

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RED FLAGS ID:c0023-p0040

• Altered level of consciousness, weakness • Anaphylaxis • Extremity weakness and/or numbness

• Severe muscle pain, cramping, twitching • Tachycardia, hypotension, uncontrolled bleeding • Visual disturbances

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TRIAGE CONSIDERATIONS Worst-case scenarios: The following should be considered as a potential for high acuity: Bites (e.g., cat/dog, human, coral snake, black widow, brown recluse), marine animal injuries, snake bites, spider bites, and stings • Venomous bites/stings to the face, tongue, mouth, and/or neck; think of potential imminent airway compromise. • In snake bites, time is tissue! Earlier antivenom administration can reduce morbidity and mortality. • Recognize a severe systemic reaction (e.g., laryngeal edema, severe bronchospasm, and/or profound hypotension). • Immediate care for affected extremity (e.g., remove jewelry, no blood pressure cuffs, no ID bands). • Do not open a container containing the source (e.g., snake); avoid handling it even if dead. • Determine the last menstrual period/pregnancy status, if applicable. ID:c0023-p0075

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KEY TIPS • Complete the following when triaging all patients but be cognizant of when this is completed during the triage process: Treatment prior to arrival, provokes/palliates, quality, region/radiation, severity/associated symptoms timing/temporal relations (PQRST), past medical history, drug and alcohol use, medications, allergies, immunization status, a full set of vital signs, O2 saturation, provide supplemental O2 if needed, and a capillary blood glucose if indicated. • Be concerned with bleeding, infection, and wound healing complications in the young and old, those with a significant history. • Human bites, even on a hand or knuckle, are very high-risk for infection. • Be alert to patient’s comorbidities, risk of wound infection, and retained foreign bodies. • Anticipate orders that may include: Labs: CBC, chemistry panel; Diagnostics: X-ray, CT, MRI; Medications: Antivenom, analgesics, antibiotics. ID:c0023-p0115

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BITES (e.g., cat, dog, other non- human mammals, and human) ID:c0023-ti0015

Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes ID:c0023-ti0010a

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• • • •

Cause of the bite injury (e.g., dog, cat, bat, rat, human)? How long ago did the bite occur? Fever or chills? Vaccination history of the animal if known?

ASSESSMENT Baseline objective assessment

• • • •

A-B-C-D-E; intervene immediately for any serious concerns Expose and visualize the wound (e.g., bleeding, redness, swelling, discoloration) Determine if color, sensation, and motor function are intact distal to the injury Determine if there is any uncontrolled bleeding

INTERVENTIONS General interventions

• • • • • • • •

Remove jewelry and restrictive clothing from the affected extremity If bleeding, apply pressure with a clean bandage or towel Loosely immobilize or splint injury if an extremity is involved Place in a position of comfort at or above heart level Apply an ice pack for pain management as needed Report the bite according to facility and health department policies and procedures Wound closure (e.g., sutures) may or may not occur; discuss with a medical provider Anticipate the need for tetanus, hepatitis, and/or rabies vaccination(s), wound debridement by the medical provider, and ongoing wound care • EKG per facility protocol • Refer to the Worst-Case Scenarios: Bites category for further information

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MARINE ANIMAL INJURIES (e.g., jelly fish, stingrays, sea urchins, venomous fish) ID:c0023-ti0020

Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes ID:c0023-ti0010b

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver ASSESSMENT Baseline objective assessment INTERVENTIONS General interventions

• • • • • • •

Cause of the sting injury if known (e.g., jellyfish, sea urchins)? How long ago did the sting(s) occur? How many stings? Location (e.g., tropical, semitropical, nontropical water, or fresh vs. salt water)? History of being bitten by marine animals in the past? Shortness of breath or chest tightness? Last menstrual period/pregnancy status (if applicable)? History of allergies related to equine (horse)-based serums if considering antivenom use (e.g., stonefish antivenom)?

• A-B-C-D-E; intervene immediately for any serious concerns • Visualize the bite or sting site • • • •

Act on signs of severe marine stings or traumatic penetrating injury (e.g., stingray) DO NOT immediately pull the spines out; bandage them in place Remove jewelry and restrictive clothing from the affected extremity Anticipate the removal of visible foreign bodies (e.g., jellyfish tentacles, bits of coral, or stingray spines) and prepare for debridement if not in major organ/vessel • Obtain a baseline EKG if >50 years old or with a cardiac history per facility protocol • Hot water immersion 120°F to 130°F (40°C to 45°C) for up to 90 minutes of involved area

INTERVENTIONS General interventions (continued)

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• • • • •

Anticipate the need for cardiac monitoring Initiate early contact with a specialized agency (e.g., Poison Control) Anticipate antivenom, analgesics, tetanus prophylaxis, and antihistamines if indicated Wash and clean injury site(s) but ensure safety with personal protective equipment (PPE) Anticipate potential surgical intervention for deep, penetrating traumatic injuries

SNAKE BITES: VIPERS (e.g., rattlesnakes, cotton mouths, copperheads, etc.) OR ELAPIDS (e.g., coral snakes, cobras, mambas, taipans, etc.)

Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes ID:c0023-ti0010c

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• • • • •

Cause of the bite injury (type of snake)? Concern that the bite was from a venomous species and how long ago did it happen? Ever received antivenom before? Any adverse reaction? Last menstrual period/pregnancy status (if applicable)? Allergies to papain chymopapain, pineapple, papaya, and/or sheep products? (continued )

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SNAKE BITES: VIPERS (e.g., rattlesnakes, cotton mouths, copperheads, etc.) OR ELAPIDS (e.g., coral snakes, cobras, mambas, taipans, etc.) (continued ) ASSESSMENT Baseline objective assessment

INTERVENTIONS General interventions

• A-B-C-D-E; intervene immediately for any serious concerns • Expose, visualize, and palpate the swelling of the wound • Measure the bite area by using a forefinger to palpate downward toward the bite until the leading edge of the swelling is palpated and/or pain occurs; this demarcation should be timed, dated, and documented and be repeated frequently • Determine if color, motor function, and sensation are intact distal to the injury • If you assess a tourniquet in place, DO NOT immediately remove it; wait until antivenom therapy has been initiated • Life-threatening bleeding or risk of airway compromise (especially with bites to the face, mouth, and/or neck), neurologic dysfunction, or cardiovascular collapse • Look for fang marks, blanching around the site, edema, and ecchymosis • Loosely immobilize the injured area, place it in position of comfort at or above heart level • Remove jewelry and restrictive clothing from the affected extremity • Mark the edge of the swelling with a permanent marker (date/time every 15 minutes) • Monitor circumference as size may increase from swelling or compartment syndrome • Anticipate early administration of antivenom and the need to clean the wound site • Obtain a baseline EKG if >50 years old or with a cardiac history per facility protocol • Initiate early contact with experts (e.g., Poison Control, pharmacy, local zoo) • Refer to the Worst-Case Scenarios: Snake Bites category for further information

SPIDER BITES (e.g., black widows and brown recluse) ID:c0023-ti0030

Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes ID:c0023-ti0010d

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver ASSESSMENT Baseline objective assessment

• • • • • • •

Cause of the bite (e.g., black widow, brown recluse, another nonvenomous spider)? How long ago did the bite(s) occur? History of being bitten by a black widow/brown recluse spider in the past? Shortness of breath or chest tightness? Weakness or paralysis? Cramping? Nausea or vomiting? Last menstrual period/pregnancy status (if applicable)?

• A-B-C-D-E; intervene immediately for any serious concerns • Visualize the bite site(s) for redness/discoloration or swelling • Determine if color, motor function, and sensation are intact distal to the injury (continued )

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SPIDER BITES (e.g., black widows and brown recluse) (continued ) ID:c0023-ti0030

INTERVENTIONS General interventions

• • • • • • • • •

Plan and prepare for management of anaphylactic reactions Monitor for systemic and severe venom reactions Remove jewelry and restrictive clothing from the affected extremity Initiate early contact with specialized agencies/experts (e.g., Poison Control, pharmacy, local zoo, physician experts) to consult regarding snake bite management Apply ice packs to the bite site(s) to reduce pain and swelling Wash and clean bite site(s) if time allows Advocate for analgesics, antiemetics, benzodiazepines, and tetanus update as indicated Obtain a baseline EKG if >50 years old or with a cardiac history per facility protocol Refer to the Worst-Case Scenarios: Spider Bites category for further information

STINGS (e.g., bee, hornet, wasp, fire ant, and scorpion) ID:c0023-ti0035

Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes ID:c0023-ti0010e

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver ASSESSMENT Baseline objective assessment

• • • • • •

Cause of the bite (e.g., bee, wasp, hornet, scorpion)? How long ago did the sting(s) occur? How many stings? History of a significant reaction to stings (anaphylaxis)? Shortness of breath or chest tightness? Itching? Last menstrual cycle/pregnancy status (if applicable)?

• A-B-C-D-E; intervene immediately for any serious concerns! • Visualize the sting site(s) and examine if there are stingers or sting sacs present • Swelling at the sting site(s) or flushing of the skin (continued )

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STINGS (e.g., bee, hornet, wasp, fire ant, and scorpion) (continued) ID:c0023-ti0035

INTERVENTIONS General interventions

• • • • • • • • •

Remove stingers by scraping them away if present Plan and prepare for the management of anaphylactic reactions Remove jewelry and restrictive clothing from the affected extremity Monitor for systemic and severe venom reactions, especially in those of extremes of age Apply ice packs to keep the sting sites cool and reduce swelling Wash and clean sting site(s) if time allows Anticipate the need for a tetanus update as necessary Obtain a baseline EKG if >50 years old or with a cardiac history per facility protocol Refer to the Worst-Case Scenarios: Stings category for further information

WORST-CASE SCENARIOS BITES ID:c0023-ti0040

• Cat/Dog: Signs and symptoms include bleeding, redness, swelling, discoloration, pain, fever, and/or chills; ED Care: If bleeding, apply pressure with a clean bandage or towel to stop the bleeding; clean wound and anticipate debridement by the medical provider; wound cultures may be considered if signs of infection; assess the range of motion; may need to provide local anesthetic and thoroughly examine wound with a range of motion evaluated; tetanus prophylaxis and antibiotics if there is concern for an infection; consultation with a specialist may be indicated; Note: Immunocompromised patients are at a higher risk for infections; bites and scratches ID:c0023-ti0045

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from a cat present a high-risk for infection; consider if the bite occurred from an aggressive cat or dog or if the animal exhibits strange behavior, especially if the animal is unvaccinated or may be unvaccinated against rabies. • Human: Signs and symptoms include bleeding, redness, swelling, discoloration, pain, fever, and/or chills; ED Care: For bleeding, apply pressure with a clean bandage or towel; clean the wound and anticipate debridement and wound cultures if signs of infection, may need to provide local anesthetic and thoroughly examine the wound and range of motion; tetanus and antibiotic prophylaxis should occur with significant human bites; primary wound closure may or may not occur; Note: Immunocompromised patients are at higher risk for infections; human bites consist of a wide range of injuries, including intentionally inflicted bites, but also any injury caused by coming in contact with the teeth of another person accidentally. ID:c0023-p1105

MARINE ANIMAL INJURIES

• Jellyfish: Signs and symptoms include painful, linear, red, urticarial lesions which typically develop within minutes to several hours; severe signs and symptoms include nausea/vomiting, diaphoresis, tachycardia, and/ or hypertension; ED Care: To remove jellyfish tentacles, wash the site with warm water and apply white vinegar for at least 30 seconds; after removing tentacles, immerse the involved area in hot water with water temperatures from 110°F to 113°F (40°C to 45°C) for up to 90 minutes; cold compresses can be applied to sting sites for a milder reaction; anticipate analgesics and/or antihistamines; Note: Jellyfish sting when their tentacles contact skin; they do not need to be alive to inject venom. ID:c0023-ti0050

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• Stingrays: Signs and symptoms include pain, edema, and/or penetrating trauma; ED Care: Deep penetrating traumatic injuries into the abdomen or chest due to sting ray barbs should be managed as penetrating trauma (see Chapter 27, Trauma Emergencies); Note: Stingrays have whip-like tails with serrated, barbed spines containing venom sacs; most injuries occur in the extremities. ID:c0023-p1115

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• Sea Urchins: Signs and symptoms include pain, edema, and/or penetrating trauma; ED Care: Immediate removal of the spines; soak the affected area in vinegar to dissolve spines, warm soaks to reduce pain; anticipate applying a mentholated balm for some stings; Note: May have single or multiple puncture wounds from the urchin spines (some urchins have venom glands at the tip of the spines). ID:c0023-p1120

• Venomous Fish: Signs and symptoms include local paresthesia, numbness, and/or edema; ED Care: Consult with an expert if there is concern for retained fish spines; immerse the involved area in hot water; consider antivenom for stonefish injury; Note: These wounds are usually caused when the fish is grasped or stepped on; they are routinely small in size but can be exceedingly painful. ID:c0023-p1125

SNAKE BITES

• Coral Snake: Signs and symptoms include paralysis with minimal local tissue impact; the presentation of signs and symptoms may be delayed; ED Care: Ongoing monitoring is needed, sometimes up to 24 hours due to a delayed presentation of signs and symptoms; obtaining antivenom can be challenging; Note: A brightly colored snake with a lack of early signs and symptoms can be underestimated; remain vigilant and assess for a change in condition. Rattlesnake: Signs and symptoms include redness around puncture site(s), numbness in the face/ limbs, difficulty breathing, blurred vision, nausea, vomiting, salivating, and/or diaphoresis; ED Care: Monitor for at least 8 hours; Note: DO NOT apply an ice pack to bite site for pain management. ID:c0023-ti0055

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SPIDER BITES

• Black Widow: Signs and symptoms include cramping and pain that may begin within the first hour and continue to worsen; severe signs and symptoms include widespread muscular pain in back, groin, abdomen, and/or chest, diaphoresis, gastrointestinal distress, hypertension, bronchospasms, and/or neurologic effects; ED Care: Clean with soap and water, place a cool compress on the bite, elevate extremity if affected; analgesics, muscle relaxant ID:c0023-ti0060

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and/or antivenom (only if severe venom reaction); Note: Signs and symptoms evolve in the first hours; the majority of bite victims fully recover with either no treatment at all or supportive care only. • Brown Recluse: Signs and symptoms include local pain, urticaria, myalgia, bleb formation, and leukocyte infiltration at the bite site; severe signs and symptoms include gastrointestinal distress, necrotic lesions at the bite site, systemic toxicity with coagulopathy, acute renal failure, and/or expanding and worsening necrotic lesions; ED Care: Clean with soap and water, place a cool compress on the bite, elevate extremity if affected; currently there is no antivenom available; Note: Initially the pain may be minor; within a few hours, local tissue destruction can begin and be seen as a blue halo forming around the bite site. Both these spiders live most commonly in the Midwest and Southern United States and prefer dark and secluded areas (e.g., basements, piles of wood, rocks, or leaves). ID:c0023-p1140

STINGS

• Bee/Hornet/Wasp: Signs and symptoms include sharp, burning, localized pain and edema; mild systemic reactions may include diffuse itching, urticaria, swelling distant from the sting site; severe systemic reactions may include laryngeal edema, severe bronchospasms, and/or profound hypotension; ED Care: Bees lose their stingers and if injected in a person should be gently scraped away (avoid picking them out as they may still have poison sacs attached that can be squeezed accidentally injecting more venom); manage ABCs, monitor and treat for signs and symptoms of anaphylaxis (e.g., epinephrine, antihistamines, steroids, IV fluids); Note: Hornets/ wasps do not lose their stingers and each can sting multiple times. ID:c0023-ti0065

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• Fire Ants: Signs and symptoms include an intense pinching or burning pain immediately after the sting then itching or burning that may be mild or intense; ED Care: Remove by scraping them away or brushing them away with a gloved hand; do not wash off with water as that may cause them to latch on with their mandibles ID:c0023-p1150

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increasing pain and making them more difficult to remove; apply cold packs to reduce pain and swelling, hydrocortisone creams and antibiotic ointments as needed; Note: Anaphylaxis with fire ants is uncommon but can be life-threatening. People with severe allergies to fire ant venom typically develop symptoms within a few minutes after being bitten. Most stings heal on their own without treatment. • Scorpion: Signs and symptoms include pain, swelling, and/or slight tenderness (neurotoxic venom typically causes mild signs and symptoms); ED Care: Initiate early contact with specialized agencies (e.g., Poison Control, local zoo) to obtain a consultation with a physician expert/toxicologist in scorpion sting management; apply cold packs to reduce pain and swelling; hydrocortisone creams and antibiotic ointments as needed; monitor for a serious allergic reaction or anaphylaxis; if the sting is from the Centruroides exilicauda or C. sculpturatus (the Bark Scorpion), antivenom may be necessary to relieve severe symptoms; Note: The potentially lethal Bark Scorpion lives in the United States (areas of risk include Arizona, New Mexico, Southwestern California, and far west Texas) but no fatalities have occurred since 1969; stings from most scorpions in North America do not require special medical treatment. ID:c0023-p1155

24

B E H AV I O R A L H E A L T H E M E R G E N C I E S

Anna Sivo Montejano and Lynn Sayre Visser (See also Chapter 4, Pediatric Considerations; Chapter 5, Older Adult Considerations; Chapter 11, Neurologic Emergencies; Chapter 20, Infectious and Communicable Disease Emergencies; and Chapter 22, Toxicology Emergencies)

CHIEF COMPLAINTS • Change in behavior: Anxious, aggressive, violent, bizarre, agitated, manic, depressed, crying (inconsolable) • Suicidal attempt: Overdose

• Suicidal attempt: Wound infliction • Suicidal or homicidal thoughts with or without intent • Visual and auditory hallucinations

RED FLAGS • Abnormal vocal sounds (e.g., stridor, high-pitched sounds, gurgling, snoring) • Altered mental status • Bleeding continuous and/or pulsatile from wound(s) • Hanging attempt • Homicidal ideation or attempt

• • • • • •

Manic behavior (e.g., flight of ideas) Overdose, known or suspected Possession of a weapon Prehospital patient on a mental health hold Psychotic episode Self-care capacity significantly diminished 301

302 PART IV Special Issues in Emergency Care

• Self-harm (e.g., cutting, burning) • Suicidal ideation, attempt, or emotional disturbance with a plan in place or a history of suicide attempt

• Tonic/clonic movement (ongoing or new onset) • Violent/aggressive behavior toward self or others or conveyed by the individual accompanying patient

TRIAGE CONSIDERATIONS Worst-case scenarios: The following should be considered as a potential for high acuity: Agitation, aggression, or violent behavior, alcohol withdrawal delirium, eating disorders (anorexia nervosa, bulimia nervosa, binge eating), homicidal ideation or attempt, mania, panic disorder, psychotic depression, psychotic episode, and suicidal ideation or attempt • Rapidly identify a person with the potential to act out. Maintain safety for yourself and others! Remember that a past attempt at self-harm is the strongest predictor of future risk of suicide. • Never turn your back on a behavioral health patient as you risk your safety. Always have an exit route. Position yourself closest to the door; if unable to exit, try to place furniture between you and the patient. The patient should ambulate in front of you, be accompanied as they move within the facility (e.g., bathroom), and have a sitter assigned to continuously observe the patient for the safety of all. • Do not place a potential suicidal or homicidal patient back into the waiting room. These patients are high acuity requiring continuous observation. If no bed is available, place the patient close to triage. • Avoid wearing anything (e.g., stethoscope) around your neck, remove visible objects (e.g., scissors, pen, badge) that could be used as a weapon, and be aware that loose long hair and ponytails can be dangerous as they can be grabbed. • Ask the patient how they eat, sleep, and care for themselves. Activities of daily living are a good indicator of the current ability to care for oneself. Speak in simple, clear sentences and provide clear directions. • Always consider a medical condition before assuming the issue is a behavioral health presentation.

• Consider a polypharmacy overdose; absorption time of the medication(s) ingested can impact the patient presentation as medications have many different signs and symptoms; refer to Chapter 22, Toxicology Emergencies, and access additional resources (e.g., pharmacists). Poison Control offers guidelines for any toxicology emergency. Recognize that the patient may not be completely truthful with you regarding the ingestion of medication(s). • For a suicidal attempt, consider trauma criteria (see Chapter 27, Trauma Emergencies) and follow facility policies. • For a recent wound injury with a small knife, consider an organ injury; the wound may be from a 7-inch blade. • For a change in behavior, consider the potential for a head injury, infectious process, abuse of one or multiple prescription medications, or an emotional event (e.g., loss of a spouse/child). Always err on the side of caution for the patient.

KEY TIPS • Complete the following when triaging all patients but be cognizant of when this is completed during the triage process: Treatment prior to arrival; provokes/palliates, quality, region/radiation, severity/associated symptoms, timing/temporal (PQRST); past medical history; drug and alcohol use; medications; allergies; immunization status; a full set of vital signs; O2 saturation; provide supplemental O2 if needed; and a capillary blood glucose if indicated. • Be familiar with the screening tool utilized in your practice setting (e.g., Ask Suicide-Screening Questions [ASQ], Manchester Self-Harm, Risk of Suicide Questionnaire [RSQ], Columbia Suicide Severity Scale). • Never judge or condemn a patient for inflicting self-harm; be aware of your nonverbal communication (e.g., crossing arms, tone of voice). • Clear rooms of potentially harmful items (e.g., monitor cables, blood pressure cuff, extra linen). • Consider that substance abuse may include prescription medication(s), not only illicit drugs. CHAPTER 24 Behavioral Health Emergencies

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• See Table 24.1: Signs and Symptoms of Alcohol Withdrawal. Refer to Clinical Institute Withdrawal Assessment of Alcohol (CIWA) Scale or your facility scoring system to objectively assess the severity of the patient’s alcohol withdrawal (https://www.ci2i.research.va.gov/paws/pdfs/ciwa-ar.pdf). • Anticipate orders that may include: Labs: CBC, chemistry panel, thyroid stimulating hormone (TSH), acetaminophen/salicylate/alcohol levels, urine toxicology, urinalysis, and pregnancy test; Diagnostics: EKG for overdoses, otherwise varies by complaint; Medications: Antipsychotics, analgesics.

CHANGE IN BEHAVIOR (e.g., anxious, aggressive, violent, bizarre, agitated, manic, depressed, crying [inconsolable]) Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• • • • • • • • •

Tell me what you are experiencing? Chest pain or shortness of breath? Suicidal/homicidal thoughts, attempt, or plan in place? Recent trauma? Headache? Recent fever? How high? For how many days? Prior treatment (e.g., antipyretic given)? Hearing voices? If “yes,” what are the voices saying? Do the voices tell you to harm yourself or others? Ingestion with intent to overdose? What was ingested? Time? Quantity? What may be causing this change in behavior? Delusional? Change in eating habits? Ability to care for self? Sleeping patterns? Recent change? (continued )

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CHANGE IN BEHAVIOR (e.g., anxious, aggressive, violent, bizarre, agitated, manic, depressed, crying [inconsolable]) (continued) ASSESSMENT Baseline objective assessment

INTERVENTIONS General interventions

• • • • • •

A-B-C-D-E; intervene immediately for any serious concerns Irritable or impulsive, pressured speech, talkative, flight of ideas Unable to sit still, restless, difficulty focusing Withdrawn, lack of eye contact, not answering questions Observe for tachypnea and/or tremors See Table 24.2: Anger Pathway: Signs and Symptoms for violent behavior signs and symptoms to assess • Verbal and nonverbal communication • Continuous observation of the patient • If there is an object involved (e.g., holding scissors), encourage surrender and involve other agencies (e.g., police, security) per policy • If an ingestion is involved, contact Poison Control immediately if available in your state, country, or jurisdiction; delegate as needed • Mental health evaluation • Provide a nonthreatening presence and calm demeanor • Ask simple, straightforward questions; be patient as you wait for a response • Orient the patient to the present as needed and limit environmental stimulation • EKG per facility protocol

SUICIDAL ATTEMPT (e.g., overdose) Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

ASSESSMENT Baseline objective assessment

• • • • •

What did you take? Quantity? Time of ingestion? What time did you take the medication(s), substance(s), and so forth? Were you trying to harm yourself? Did you take the medications with alcohol, drugs, water, or anything else? Have you ever done this before? What was the outcome? Who do these medications belong to? • Tonic/clonic movement(s)? Length of the episode? Full body or localized to one area? Continuous or intermittent? • Visual or auditory hallucinations? • A-B-C-D-E; intervene immediately for any serious concerns • Assess for signs and symptoms of alcohol withdrawal; refer to Table 24.1: Signs and Symptoms of Alcohol Withdrawal • Calculate the number of pills ingested and estimate the total dose (continued )

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SUICIDAL ATTEMPT (e.g., overdose) (continued) ID:c0024-ti0025

INTERVENTIONS General interventions

• • • • • • • •

Continuous observation of the patient Advocate for initiation of seizure precautions if indicated Remove all belongings, substances, or medications from the patient’s possession Contact Poison Control immediately if available in your state, country, or jurisdiction Place patient in a safe area where potentially harmful objects are removed (e.g., cords, cables) Notify crisis management per facility policy and provide emotional support Mental health evaluation EKG per facility protocol (especially with tricyclic overdoses)

SUICIDAL ATTEMPT (e.g., wound infliction) Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver ASSESSMENT Baseline objective assessment INTERVENTIONS General interventions

• What did you do? Were you trying to harm yourself? • Do you hear voices? What are they telling you? • If an object was involved, what was it (e.g., knife, scissors), and what size (width and depth)? How deep did it penetrate (length)? • Have you ever tried to hurt yourself in the past? What was the outcome? • A-B-C-D-E; intervene immediately for any serious concerns • Visualize the wound and assess for bleeding • Continuous observation of the patient, ensuring the safety of the patient, self, and other • Control bleeding if indicated • Mental health evaluation • EKG per facility protocol

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SUICIDAL OR HOMICIDAL THOUGHTS WITH OR WITHOUT INTENT Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver ASSESSMENT Baseline objective assessment INTERVENTIONS General interventions

• Do you have a plan? Do you have the means to carry out the plan? • Do you have anything with you right now that you could use to harm yourself or others? • Refer to the suicide risk assessment tool (see Box 24.1: Warning Signs of a Suicide and Box 24.2: Degree/Severity of a Suicide Risk) • Have you ever experienced this before? What was the outcome? • A-B-C-D-E; intervene immediately for any serious concerns

• Continuous observation of the patient • Involve police, security, and so forth, in surrendering any potentially dangerous objects and in securing your safety; follow facility policy • Place the patient in a safe area where potentially harmful objects such as cables and cords are removed • Mental health evaluation • EKG per facility protocol

VISUAL AND AUDITORY HALLUCINATIONS Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver ASSESSMENT Baseline objective assessment INTERVENTIONS General interventions

• • • •

What are you seeing and/or hearing? Are the voices telling you to harm yourself/others? Did you take medications/drugs that could be causing this behavior? Did you miss a dose of a medication taken routinely?

• A-B-C-D-E; intervene immediately for any serious concerns • As the patient is talking, listen carefully for indications regarding thoughts • Continuous observation, decrease stimuli; if able, place the patient in a quiet room • Approach patient with reality-based intervention; the hallucinations are real to the person but need to stay reality focused • Mental health evaluation • EKG per facility protocol

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WORST-CASE SCENARIOS • Agitation, Aggression, or Violent Behavior: Signs and symptoms include pressured speech, use of foul language, pacing, restlessness, trembling, shaking, repetitive movements, jaw or fists clenched, disrespecting authority, blaming others for mistakes, avoiding eye contact, violent gestures, and/or diaphoresis; ED Care: De-escalation is critical before further escalation puts many in danger; de-escalation techniques include: listen with empathy, provide individualized attention and focus on their feelings, be nonjudgmental, allow time to be silent, avoid crossing arms, and use clarifying statement (Dufresne, 2017); Note: Signs and symptoms could be related to abuse of prescription medication(s), an emotional event from a loss, a medical condition (metabolic), or behavior (psychosis, substance abuse). • Alcohol Withdrawal Delirium (AWD): Signs and symptoms include anxiety, agitation, irritability, headache, confusion, sudden change in mood, delusions, delirium, hallucinations, seizures, involuntary muscle movements (e.g., hand tremors), restlessness, nightmares, chest pain, fatigue, diaphoresis, fever, sensitivity to sound, light, and/or touch; ED Care: Close observation, a quiet room, capillary blood glucose, vascular access, labs (e.g., electrolytes), IV fluids, EKG, medications (e.g., thiamine, electrolyte replacement, anticonvulsants, benzodiazepines, sedative hypnotics); Note: Controlling agitation is the initial goal in patients with AWD (Mayo-Smith et al., 2004). Consider the need for a sitter or restraints. • Eating Disorders (Anorexia Nervosa, Bulimia Nervosa, Binge Eating): Signs and symptoms include dehydration, muscle weakness/spasms/cramps, headache, restlessness, irritability, fatigue, coma, tachycardia, tachypnea, confusion, seizures, and/or arrhythmias; ED Care: Provide a safe and nonjudgmental environment, EKG, vascular access and fluid administration if indicated, cardiac and blood pressure monitoring; capillary blood glucose, CBC, chemistry panels, urinalysis, toxicology screen, arterial blood gas (ABG); electrolyte replacement and antiarrhythmic; mental health evaluation; Note: Although the signs and symptoms for eating disorders vary, the focus should be on

treating electrolyte imbalances. Eating disorders are frequently associated with anxiety, depression, and substance abuse; inquire about eating habits. Assess knuckles for abrasions, callouses, and so forth. • Homicidal Ideation or Attempt: Signs and symptoms include thoughts of killing self or an attempt to kill another person, agitation, violent behavior, brandishing a weapon, verbal threats (e.g., “I’m going to kill you, shoot you, stab you”), increasing anger, aggression, or destructive behaviors accompanied by tachycardia, hypertension, pallor, and/or diaphoresis; ED Care: Suicide risk assessment; provide a calm, safe environment free from objects that may cause harm, continuous direct observation; provide safe activities (e.g., TV); encourage surrender of weapons or harmful objects; involve police or security as necessary and per policy; restraints as necessary and per policy; EKG; labs (e.g., CBC, electrolytes, toxicology screen, alcohol level, drug levels such as lithium, aspirin/acetaminophen levels if indicated; medications (e.g., antipsychotics); mental health evaluation; Note: Risk factors include, but are not limited to, anxiety, depression, hallucinations (e.g., visual or auditory) or delusions, maltreatment (e.g., emotional trauma), self-harm behaviors, recent assault of another child, involvement in gangs, limited parental involvement, or community participation among other things. • Mania: Signs and symptoms include periods of excitement, hyperactivity, and disorganized behavior; grandiose ideas and behavior, impulsive with increased activity, or risky behaviors; mood increased or highly irritable; needs less sleep than normal, lacks realism; rapid, pressured speech, racing thoughts; ED Care: Provide a calm/safe environment and orient to reality; continuous, direct observation; medications (e.g., lithium, anti-epileptics and antipsychotics); Note: May mimic thyroid disorders; drugs (e.g., amphetamines, cocaine) can exacerbate the manic phase; the patient worries their joy will be taken away. • Panic Disorder: Signs and symptoms include sweating, trembling, shortness of breath, chest pain, palpitations, nausea, tingling/numb hands, fear of dying or losing control; ED Care: Provide a calm/safe environment and orient to reality; medications (e.g., selective serotonin reuptake inhibitor [SSRIs], serotonin-norepinephrine CHAPTER 24 Behavioral Health Emergencies

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reuptake inhibitor [SNRIs], benzodiazepines); Note: The risk of suicide is much higher in individuals with panic disorders (Cackovic et al., 2022). • Psychotic Depression: Signs and symptoms include major depression that is accompanied by delusions and agitation and/or hallucinations, irritability or sadness, difficulty caring for self or limited motivation to care for self, lacks energy, slower psychomotor skills, impaired and disorganized thoughts; ED Care: Provide a calm/safe environment and orient to reality; continuous, direct observation; monitor for extrapyramidal symptoms including dystonia, akathisia, dyskinesia, pseudo parkinsonism; labs (e.g., electrolytes, toxicology screen, alcohol level, aspirin/acetaminophen, drug levels such as lithium; medications (e.g., antipsychotic or antidepressant); mental health evaluation; Note: Some depressed patients will not state that they are having psychotic symptoms for several reasons, such as they do not feel it is abnormal or they do not want to be considered ill (Dubovsky et al., 2020). • Psychotic Episode: Signs and symptoms include agitation, hallucinations, delusions, disorganized thought and speech, paranoia, catatonia, withdrawI from others, and poor hygiene; ED Care: Provide a calm/safe environment and orient to reality; continuous, direct observation; medications (e.g., antipsychotics); mental health evaluation; Note: A psychotic episode may result from a mental health condition, physical illness or injury (e.g., stroke, traumatic brain injury), substance use (e.g., marijuana), or a traumatic event (e.g., sexual assault). • Suicidal Ideation or Attempt: Signs and symptoms include thoughts or attempts to harm self with the intention of dying; flat affect, withdrawn behavior, absence of eye contact, agitation, verbal statements (e.g., “I want to kill myself” or “I want to die”), verbal statements reflecting a feeling of worthlessness, self-harming behaviors, headache, chest pain, shortness of breath, erratic sleeping patterns; ED Care: Provide a safe environment; continuous, direct observation; remove any potentially harmful objects or cables from room; encourage surrender of weapons or harmful objects; involve police or security as necessary and per policy; restraints as necessary and per policy; contract with patient for safety for self and others; stabilize medical conditions/treat injuries,

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control bleeding, apply clean, dry dressing as appropriate; IV access; labs (e.g., CBC, electrolytes, toxicology screen, aspirin/acetaminophen, alcohol level, drug levels such as lithium); medications (e.g., antidepressants as indicated); mental health evaluation; Note: Past attempt at self-harm is the strongest predictor of future risk of suicide; assess for suicidal intent, plan, or attempt(s).

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RESOURCES Box 24.1: Warning Signs of Suicide • • • • • • • • • •

Loss of interest in things the person used to care about Irritability and edginess increases Giving things away Visiting or calling people and saying “Goodbye” Methodically making amends, settling quarrels Withdrawal and isolation from friends and family Sudden decline in functioning at school or work Suddenly happier, right after a long, deep depression Change in appearance—hygiene, and so forth Increased risk-taking behavior (e.g., use of drugs, reckless driving) • Talking about feeling hopeless, helpless, or worthless • Hoarding of pills, hiding of weapons

• Talking about suicide and/or what it would be like to die (preoccupied with death) • Self-injury • Threatening suicide INDIRECT STATEMENTS • “What’s the use of going on?” • “My parents would be happier if I’d never been born.” • “I just can’t take it anymore.” DIRECT STATEMENTS • “Sometimes I just feel like killing myself.” • “If I killed myself, then people would be sorry.” • “You won’t have to worry about me much longer.”

Box 24.2: Degree/Severity of Suicide Risk • Does the person have a plan? • If yes, what is the plan, and does the person have access to items necessary for this plan? • How often does the person think about suicide? • How badly does the person wish to end their life? • Has the person felt suicidal in the past or is this the first time?

• Has the person ever attempted suicide before? When? How? • Is the person using drugs or alcohol? Do they have access to these? • Will the person be home alone? • Does the person take medications for mental health concerns—have they been taking them?

Table 24.1: Signs and Symptoms of Alcohol Withdrawal STAGES

EARLY

Signs and Symptoms

• • • • •

Last Drink

6–8 hours

Anxiety Tremors Restlessness Piloerection Mood—labile

SEIZURE

HALLUCINATION

DELIRIUM TREMENS

• Tonic/clonic movement

• Auditory • Visual • Tactile

• • • • •

6–48 hours

12–48 hours

48–96 hours

Increased heart rate Increased blood pressure Diaphoresis Agitation Delirium

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Table 24.2: Anger Pathway: Signs and Symptoms ANGER PATHWAY

SIGNS AND SYMPTOMS

NURSING INTERVENTIONS

Anxiety

Tense, tremors, feeling something bad is about to happen, palpitations, tachycardia, hyperventilation, dry mouth, paresthesia, chest pressure, and/or urinary frequency

• Use active listening • Use a direct, simple approach when answering questions • Encourage and support the patient

Agitation

Tone (e.g., upset), speech (e.g., pressured), may use profanity

• • • • •

Do not react to the anger by giving it validation Actively listen and speak calmly; decrease stimuli Reassure that “we” are here to help Patient’s responses need to be acknowledged Do not criticize the patient or tell them what to do, such as: “You cannot swear here. There are little children present!” • Maintain distance when introducing yourself • Do not cross your arms; keep a nonthreatening position

ANGER PATHWAY Aggression

SIGNS AND SYMPTOMS Pacing, restless, trembling, shaking, repetitive movements, jaw or fists clenched, disrespectful to authority, use of foul language, blaming others for mistakes, avoiding eye contact, violent gestures, and/or diaphoresis

NURSING INTERVENTIONS • Notify security or initiate an overhead alert to increase awareness of the situation • Appear in control and unthreatened • Keep at least a 5 ft distance from the patient to ensure safety • Avoid eye contact • Be aware of your surroundings to ensure an escape route

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S E X UA L A S S AU LT A N D I N T I M AT E PA R T N E R V I O L E N C E

Lynn Sayre Visser and Anna Sivo Montejano (See also Chapter 4, Pediatric Considerations; Chapter 5, Older Adult Considerations; Chapter 11, Neurologic Emergencies; Chapter 12, Abdominal Emergencies; Chapter 15, Gynecologic Emergencies; Chapter 16, Male Reproductive Emergencies; Chapter 17, Ocular Emergencies; Chapter 18, Dental, Ear, Nose, Throat, and Facial Emergencies; Chapter 26, Human Trafficking; and Chapter 27, Trauma Emergencies)

CHIEF COMPLAINTS Sexual assault and intimate partner violence (IPV) is an act perpetrated against a victim. Therefore, there is no specific chief complaint but rather a myriad of findings which may be physical, psychological, social, and behavioral. The patient may present with law enforcement for a physical and forensic exam or may present alone with the complaint of being assaulted. Victims of IPV may present with medical complaints and seek help or refuge from their abuser.

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RED FLAGS

PHYSICAL

ADULT

ADOLESCENT/PEDIATRIC

• Accompanied by a person who appears controlling, speaks for the patient, and/or will not leave the patient’s side • Anal, genital, and oral injuries, or unexplained bleeding • Bite marks, ecchymosis, petechiae • Bruises or abrasions to core areas (neck, torso, breasts, genitalia, inner thighs) or in various stages of healing • Chronic pain or somatic symptoms (headache, abdominal pain) • Delay in seeking medical care, lack of self-care/hygiene • Increase in unexplained health problems • Injuries that do not align with the history or mechanism of injury • Pregnancy (unplanned, unwanted, miscarriage) • Sexually transmitted infections • Weight loss or weight gain

• Accompanied by a person/guardian who appears controlling, speaks for the patient, and/or will not leave the patient’s side • Anal, genital, and oral injuries, or unexplained bleeding • Bite marks, ecchymosis, petechiae • Bruises or abrasions to core areas (neck, torso, breasts, genitalia, inner thighs) or in various stages of healing • Injuries that don’t align with developmental level, history, or mechanism of injury • Lack of clothing, unsuitable for the weather • Lack of prior medical care • Poor self-care, hygiene • Pregnancy (unplanned, unwanted, miscarriage) • Sexually transmitted infections • Somatic symptoms (headache, abdominal pain) • Weight loss or weight gain, malnourished (continued ) CHAPTER 25 Sexual Assault and Intimate Partner Violence

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ADULT

ADOLESCENT/PEDIATRIC

EMOTIONAL

• Anxiety or depression • Fear of specific family members/friends • Panic attacks and/or posttraumatic stress symptoms

• • • •

Anxiety or depression Fear of specific family members/friends Lack of emotion, flat affect Panic attacks and/or posttraumatic stress symptoms

BEHAVIORAL

• • • • • •

• • • • •

Alcohol/substance use Bedwetting, inability to control bowel movements Cyberbullying Defensive, aggressive, withdrawn Difficulty concentrating, sleep difficulty, nightmares Eating disturbances/disorders Poor academic performance, poor school attendance Poor eye contact Regression behavior (e.g., thumb sucking) Suicidal thoughts or self-harm Unfamiliarity with location/area or identification Use of words, phrases, or mannerisms that seem “too adult” for the child’s age

Alcohol/substance use Defensive, aggressive, withdrawn Difficulty concentrating Eating disturbances Poor eye contact Reports of sleep difficulty, nightmare

• • • • • • •

The presence of the preceding indicators does not necessarily indicate sexual assault or intimate partner violence; rather these findings should alert the user to consider the possibility. Additional indicators and risks are covered in the content that follows.

TRIAGE CONSIDERATIONS • Ensure the safety of the patient; notify security as needed • Screen for sexual assault and IPV in a private area with only the patient. • Involve law enforcement and crisis counseling services per protocol for your jurisdiction, state, or federal laws, or per patient request. Anonymous reporting is also an option. • The triage nurse should assure the patient that you believe them and that the assault/violence is not their fault. • Ensure confidentiality and emotional support. Actively listen, use open-ended questions, and speak with plain, simple language. Document what the patient says in their own words. • Advise the patient not to wash up, change clothes, and so forth until the treatment plan can be discussed/performed. • Any evidence a patient brings with them into the facility should be collected and stored per policies (e.g., typically in a paper bag with name, date of birth, date/time, and the receiver’s initials); it is critical to follow the chain of evidence protocols and forensic standards of care. See Box 25.1: Collection of Evidence.

Sexual Assault

• Some patients who have experienced a sexual assault often feel ashamed that they should have prevented the occurrence. As the triage nurse, you want the patient to be able to speak comfortably and honestly; thus you need to show caring and compassion. • Sexual assault is a high-risk presentation and should be assigned a high acuity level or index score. • Adults have the right to choose whether or not to report the assault to law enforcement. If a patient chooses not to report, consider the option for a non-report exam in accordance with local jurisdiction, state, or federal laws. • For questions or assistance related to a sexual assault call the National Sexual Assault Hotline at 800-656-HOPE (4673) or chat online at online.rainn.org • See Box 25.2: Risk Factors for Sexual Assault. CHAPTER 25 Sexual Assault and Intimate Partner Violence

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Intimate Partner Violence

• For concerns regarding intimate partner violence call 1-800-799-SAFE (7233) or access additional information at https://www.thehotline.org/identify-abuse/domestic-abuse-warning-signs/. • Remember with pregnancy, you have two patients; don’t forget about the fetus! • Barriers to screening exist (concern with offending the patient, irritation with the patient’s denial, fear of finding out more issues due to asking more questions). Do not let these barriers stop you from doing what is right (Zink et al., 2004). • The perpetrator may stick close to the patient’s side or answer questions for the patient. Make efforts to question and assess the patient alone. The need for a urine sample or an x-ray is often a good opportunity to separate the patient from the companion for private questioning. • Do not let on to your suspicion of IPV; the perpetrator may leave the department with the patient putting the patient at additional risk. • The risk of IPV in pregnancy is increased. Have a heightened awareness of IPV in this patient population. • Bruises in different stages of healing should always be concerning. • See Box 25.3: Risk Factors for Intimate Partner Violence (IPV).

KEY TIPS • Be aware of mandated reporting requirements (injury, disease, abuse) in accordance with local jurisdiction, state, and federal laws. A complete list of resources by state can be found at https://www.victimrights.org/ resource-library or https://www.cdc.gov/std/treatment-guidelines/clinical-reporting.htm • A thorough assessment for strangulation should be emphasized for this patient population.

• Call for resources available per policy (e.g., sexual assault nurse examiner [SANE], social worker, chaplain, victim’s advocate). • Anticipate orders that may include: Labs: sexually transmitted infection [STI] panel, gonorrhea/chlamydia, HIV, hepatitis panel, urinalysis, pregnancy test, drug screen; Diagnostics: x-rays, CT, ultrasound; Medications: analgesics, antibiotics, antianxiety, antiemetics, emergency contraception, antiretrovirals.

Sexual Assault

• Anticipate a sexual assault evidentiary exam with a SANE when available, if the patient presents within the first 96 hours following the incident; limit the amount of repetitive questioning that the patient experiences. • The literature shows that 93% of minors who are sexually assaulted know the perpetrator (RAINN, 2022). • The highest risk for rape is during the ages of 12 to 34, with 1 out of 6 women and 1 out of 10 men experiencing this. Sexual assault is often underreported in the military (RAINN, 2022). • The statistics of sexual assault are alarming as gay men are perpetrated upon 15 times more often than heterosexual men and lesbian and bisexual women are three times more likely to be perpetrated upon than heterosexual women (Pedrotty, 2020, p. 642). • The reasons for sexual assault of LGBTQ and heterosexual men are the same as for heterosexual women (Pedrotty, 2020, p. 642). • Bisexual women experience sexual assault at a significantly higher prevalence than heterosexual and lesbian women.

Intimate Partner Violence (IPV)

• Call for resources available per policy (e.g., SANE, social worker, crisis advocate, chaplain). • Patients older than 60 can be involved in an IPV scenario. Do not assume this is elder abuse or neglect (Zink et al., 2004). CHAPTER 25 Sexual Assault and Intimate Partner Violence

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• Do not provide your own judgment, ignore the patient’s complaints, or tell them to leave their partner (if they are unprepared, serious risk of harm can occur; Gordon, 2016). • The perpetrator often uses many behaviors to have power and control over their victim. See https://www.thehotli ne.org/identify-abuse/power-and-control/ for additional information.

RESOURCES Box 25.1: Collection of Evidence • Ensure patient is stable prior to collecting evidence; medical needs are the priority • First priority: Seek a local SANE or trained individual; if you do not have access locally, contact your state SANE for assistance or for help with access to free technical support • A thorough patient interview should ideally be performed by an expert; most often it should not be conducted in the presence of law enforcement • Obtain consent for the collection of evidentiary specimens and photographs • When documenting, use the patient’s words and quotations, when possible, and do not lead the patient in your questioning • Document the place/time of assault, number of perpetrators, and any objects used (e.g., rope); do not ask for the specifics but rather leave that to the experts

• If consent is obtained and a camera is available, take photographs and place them in the patient chart • Clothing collection requires careful preservation; if injuries require immediate removal of clothing, cut around any stains or holes • Place each article of clothing in individual paper bags and label with patient identifiers and number accordingly (e.g., “bag 1 of 2”); change gloves frequently to prevent cross contamination • Seal the evidence per protocols and complete appropriate forms; do not lick envelopes • Follow the chain of command • Healthcare providers should familiarize themselves in advance with the contents of the evidentiary kit and the jurisdiction’s instructions for collection

Sexual assault and intimate partner violence are highly sensitive situations that require expertise in interviewing the patient as well as handling forensic evidence. Know your resources and where to access additional assistance and guidance if there is not an expert available in your facility! Every facility should aim to have a few individuals with advanced training in this area. Evidence can easily be compromised if it is not collected following specific protocols and the appropriate chain of command is not followed. Collected evidence will need to be stored through the statute of limitations. CHAPTER 25 Sexual Assault and Intimate Partner Violence

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Box 25.2: Risk Factors for Sexual Assault • • • • • • • •

A familiar person Alcohol/drug use Cognitive and/or physical disabilities Depression Failing grades or withdrawing from classes Homelessness Limited contact with others Low self-esteem

• Partner pressuring them to do things that they are uncomfortable with • Partner not wanting to use birth control • Partner controls communication or answers text messages or phone • Teen runaway • The teen has a relationship with an adult that includes secrecy

Box 25.3: Risk Factors for Intimate Partner Violence (IPV) • • • • • • • • •

Financial stress History of alcohol and drug use History of childhood abuse History of prior IPV Hostile relationship or a breakup Impulsiveness Low level of education Lack of social support Low self-esteem

• • • • • • • •

Low socioeconomic status Poor control of behaviors Pregnancy Social isolation Substance abuse Teens and young adults Unplanned pregnancy in young women Witnessed violence in the past

26

HUMAN TRAFFICKING

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Lynn Sayre Visser (See also Chapter 4, Pediatric Considerations; Chapter 12, Abdominal Emergencies; Chapter 14, Obstetric Emergencies; Chapter 15, Gynecologic Emergencies; Chapter 16, Male Reproductive Emergencies; Chapter 24, Behavioral Health Emergencies; and Chapter 27, Trauma Emergencies) ID:c0026-p0005

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CHIEF COMPLAINTS ID:c0026-ti0010

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Human trafficking is an action perpetrated against victims by force, fraud, or coercion. Trafficking encompasses several labor markets including agriculture, manufacturing, hospitality, healthcare, domestic service, drug cartels, commercial sex work, and illegal organ procurement. Therefore, there is no specific chief complaint but rather a myriad of findings that may indicate trafficking including: physical, psychological, social, and behavioral.

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330 PART IV Special Issues in Emergency Care

RED FLAGS • Accompanied by a person who won’t leave their side and often answers questions posed to the patient • Anxiety and/or depression • Bruises/burns in various healing stages and/or old scars • Child not enrolled in school • Defers to another to speak for them • Delay in seeking care • Does not know their personal address, phone no., etc. • Fearful, hypervigilant, paranoid • Hesitant to answer questions about injuries • Inconsistent, scripted, or robotic answers to questions (coached what to say) • Injuries consistent with strangulation: patterned bruising, ligature marks, petechial hemorrhages • Lacks identification or has a fake identification • Lacks medical care, sleep, water, and/or food • Lacks personal items and/or does not have control over personal documents • Lives in housing provided by employer ID:c0026-p0020

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• Looks for permission from the adult present before speaking • Nightmares or lack of sleep • Oral or dental injuries • Pregnancy and/or history of abortions or miscarriages • Raised area on skin (evidence of an implantation chip on the inside of forearm, behind earlobe, in the web of thumb and pointer finger) • Refusal to remove clothing and/or inappropriate clothing for the season or weather • Sexually transmitted infection, frequent or untreated • Substance abuse or drug withdrawal • Suicidal or self-harm • Tattoos or branding (names, dollar signs, numbers) on neck, chest, lower back, extremities • Unaware of immediate location (city) or time • Uncomfortable with mention of law enforcement • Urinary tract infections • Vaginal or rectal trauma • Vague historian ID:c0026-p0100

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Presence of the preceding indicators does not necessarily indicate human trafficking is occurring; rather these findings should alert you to the possibility of trafficking. ID:c0026-p0095

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TRIAGE CONSIDERATIONS • Trafficking does not necessarily require the movement of persons. Victims may be in their own homes or communities. • Observe for nonverbal communication that may indicate clues of trafficking; remain calm throughout any interactions, avoiding facial gestures that may indicate a look of surprise, disgust, and so on. • Use a trauma-informed approach: Ask for permission to touch the patient, move slowly, and provide verbal explanations prior to any procedures; the patient should feel in control of the physical exam. • Attempt to interview the patient alone; a trip to the restroom for a urinalysis or to radiology are potential opportunities for solo questioning. Avoid repeated interviews by multiple providers (may cause re-traumatization). • Victims often go undetected in the ED; 56% of trafficking survivors report being seen in the ED/urgent care while being trafficked. Maintain a high index of suspicion (Lamb-Susca & Clements, 2018). • Professional medical interpreters, related to the patient or situation, should be used. • Consider providing screening questionnaires on an electronic tablet to increase confidentiality. • Involve security (if available) according to facility policy; maintain safety for the patients and staff. • See Box 26.1: Risk Factors for Human Trafficking and Box 26.2: Questions to Ask When Suspecting Human Trafficking. ID:c0026-p0180

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CHAPTER 26 Human Trafficking

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332 PART IV Special Issues in Emergency Care

KEY TIPS • Awareness of the red flags associated with human trafficking is critical for identifying and intervening with such victims. • Improving the health of the potential victim and ensuring safety should be the primary concern. • In the United States, the National Human Trafficking Hotline at 1-888-373-7888 (TTY: 711) or Text 233733 will help in determining if trafficking (sex or labor) may be occurring. The hotline staff will assist with service referrals or connect you with law enforcement as deemed necessary, and you will remain anonymous. Translators are available. Additional information is available at www.traffickingresourcecenter.org. For areas outside the United States, please refer to your local experts and/or governmental agencies for additional resources. Printed materials may not be appropriate since they may raise the suspicion of the trafficker. Help the victim to remember the phone number by grouping it as 888-3737-888. • If the patient is forthcoming about trafficking circumstances provide resources available at www.traffickingresourc ecenter.org. • Incorporating preprinted victim service hotlines (Human Trafficking, Domestic Violence, Sexual Violence, Suicide) on all discharge instructions can help increase the victims reached and decrease suspicion from abusers. • Call 1-866-347-2423 to report suspected human trafficking to federal law enforcement in the United States. • Involve social services (if available) and child protective services as applicable; if trafficking is suspected the services of multiple agencies may be required. For minors, law enforcement should be involved per state guidelines and institutional policies should be followed. • Clearly demonstrate caring while communicating to the patient that they are safe with you. • The patient may not want to be “rescued.” The goal is to provide medical care and allow patients to feel safe, secure, validated, and empowered to disclose. • Be familiar with state, jurisdiction, facility policies/procedures, and reporting laws. ID:c0026-p0230

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• In the United States, for a complete list of mandated reporting requirements by state: https://www.victimrights.org/ privacy-cards-english. • Anticipate orders that may include: Labs: Sexually transmitted infection (STI) panel, gonorrhea/chlamydia, HIV, hepatitis panel, urinalysis, pregnancy test, drug screen; Diagnostics: X-ray; Medications: Analgesics, antibiotics, anti-anxiety, antiemetics, emergency contraception, anti-retrovirals. ID:c0026-p0285

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ID:c0026-ti0015

334 PART IV Special Issues in Emergency Care

RESOURCES Box 26.1: Risk Factors for Human Trafficking ID:c0026-ti0015

ID:c0026-ti0020

• • • • • • • • • • • •

Child welfare system involvement Chronic medical conditions left untreated Depression or low self-esteem Disabilities Drug trafficking: Body packing or stuffing Fear of harm to their family Fear of law enforcement Fear of the person in charge of them History of abuse as a child Homeless youth Immigrant/migrant worker Involvement in a natural or manmade disaster

• Labor trafficking: Unsafe ventilation, repetitive motion, limited training in using heavy and high-risk equipment, frostbite, infections such as tuberculosis, skin infections, no personal protective equipment for hazardous work • Lack of financial resources • Lack of social circle • Language barrier • LGBTQIA individuals • Mental health issues • Psychological instability • Racial/ethnic minorities, especially Native Americans and indigenous persons • Recent relocation • Rural location • Substance use • 12- to 16-year-old female

Box 26.2: Questions to Ask When Suspecting Human Trafficking ID:c0026-ti0025

• • • • • • • • • •

Who cares for you? Where do you live? Who lives with you? Do you feel trapped? Has your family been threatened? Does someone other than yourself hold your passport or identification documents? Can you tell me about your tattoos? Is anyone making you do things you do not want to do, like sexual acts for money or favors? Do you have a debt to someone you cannot pay off? Have you been denied food/water/medical care/ sleep/access to your family?

• Have you ever felt you couldn’t leave the place you work/live? Are you free to come and go from your home as you please? Have you ever worked without receiving the payment you expected? Does someone take part of your earnings? • Have you ever worked in a place that was different from what you were promised or told it would be? • Does anyone at your work make you feel scared or unsafe? • Did anyone at your workplace threaten to harm you? • How many hours do you work in a week? • Do you owe your employer money? Does your home have bars on windows, windows you can’t see through, or security cameras?

This list is not all-inclusive but provides a foundation from which to start. ID:c0026-p0615a

CHAPTER 26 Human Trafficking

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Part V: Trauma Care

27 ID:c0027-ti0005a

TRAUMA EMERGENCIES

ID:c0027-ti0005

Dawn Friedly Gray (See also Chapter 4, Pediatric Considerations; Chapter 5, Older Adult Considerations; Chapter 9, Respiratory Emergencies; Chapter 10, Cardiac Emergencies; Chapter 11, Neurologic Emergencies; Chapter 12, Abdominal Emergencies; Chapter 14, Obstetric Emergencies; Chapter 17, Ocular Emergencies; Chapter 19, Musculoskeletal Emergencies; Chapter 24, Behavioral Health Emergencies; and Chapter 28, Burn Emergencies) ID:c0027-p0005

ID:c0027-p0010

CHIEF COMPLAINTS • Amputation proximal to the wrist and ankle • Blunt trauma (e.g., motor vehicle collision [MVC], motorcycle collision [MCC], all-terrain vehicle [ATV]/ recreational vehicle accident, pedestrian or vehicle/ cyclist impact, large animal impact, explosion, assault, fall from a ladder, car falling off a jack) ID:c0027-p0015

ID:c0027-p0020

336

• Falls (e.g., head injury, spinal cord injury) • Falls: Other injuries • Penetrating trauma (e.g., gunshot/projectile, stab wound, or high-pressure injury) ID:c0027-p0025

ID:c0027-p0030

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RED FLAGS Physiologic Trauma Triage Criteria ID:c0027-p0040

• Altered mental status including loss of consciousness after trauma, Glasgow Coma Scale (GCS) 15 mph • Fall: Adult >20 feet, pediatric >10 feet or two to three times the height of the child; if 30 minutes) • Unrestrained person in a motor vehicle crash or without a helmet in a motorcycle crash ID:c0027-p0100

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CHAPTER 27 Trauma Emergencies

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338 PART V Trauma Care

Anatomic Trauma Triage Criteria • • • • • ID:c0027-p0115

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Amputation proximal to wrist or ankle Crushed, degloved, or mangled extremity Flail chest Impalement injury Open fracture or fracture of two or more long bones

ID:c0027-p0130

• Paralysis or other focal neurologic deficits • Penetrating trauma to the head, neck, thorax, or abdomen • Seatbelt sign • Shoulder pain after abdominal trauma ID:c0027-p0140

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Special Considerations for Trauma Triage Criteria • Head injury if taking blood thinners • Low-impact mechanism (e.g., ground level falls) in adults 65 years or older ID:c0027-p0160

• Pregnancy >20 weeks with trauma ID:c0027-p0170

ID:c0027-p0165

TRIAGE CONSIDERATIONS Worst-case scenarios: The following should be considered as a potential for high acuity: Cardiac tamponade, hemothorax, pulmonary contusion, splenic injury, and tension pneumothorax • Think GOLDEN HOUR! Initiate a trauma alert if indicated and available in the facility. • Think C-A-B-D-E! For trauma cases with bleeding (internal and/or external) and hypotension, immediate attention to circulatory collapse may improve airway compromise. Anticipate the need to hang blood immediately and consider giving tranexamic acid, then assess to determine the potential cause. ID:c0027-p0175

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• Trauma patients younger than 5 years of age and older than 55 years of age are at the greatest risk for death and disability. • Consider the mechanism of injury to determine if more in-depth questioning is warranted. • The time of injury is important to consider with all trauma patients. The mechanism of injury can indicate the level of risk, but the risk decreases as more time passes since the traumatic event. Never let your guard down. • Trauma patients can initially present with minimal symptoms and then deteriorate. Stay alert for potential changes. • Children will remain physiologically stable for longer, masking underlying trauma. • An isolated shoulder pain without injury (especially to the left shoulder) can be referred pain from the abdominal cavity. Do not discount its importance. • Spinal cord injuries can present with varying signs and symptoms including unusual presentations of pain, numbness, and tingling. Any and all abnormal neurologic assessment findings should be taken seriously. • A patient under the influence of alcohol or other substances cannot have their cervical spine cleared without imaging. Remember that a change in mental status can be caused by alcohol/drugs. • For assault situations, maintain a strict chain of evidence and follow policies and procedures. ID:c0027-p0195

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KEY TIPS • Complete the following when triaging all patients but be cognizant of when this is completed during the triage process: Treatment prior to arrival, provokes/palliates, quality, region/radiation, severity/associated symptoms, timing/temporal relations (PQRST), past medical history, drug and alcohol use, medications, allergies, immunization status, a full set of vital signs, O2 saturation, provide supplemental O2 if needed, and a capillary blood glucose if indicated. ID:c0027-p0240

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340 PART V Trauma Care

Amputation

• An amputation is considered a “potential threat to life or limb;” time is critical for successful reattachment, but stabilizing the patient always comes before attending to the amputated part. • Consider the cause of the amputation (e.g., possible abuse in children). Remember that reimplantation is attempted more often in children, so anticipate the potential need for surgical intervention. ID:c0027-ti0035

ID:c0027-p0250

ID:c0027-p0255

Blunt Trauma

• Patients with an epidural bleed may have a positive loss of consciousness followed by a lucid period and then a rapid deterioration. Ipsilateral pupil dilation may be present (impending herniation). Any loss of consciousness is suspicious! • Distracting injuries (burns, amputations, open fractures) can mask more serious underlying conditions. Assess this! • A seatbelt sign (chest and abdomen) is highly concerning and may lead to serious injuries. Always assess both the chest and abdomen. • Injuries associated with explosions can be more extensive than the patient presentation and complaint. • Adults with multiple rib fractures may present later with pulmonary contusion, pneumothorax, and aspiration. • Blunt trauma patients are at high risk for internal injury without any external signs. A full assessment and rapid imaging are required to determine potential life-threatening injuries (the Golden Hour). The spleen is one of the most commonly injured solid organs. Assess for orthostatic hypotension, abdominal pain, and/or left shoulder pain. If there is suspicion of a splenic injury, inquire with the patient if they were involved in a motor vehicle crash within the last three weeks. • Scapular, sternal, and clavicle fractures require tremendous force; if these are present, consider other injuries. • Bilateral calcaneus fractures are distracting injuries and are often associated with spinal and pelvic fractures. ID:c0027-ti0040

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• Anticipate orders that may include Labs: CBC, chemistry and coagulation panel, type and cross; Diagnostics: Multiple x-rays, face numbness, arm weakness, speech difficulty, time (FAST) exam, CT, MRI; Medications: IV fluids, blood products, analgesics. ID:c0027-p0300

Penetrating Trauma

• Injuries below the nipple line impact chest and abdominal organs. • With pregnancy and penetrating trauma, maternal mortality risk is low and fetal mortality risk is high. Refer to Chapter 14, Obstetric Emergencies, for additional pregnancy related information. • A penetrating injury to the liver is the most common; assess for this! • High-pressure device injuries can appear as small puncture wounds but put the patient at high-risk for future disability and/or compartment syndrome. These presentations may require emergency surgery! ID:c0027-ti0045

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AMPUTATION PROXIMAL TO THE WRIST AND ANKLE ID:c0027-ti0050

Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes ID:c0027-ti0055

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• • • • •

What was amputated? Where is the amputated part (currently with the patient or elsewhere)? What occurred? Time of the incident? How long has the part been amputated? What caused the amputation to occur (e.g., dizziness, potential for abuse, intentional)? Other injuries? (continued ) CHAPTER 27 Trauma Emergencies

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342 PART V Trauma Care

AMPUTATION PROXIMAL TO THE WRIST AND ANKLE (continued) ID:c0027-ti0050

ASSESSMENT Baseline objective assessment

• C-A-B-D-E; intervene immediately for any serious concerns • Examine for partial or total amputation • Assess for hemodynamic instability (e.g., tachycardia, hypotension, cool, pale skin, altered mental status) • Quickly assess circulation, sensation, and movement to the affected part to evaluate for neurologic deficits • Reassess for circulation, sensation, and movement as indicated • Control bleeding as indicated with a pressure dressing and consider a tourniquet when applicable • If a tourniquet is present, indicate the date and time of placement in the patient’s medical record and on the device itself

INTERVENTIONS General interventions

• Apply direct pressure or a tourniquet to control bleeding followed by a pressure dressing • Never place an amputated part directly onto ice or in ice water; rinse off debris and place the amputated part in a moistened sterile gauze, place into a container, then immerse the container directly on ice or in ice water; be sure to label the container with the patient name and date of birth. • Give nothing by mouth • Expect antibiotic and tetanus administration • Remove jewelry and restrictive clothing from the affected extremity • Splint above and below the joint if a fracture is present • Elevate the extremity

ID:c0027-ti0060

BLUNT TRAUMA (e.g., MVC, MCC, ATV/recreational vehicle accident, pedestrian or vehicle/cyclist impact, large animal impact, explosion, assault, fall from a ladder, car falling from a jack)

Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes ID:c0027-ti0065

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• What happened? Speed of vehicle/motorcycle/cyclist? Number of vehicles/cyclists involved? • When did the incident occur? What side of the vehicle was struck and how much damage occurred to the vehicle? • Restraints? Safety devices? Self-extrication? • Where was the patient located prior to the impact (e.g., driver’s seat, front seat passenger)? • For an explosive injury, was the patient thrown? How far? • Any shortness of breath? Pain on inspiration? • Loss of consciousness? For how long? Change in mentation since the incident? • Chest or abdominal pain? Shoulder pain (referred pain)? • Pregnancy >20 weeks? (continued )

CHAPTER 27 Trauma Emergencies

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344 PART V Trauma Care

ID:c0027-ti0060

BLUNT TRAUMA (e.g., MVC, MCC, ATV/recreational vehicle accident, pedestrian or vehicle/cyclist impact, large animal impact, explosion, assault, fall from a ladder, car falling from a jack) (continued) ASSESSMENT Baseline objective assessment

• • • • • • • • • • •

INTERVENTIONS General interventions

C-A-B-D-E; intervene immediately for any serious concerns Palpate for cervical spine tenderness and assess for focal neurologic deficits Assess for a flail chest Assess for hemodynamic instability (e.g., tachycardia, hypotension, cool, pale skin, altered mental status) Presence of a seatbelt sign (especially significant when present over the abdomen) Glasgow Coma Scale (GCS); see age-appropriate Tables 27.1: Adult Glasgow Coma Scale, 27.2: Pediatric Glasgow Coma Scale, and 27.3: Glasgow Coma Scale Children 14 weeks Breath sounds (wheezing, crackles, diminished, absent) and heart tones Pulse quality; regular/irregular, fast/slow, bounding/weak/nonpalpable Inspect and palpate the abdomen (e.g., rebound tenderness, voluntary/involuntary guarding) Presence of deformities

• Place in c-spine immobilization for a suspected cervical injury • Anticipate the need for an EKG and oxygen as indicated • Ventilate if hypoventilation is present (“cure” for flail chest)

FALLS (e.g., head injury, spinal cord injury) ID:c0027-ti0070

Rapid Triage Assessment goal is 60 to 90 seconds; Comprehensive Triage Assessment goal is 2 to 5 minutes) ID:c0027-ti0075

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• How far was the fall (e.g., number of feet)? • Loss of consciousness? If yes, was there a period of lucidity (for up to 6 hours with a subsequent altered mental status)? • Prescribed blood thinners? • Potential cervical injury? Numbness or tingling in extremities? • When did this happen? • Cause of the fall (e.g., syncopal episode, dizziness, lightheadedness, stroke, cardiac event)? • Any additional injuries? (continued )

CHAPTER 27 Trauma Emergencies

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346 PART V Trauma Care

FALLS (e.g., head injury, spinal cord injury) (continued) ID:c0027-ti0070

ASSESSMENT Baseline objective assessment

• C-A-B-D-E; intervene immediately for any serious concerns • Assess for hemodynamic instability (e.g., tachycardia, hypotension, cool, pale skin, altered mental status) • Glasgow Coma Scale; see Tables 27.1: Adult Glasgow Coma Scale, 27.2: Pediatric Glasgow Coma Scale, and 27.3: Glasgow Coma Scale for Children 65 years with even a ground-level fall due to increased risk from fragile bones and osteoporosis • Apply a pressure dressing if bleeding • If visible rhinorrhea and/or otorrhea, preform a halo test (drop leaking fluid onto a paper towel or 4x4 gauze; a positive test for cerebral spinal fluid indicates two distinct rings) • Consider the need for an EKG following syncope, lightheadedness, etc.

FALLS —OTHER INJURIES ID:c0027-ti0080

Rapid Triage Assessment g oal i s 60 t o 90 s econds ; Comprehensive Triage Assessment goal is 2 to 5 minutes ID:c0027-ti0085

QUESTIONS Examples of questions to elicit pertinent information from the patient or caregiver

• How far was the fall (adults >20 feet or pediatrics >10 feet or two to three times the height of the child or if 2 seconds • Altered mentation in adults and/or posturing in pediatrics Expectant/Deceased Care Patients: Black Tag Patients that are deceased or unsalvageable. These patients may include: • Adults with no return of spontaneous respirations after opening the airway • Pediatric patients with no spontaneous respirations after opening the airway and providing five rescue breaths • No palpable pulse; remember, do not perform CPR in MCI Triage unless adequate personnel resources are available • Unsalvageable due to massive injury or obvious signs of death • Expectant victims still receive palliative care as resources allow *Note: Do not gravitate toward pediatric patients or individuals you know. Look at the bigger picture and use your protocols to guide you.

CHAPTER 30 Emergency Management During a Disaster

395

396 PART VI Disaster Emergencies

DISASTER RESPONSE FOR VULNERABLE POPULATIONS: FOR PEDIATRIC, PREGNANT, AND OLDER ADULT PATIENTS Pediatric Considerations • • • • • •

Infants have larger heads and are at higher risk for cervical spine and traumatic brain injury (TBI). Chest injuries by blunt-force impact are a common cause of death in children. Children are more prone to abdominal injuries because of smaller, more pliable ribs. Children have narrower airways and as a result are more prone to bronchospasm and obstruction. Delayed and more abrupt decompensation. Cardiac arrest is more commonly associated with respiratory emergencies.

Pregnancy Considerations

• A minimum of two patients are being treated. • Incidents involving high explosives can travel through the amniotic fluid, causing injury to the placenta (e.g., detachment). • Second or Third Trimester of Pregnancy: After life-threatening conditions have been stabilized, consider admission to labor and delivery for fetal monitoring and further testing.

Older Adult Considerations

• Increased risk of fractures (loss of bone calcium and muscle density). • Thinner skin and decreased subcutaneous fat contribute to maintaining body thermoregulation. • Natural changes in brain size with aging; older patients can sustain a significant amount of intracranial bleeding from a closed head injury before symptoms occur.

• Chronic medical conditions exacerbated by the incident and potential medication history. • Diminished sensory (vision, hearing) and cognitive function and adaptability to adverse conditions.

People With Access and Functional Needs

• Provide for special needs in these areas: ■ Communications, including visual, hearing, and speech impairment, and language challenges ■ Mobility impairments ■ Cognitive impairments • Consider predispositions due to lifestyle conditions (e.g., poverty, homelessness, healthcare deficits).

CRITICAL INCIDENT STRESS MANAGEMENT DURING AND AFTER A DISASTER • Disaster incidents cause powerful emotional reactions, especially in children. • Choices you make may stay with you forever. • Recognize signs of critical incident stress (e.g., difficulty sleeping, stomach problems, confusion, anxiety, agitation, memory issues, cognitive challenges). Acknowledge and focus on strengths, and accept help in order to recover. • Talk with family, friends, chaplains, and Employee Assistance Programs can assist with incident stress debriefing and counseling. Consider activating these services early. • Recognize the anniversaries of the incident and the emotional difficulty.

CHAPTER 30 Emergency Management During a Disaster

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398 PART VI Disaster Emergencies

STATE AND REGIONAL DISASTER MEDICAL RESOURCES Response Teams

NAME/LOCATION

DESCRIPTION/CAPABILITIES

ACTIVATION/CONTACT INFORMATION

Equipment, Supply and Pharmaceutical Stockpiles

NAME/LOCATION

DESCRIPTION/CAPABILITIES

ACTIVATION/CONTACT INFORMATION

CHAPTER 30 Emergency Management During a Disaster

399

ID:c0004-p1294 ID:c0004-p1293 ID:c0004-p1292 ID:c0004-p12917 ID:c0004-p12916 ID:c0004-p12915 ID:c0004-p12914 ID:c0004-p12913 ID:c0004-p12912 ID:c0004-p12911 ID:c0004-p1291 ID:c0004-p1299 ID:c0004-p1298 ID:c0004-p1297 ID:c0004-p1296 ID:c0004-p1295 ID:c0004-p1290 ID:c0004-p1285 ID:c0004-p1280

400 PART VI Disaster Emergencies

NOTES                   

ID:u0008-p0037 ID:u0008-p0036 ID:u0008-p0034 ID:u0008-p0033 ID:u0008-p0032 ID:u0008-p0031 ID:u0008-p0029 ID:u0008-p0028 ID:u0008-p0027 ID:u0008-p0026 ID:u0008-p0025 ID:u0008-p0020 ID:u0008-p0015 ID:u0008-p0010 ID:u0008-p0005

NOTES NOTES               

401

ID:u0008-p0065 ID:u0008-p0063 ID:u0008-p0062 ID:u0008-p0061 ID:u0008-p0060b ID:u0008-p0060a ID:u0008-p0059 ID:u0008-p0058 ID:u0008-p0057 ID:u0008-p0056 ID:u0008-p0055a ID:u0008-p0054 ID:u0008-p0053 ID:u0008-p0052 ID:u0008-p0051 ID:u0008-p0045 ID:u0008-p0040 ID:u0008-p0035 ID:u0008-p0030

402 Notes

NOTES                   

ID:u0008-p0084 ID:u0008-p0083 ID:u0008-p0082 ID:u0008-p0081 ID:u0008-p0080a ID:u0008-p0079 ID:u0008-p0078 ID:u0008-p0077 ID:u0008-p0076 ID:u0008-p0075 ID:u0008-p0074 ID:u0008-p0073 ID:u0008-p0072 ID:u0008-p0071 ID:u0008-p0070 ID:u0008-p0065a ID:u0008-p0060 ID:u0008-p0055

NOTES                  

Notes 403

ID:u0008-p0144 ID:u0008-p0133 ID:u0008-p0122 ID:u0008-p0111 ID:u0008-p0110 ID:u0008-p0109 ID:u0008-p0108 ID:u0008-p0107 ID:u0008-p0106 ID:u0008-p0105 ID:u0008-p0104 ID:u0008-p0103 ID:u0008-p0102 ID:u0008-p0101 ID:u0008-p0095 ID:u0008-p0090 ID:u0008-p0085 ID:u0008-p0080

404 Notes

NOTES                  

ID:u0008-p0134 ID:u0008-p0133a ID:u0008-p0132 ID:u0008-p0131 ID:u0008-p0130 ID:u0008-p0129 ID:u0008-p0128 ID:u0008-p0127 ID:u0008-p0126 ID:u0008-p0125 ID:u0008-p0124 ID:u0008-p0123 ID:u0008-p0122a ID:u0008-p0121 ID:u0008-p0120 ID:u0008-p0115 ID:u0008-p0110a ID:u0008-p0105a

NOTES                  

Notes 405

ID:u0008-p0163 ID:u0008-p0162 ID:u0008-p0161 ID:u0008-p0160 ID:u0008-p0159 ID:u0008-p0158 ID:u0008-p0157 ID:u0008-p0156 ID:u0008-p0155 ID:u0008-p0154 ID:u0008-p0153 ID:u0008-p0152 ID:u0008-p0151 ID:u0008-p0150 ID:u0008-p0145 ID:u0008-p0140 ID:u0008-p0135 ID:u0008-p0130a

406 Notes

NOTES                  

ID:u0008-p0185 ID:u0008-p0184 ID:u0008-p0183 ID:u0008-p0182 ID:u0008-p0181 ID:u0008-p0180 ID:u0008-p0179 ID:u0008-p0178 ID:u0008-p0177 ID:u0008-p0176 ID:u0008-p0175 ID:u0008-p0174 ID:u0008-p0173 ID:u0008-p0172 ID:u0008-p0171 ID:u0008-p0170 ID:u0008-p0165 ID:u0008-p0160a ID:u0008-p0155a

NOTES                   

Notes 407

ID:u0008-p0213 ID:u0008-p0212 ID:u0008-p0211 ID:u0008-p0210 ID:u0008-p0209 ID:u0008-p0208 ID:u0008-p0207 ID:u0008-p0206 ID:u0008-p0205 ID:u0008-p0204 ID:u0008-p0203 ID:u0008-p0202 ID:u0008-p0201 ID:u0008-p0200 ID:u0008-p0195 ID:u0008-p0190 ID:u0008-p0185a ID:u0008-p0180a

408 Notes

NOTES                  

ID:u0008-p0234 ID:u0008-p0233 ID:u0008-p0232 ID:u0008-p0231 ID:u0008-p0230 ID:u0008-p0229 ID:u0008-p0228 ID:u0008-p0227 ID:u0008-p0226 ID:u0008-p0225 ID:u0008-p0224 ID:u0008-p0223 ID:u0008-p0222 ID:u0008-p0221 ID:u0008-p0220 ID:u0008-p0215 ID:u0008-p0210a ID:u0008-p0205a

NOTES                  

Notes 409

ID:u0008-p0263 ID:u0008-p0262 ID:u0008-p0261b ID:u0008-p0260b ID:u0008-p0259b ID:u0008-p0258b ID:u0008-p0257b ID:u0008-p0256b ID:u0008-p0255b ID:u0008-p0254b ID:u0008-p0253b ID:u0008-p0252b ID:u0008-p0251b ID:u0008-p0250b ID:u0008-p0245b ID:u0008-p0240b ID:u0008-p0235b ID:u0008-p0230b

410 Notes

NOTES                  

REFERENCES CHAPTER 2 Emergency Nurses Association. (2020). Provider manual ENPC emergency nursing pediatric course (5th ed.). Jones and Bartlett. McNair, R. S. (2019). ED Triage Comprehensive Curriculum, Version 2020. Triage First.

CHAPTER 4 Emergency Nurses Association. (2020a). Emergency nursing pediatric course provider manual (5th ed.). Jones and Bartlett. Emergency Nurses Association. (2020b). Sheehy’s emergency nursing principles and practice (7th ed.). Elsevier. Gordon, C. (2016). Intimate partner violence is everyone’s problem but how should we approach it in a clinical setting? The South African Medical Journal, 106(10), 962–965. https://doi.org/10.7196/SAMJ.2016.v106i10.11408 Hinton, C., & Trop, A. (2020). TEN-4 FACES P: A mnemonic to help you spot signs of child abuse. ACEPNow. https://www.acepnow.com /article/ten-4-faces-p-a-mnemonic-to-help-you-spot-signs-of-child-abuse/ Shenot, P. J. (2021). Testicular torsion. Merck Manual Professional Version. https://www.merckmanuals.com/professional/ genitourinary-disorders/penile-and-scrotal-disorders/testicular-torsion

CHAPTER 5 Murano, T., & Ravi, C. (2020). Airway management in older adult trauma patients. Trauma Reports, 21(4), 1–12. https://www.reliasmedia. com/articles/146369-airway-management-in-older-adult-trauma-patients Touhy, T. A., & Jett, K. (2018). Ebersole and Hess’ Gerontological nursing and healthy aging. Elsevier.

411

412 References

CHAPTER 7 Centers for Medicare & Medicaid Services. (2021). Emergency Medical Treatment and Labor Act (EMTALA). https://www.cms.gov/ Regulations-and-Guidance/Legislation/EMTALA

CHAPTER 12 Rajaguru, K., & Sheong, S. C. (2021). Case report on a rare cause of small bowel perforation perforated ileal diverticulum. International Journal of Surgery Case Reports, 87, 1–6. https://doi.org/10.1016/j.ijscr.2021.106465 Ullah, W., Khanal, S., Sattar, Z., Roomi, S., Sattar, Y., & Figueredo, V. M. (2019). Singultus as a presentation for aortic dissection. IHJ Cardiovascular Case Reports (CVCR), 3(2), 84–86. https://doi.org/10.1016/j.ihjccr.2019.08.002 Wilkes, G. (2017). Hiccups. In S. C. Dronen (Ed.), Medscape. http://emedicine.medscape.com/article/775746-overview#a1

CHAPTER 13 Morton, P. G., & Fontaine, D. K. (2018). Critical care nursing (11th ed., pp. 862–890). Wolters Kluwer.

CHAPTER 14 American College of Obstetricians and Gynecologists. (2018). ACOG Committee Opinion No. 736: Optimizing postpartum care. Obstetrics and Gynecology, 131(5), e140–e150. https://pubmed.ncbi.nlm.nih.gov/29683911/ American College of Obstetricians and Gynecologists. (2019). ACOG Practice Bulletin No. 212: Pregnancy and heart disease. Obstetrics and Gynecology, 133(5), e320–e356. https://pubmed.ncbi.nlm.nih.gov/31022123/ Emergency Nurses Association. (2020). Sheehy’s emergency nursing principles and practice (7th ed.). Elsevier. Jennings, L. K., & Mahdy, H. (2022). Hyperemesis gravidarum. National Library of Medicine. https://pubmed.ncbi.nlm.nih.gov/30422512/

CHAPTER 15 American College of Obstetricians and Gynecologists, & American College of Obstetricians and Gynecologists' Committee on Health Care for Underserved Women. (2021, March). Health care for transgender and gender diverse individuals: ACOG Committee Opinion, Number 823. Obstetrics and Gynecology, 137(3), e75–e88. https://www.acog.org/-/media/project/acog/acogorg/clinical/file s/committee-opinion/articles/2021/03/health-care-for-transgender-and-gender-diverse-individuals.pdf Jordon, K. S. (2020). Obstetric and gynecologic emergencies. In V. Sweet& A. Foley (Eds.), Sheehy’s emergency nursing: Principles and practice (7th ed.). Elsevier.

CHAPTER 16 Bivalacqua, T. J., Allen, B. K., Brock, G., Broderick, G. A., Kohler, T. S., Mulhall, J. P., Oristaglio, J., Rahimi, L. L., Rogers, Z. R., Terlecki, R. P., Trost, L., Yaki, F. A., & Bennett, N. E. (2021). Acute ischemic priapism: An AUA/SMSNA guideline. The Journal of Urology, 206, 1114–1121. https://www.auajournals.org/doi/10.1097/JU.0000000000002236

CHAPTER 17 Kumar, S., & Blace, N. (2021). Retrobulbar hematoma. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK576417/

CHAPTER 18 Ramasamy, V., & Nadarajah, S. (2018). The hazards of impacted alkaline battery in the nose. Journal of Family Medicine and Primary Care, 7(5), 1083–1085. https://doi.org/10.4103/jfmpc.jfmpc_47_18 Wajdowicz, M. N. (2020, November). Fractured and avulsed teeth. Merck Manual Professional Version. https://www.merckmanuals.com/ professional/dental-disorders/dental-emergencies/fractured-and-avulsed-teeth

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414 References

CHAPTER 19 Hadeed, A., Anthony, J. H., & Hoffler, C. E. (2021). Hand high pressure injury. National Library of Medicine. https://www.ncbi.nlm.nih.gov /books/NBK542210/ Long, B., Koyfman, A., & Gottlieb, M. (2020). Evaluation and management of cauda equina syndrome in the emergency department. The American Journal of Emergency Medicine, 38(1), 143–148.

CHAPTER 20 Centers for Disease Control and Prevention. (2015, November 5). Clinical syndromes or conditions warranting empiric transmission-based precautions in addition to standard precautions. https://www.cdc.gov/infectioncontrol/guidelines/isolation /appendix/transmission-precautions.html Kim, A. Y., & Gandhi, R. T. (2022). COVID-19: Management in hospitalized patients. UpToDate. https://www.uptodate.com/contents/ covid-19-management-in-hospitalized-adults?search=covid%2019%20treatment&source=search_result&selectedTitle=1~150&usa ge_type=default&display_rank=1#H3855514466 Palmore, T. N., & Smith, B. A. (2022). COVID-19: Infection prevention for persons with SARS-CoV-2 infection. UpToDate. https://www.up todate.com/contents/covid-19-infection-prevention-for-persons-with-sars-cov-2-infection#H4047319314

CHAPTER 21 Friend, A., & Girzadas, D. (2021). Acute chest syndrome. National Library of Medicine. https://pubmed.ncbi.nlm.nih.gov/28722902/ Punnapuzha, S. Edemobi, P. K, & Elmoheen, A. (2021). Febrile neutropenia. National Library of Medicine. https://www.ncbi.nlm.nih.gov/ books/NBK541102/

CHAPTER 22 De Laby, M., & Sturt, P. (2020). Toxicologic emergencies. In V. Sweet & A. Foley (Eds.), Sheehy’s emergency nursing: Principles and practice (7th ed., pp. 345–348). Elsevier. Liebelt, E. L. (2021). Acute iron poisoning. UpToDate. https://www.uptodate.com/contents/acute-iron-poisoning?search=iron%20toxicity &source=search_result&selectedTitle=2~146&usage_type=default&display_rank=3#H8 O’Malley, G. F., & O’Malley, R. (2022). Iron poisoning. Merck manual: Professional version https://www.merckmanuals.com/professional/ injuries-poisoning/poisoning/iron-poisoning#v1119369 Runde, T. J., & Nappe, T. M. (2022). Salicylates toxicity. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK499879/ Sivilotti, M. L. A. (2021). Isopropyl alcohol poisoning. UpToDate. https://www.uptodate.com/contents/isopropyl-alcohol-poisoning Sivilotti, M. L. A. (2020). Methanol and ethylene glycol poisoning: Pharmacology, clinical manifestations, and diagnosis. UpToDate. https:/ /www.uptodate.com/contents/methanol-and-ethylene-glycol-poisoning-pharmacology-clinical-manifestations-and-diagnosis?searc h=Methanol%20and%20ethylene%20glycol%20poisoning:%20Pharmacology,%20clinical%20manifestations,%20and%20diagnos is&source=search_result&selectedTitle=1~46&usage_type=default&display_rank=1

CHAPTER 24 Cackovic, C., Nazir, S., & Marwaha, R. (2022). Panic disorder. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK43 0973/ Dubovsky, S. L., Ghosh, B. M., Serotte, J. C., & Cranwell, V. (2020). Psychotic depression: Diagnosis, differential diagnosis, and treatment. Psychotherapy and Psychosomatics, 90, 160–177. https://www.karger.com/Article/Pdf/511348 Mayo-Smith, M. F., Beecher, L. H., Fischer, T. L., Gorelick, D. A., Guillaume, J. L., Hill, A., Jara, G., Kasser, C., & Melbourne, J. (2004). Management of alcohol withdrawal delirium: An evidence-based practice guideline. Archives of Internal Medicine, 164(18), 1405–1412. https://pubmed.ncbi.nlm.nih.gov/15249349/

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416 References

CHAPTER 25 Gordon, C. (2016). Intimate partner violence is everyone’s problem but how should we approach it in a clinical setting? The South African Medical Journal, 106(10), 962–965. https://doi.org/10.7196/SAMJ.2016.v106i10.11408 Pedrotty, C. (2020). Sexual assault. In V. Sweet & A. Foley (Eds.), Sheehy’s emergency nursing: Principles and practice (7th ed., p. 642). Elsevier. Rape, Abuse, & Incest National Network [RAINN]. (2022). Victims of sexual violence: Statistics. https://www.rainn.org/statistics/ victims-sexual-violence Zink, T., Regan, S., Goldenhar, L., Pabst, S., & Rinto, B. (2004). Intimate partner violence: What are physicians’ perceptions? The Journal of the American Board of Family Medicine, 17(5), 332–340. https://doi.org/10.3122/jabfm.17.5.332

CHAPTER 26 Lamb-Susca, L., & Clements, P. L. (2018). Intersection of human trafficking and the emergency department. Journal of Emergency Nursing, 44(6), 563–569. https://doi.org/10.1016/jen.2018.06.001

ADDITIONAL READING CHAPTER 1 Emergency Nurses Association. (2020). Sheehy’s emergency nursing principles and practice (7th ed.). Elsevier. Jeffries, D., & Visser, L. (2022). Rapid access guide for pediatric emergencies. Springer Publishing.

CHAPTER 2 Australasian College of Emergency Medicine. (2016). Guidelines on the Implementation of the Australasian Triage Scale in Emergency Departments V04. https://ed-areyouprepared.com/wp-content/uploads/2018/11/Australasian-Triage-Scale-inEmergency-Departments.pdf Beveridge, R., Clarke, B., Janes, L., Savage, N., Thompson, J., Dodd, G., Murray, M., Jordan, C. N., Warren, D., & Vadeboncoeur, A. (2013). CTAS implementation guidelines. CAEP. http://caep.ca/resources/ctas/implementation-guidelines Bullard, M. J., Chad, T., Brayman, C., Warren, D., Musgrave, E., & Unger, B. (2016). Members of the CTAS National Working Group. Revisions to the Canadian emergency department triage and acuity scale (CTAS) guidelines. Canadian Journal of Emergency Medicine, 1–5. https://doi.org/10.2310/8000.2014.012014 Emergency Nurses Association. (2020). Provider manual ENPC emergency nursing pediatric course (5th ed.). Jones and Barlett. Fernandes, C. M., Tanabe, P., Gilboy, N., Johnson, L., McNair, R., Rosenau, A., Sawchuk, P., Thompson, D. A., Travers, D. A., Bonalumi, N., & Suter, R. (2005). Five-level triage: A report from the ACEP/ENA five-level triage task force. Journal of Emergency Nursing, 31(1), 39–50. Fung, J. S. T., Akech, S., Kissoon, N., Wiens, M. O., English, M., & Ansermino, J. M. (2019). Determining predictors of sepsis at triage among children under 5 years of age in resource-limited settings: A modified Delphi process. PloS One, 14(1), e0211274.

417

418 Additional Reading Gilboy, N., Tanabe, P., Travers, T., Eitel, D., & Wuerz, R. (2012). The Emergency Severity Index (ESI) implementation handbook, Version 4. Agency for Healthcare Research and Quality. Horeczko, T., Enriquez, B., McGrath, N. E., Gausche-Hill, M., & Lewis, R. J. (2013). The pediatric assessment triangle: Accuracy of its application by nurses in the triage of children. Journal of Emergency Nursing: JEN: official publication of the Emergency Department Nurses Association, 39(2), 182–189. https://doi.org/10.1016/j.jen.2011.12.020 Jeffries, D., & Visser, L. (2022). Rapid access guide for pediatric emergencies. Springer Publishing. Manchester Triage Group. (2014). Emergency triage: Manchester triage group (3rd ed.). John Wiley & Sons. Zachariasse, J. M., Seiger, N., Rood, P. P. M., Alves, C. F., Freitas, P., Smit, F. J., Roukema, G. R., & Moll, H. A. (2017). Validity of the Manchester triage system in emergency care: A prospective observational study. PloS One, 12(2), e0170811–e0170811. https:// doi.org/10.1371/journal.pone.0170811

CHAPTER 3 American Heart Association. (2018). Phase III target: Stroke—Higher goals for the greater good. https://www.heart.org/-/media/Files /Professional/Quality-Improvement/Target-Stroke/Target-Stroke-Phase-III/TS-Phase-III-5-6-19/FINAL5619-Target-Stroke-Phase -3-Brochure.pdf Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C., French, C., Machado, F., Mcintyre, L., Ostermann, M., Prescott, H., Schorr, C., Simpson, S., Wiersinga, W., Alshamsi, F., Angus, D., Arabi, Y., Azevedo, L., Beale, R., Beilman, G. … Levy, M. (2021). Surviving sepsis campaign: International guidelines for management of sepsis and septic shock 2021. Critical Care Medicine, 49(11), e1063–1143. https://doi.org/10.1097/CCM.0000000000005337 Gulati, M., Levy, P. D., Mukherjee, D., Amsterdam, E., Bhatt, D. L., Birtcher, K. M., Blankstein, R., Boyd, J., Bullock-Palmer, R. P., Conejo, T., Diercks, D. B., Gentile, F., Greenwood, J. P., Hess, E. P., Hollenberg, S. M., Jaber, W. A., Jneid, H., Joglar, J. A., Morrow, D. A., & Shaw, L. J. (2021). 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the evaluation and diagnosis of chest pain: A report of the American College of Cardiology/American Heart Association joint committee on clinical practice guidelines. Circulation, 144, e368–e454. https://doi.org/10.1161/CIR.0000000000001029

Neto, J. N. A. (2018). Morphine, oxygen, nitrates, and mortality reducing pharmacological treatment for acute coronary syndrome: An evidence-based review. Cureus, 10(1), e2114. https://doi.org/10.7759/cureus2114 https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC5866121/?report=classic Powers, W., Rabinstein, A., Ackerson, T., Adeoye, O., Bambakidis, N., Becker, K., Biller, J., Brown, M., Demaerschalk, B., Hoh, B., Jauch, E., Kidwell, C., Leslie-Mazwi, T., Ovbiagele, B., Scott, P., Sheth, K., Southerland, A., Summers, D., & Tirschwell, D. (2019). Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 50, e344–418. https://www.ahajournals.org/doi/10.1161/STR.0000000000000211 Reeder, G., & Kennedy, H. (2021). Overview of the acute management of ST-elevation myocardial infarction. UpToDate. https://www.upto date.com/contents/overview-of-the-acute-management-of-st-elevation-myocardial-infarction#H27 Reilly, K. (2020, February 19). The pharmacist’s guide to acute coronary syndrome. U.S.Pharmacist. https://www.uspharmacist.com/ article/the-pharmacists-guide-to-acute-coronary-syndrome

CHAPTER 4 American College of Surgeons. American Heart Association. (2018). Advanced trauma life support. Pediatric advanced life support. 2016 10th American Optometric Association. (2019). Preschool vision: 3 to 5 years of age, https://www.aoa.org/healthy-eyes/eye-health-for-life/ preschool-vision?sso=y Cleveland Clinic. (2019). Children’s eye care. https://my.clevelandclinic.org/health/articles/5445-childrens-eye-care Emedicine. (2015). Pediatric apnea. http://emedicine.medscape.com Gilboy, N., Tanabe, P., Travers, D., & Rosenau, A. M. (2012). Emergency Severity Index (ESI): A triage tool for emergency department care, version 4, implementation handbook 2012 edition. Agency for Healthcare Research and Quality. Harding, M. M. (2019). Acute compartment syndrome: An orthopedic emergency. The Nurse Practitioner, 44(4), 23–28. https:// doi.org/10.1097/01.NPR.0000554087.90202.2b Jeffries, D., & Visser, L. (2022). Rapid access guide for pediatric emergencies. Springer Publishing.

Additional Reading 419

420 Additional Reading Rocker, J. A. (2018). Pediatric apnea. In K. A. Bechtel (Ed.), Medscape. https://emedicine.medscape.com/article/800032-overview Shea, S. S., Hoyt, K. S., & Jordan, K. S. (2016). Pediatric emergency/urgent and ambulatory care: The Pocket NP. Springer Publishing. Shinnar, S. R., & Sinnar, S. (2017). Febrile seizures. Child Neurology Foundation. http://www.childneurologyfoundation.org Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2007 July 22). Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. CDC. https://www.cdc.gov/ infectioncontrol/pdf/guidelines/isolation-guidelines.pdf Slota, M. C. (Ed.). (2019). Pediatric high acuity, progressive, and critical care nursing (3rd ed.). Springer Publishing. The Children’s Hospital of Philadelphia. (2019). Age appropriate vision milestones. https://www.chop.edu/conditions-diseases/ age-appropriate-vision-milestones

CHAPTER 5 American College of Emergency Physicians. (2013). Geriatric emergency department guidelines. https://www.acep.org/globalassets/uplo ads/uploaded-files/acep/clinical-and-practice-management/resources/geriatrics/geri_ed_guidelines_final.pdf Mulkey, M. (2021). Understanding disorders of consciousness: Opportunities for critical care nurses. Critical Care Nurse, 41(6), 36–44. https://doi.org/10.4037/ccn2021344 Shea, S. S., Hoyt, K. S., & Holleran, R. (2016). Geriatric emergent/urgent and ambulatory care: The pocket NP. Springer Publishing.

CHAPTER 6 Visser, L., & Montejano, A. (2019). Fast facts for the triage nurse: An orientation and care guide. Springer Publishing.

CHAPTER 7 Centers for Medicare and Medicaid Services. (2010a). CMS manual system: Pub. 100-07 state operations provider certification. http:// www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R60SOMA.pdf Centers for Medicare and Medicaid Services. (2010b). State operations manual: Appendix V–interpretive guidelines—responsibilities of Medicare participating hospitals in emergency cases. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/ Downloads/som107ap_v_emerg.pdf Emergency Nurses Association. (2020). Sheehy’s emergency nursing principles and practice (7th ed.). Elsevier.

CHAPTER 8 Emergency Nurses Association. (2020). Trauma nursing core course provider manual (8th ed.). Jones and Bartlett. Visser, L., & Montejano, A. (2019). Fast facts for the triage nurse: An orientation and care guide. Springer Publishing.

CHAPTER 9 Alpert-Rathhauser, E., & Farkas, J. (2022). Epiglottitis. In F. Ferri (Ed.), Ferri’s clinical advisor 2022 (pp. 590–591.e1). Elsevier. Milici, J. (2018). Respiratory emergencies. In V. Sweet (Ed.), Emergency nursing core curriculum (pp. 452–472). Elsevier.

CHAPTER 10 Berens, P. (2022). Overview of the postpartum period: Disorders and complications. UpToDate. https://www.uptodate.com/contents/ overview-of-the-postpartum-period-disorders-and-complications#!

Additional Reading 421

422 Additional Reading Gibson, M., Corbalan, R., & Alexander, T. (2020, April 21). Acute ST-elevation myocardial infarction: The use of fibrinolytic therapy. UpToDate. https://www.uptodate.com/contents/acute-st-elevation-myocardial-infarction-the-use-of-fibrinolytic-therapy Jeffries, D., & Visser, L. (2022). Rapid access guide for pediatric emergencies. Springer Publishing. National Marfan Foundation. (2007). Aortic dissection: Red flag for the emergency triage nurse. Author. Navarroli, J. (2018). Cardiovascular emergencies. In V. Sweet (Ed.), Emergency nursing core curriculum (7th ed., pp. 142–182). Elsevier. O’Connell, K. (2018). Thoracic trauma. In V. Sweet (Ed.), Emergency nursing core curriculum (7th ed., pp. 598–611). Elsevier. Reeder, G. S., Awtry, E., & Mahler, S. A. (2022). Initial evaluation and management of suspected acute coronary syndrome (myocardial infarction, unstable angina) in the emergency department. UpToDate. https://www.uptodate.com/contents/initial-evaluationand-management-of-suspected-acute-coronary-syndrome-myocardial-infarction-unstable-angina-in-the-emergency-department?s earch=Initial%20evaluation%20and%20management%20of%20suspected%20acute%20coronary%20syndrome%20(myocardial %20infarction,%20unstable%20angina)%20in%20the%20emergency%20department.&source=search_result&selectedTitle=1~150 &usage_type=default&display_rank=1 Wilkes, G. (2017). Hiccups. In S. C. Dronen (Ed.), Medscape. http://emedicine.medscape.com/article/775746-overview#a

CHAPTER 11 American Stroke Association. (2022). Acute ischemic stroke. https://www.strokeassociation.org Cleveland Clinic. (2022). Brain bleed, hemorrhage. https://my.clevelandclinic.org/health/diseases/14480-brain-bleed-hemorrhageintracranial-hemorrhage#prevention Hammond, B. B., & Zimmermann, G. P. (Eds.). (2020). Sheehy’s manual of emergency care, (7th ed.). Elsevier. Jeffries, D., & Visser, L. (2022). Rapid access guide for pediatric emergencies. Springer Publishing. Mayo Clinic. (2022). Concussion. https://www.mayoclinic.org/diseases-conditions/concussion/symptoms-causes/syc-20355594 National Library of Medicine. (2022). Stroke. https://medlineplus.gov/stroke.html Payne, W., De Jesus, O., & Payne, A. (2022, May 29). Contrecoup brain injury. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/ books/NBK536965/

The Johns Hopkins University. (2022). Types of seizures. https://my.clevelandclinic.org/health/diseases/14480-brain-bleed-hemorrhage -intracranial-hemorrhage#prevention

CHAPTER 12 Flanagan, M. (2018). In V. Sweet (Ed.), Emergency nursing core curriculum (7th ed., pp. 126–141). Jeffries, D., & Visser, L. (2022). Rapid access guide for pediatric emergencies. Springer Publishing. Pergolizzi, J., Jr., LeQuang, J., & Bisney, J. (2018). Cannabinoid hyperemesis. Medical Cannabis and Cannabinoids, 1, 73–95. Triadafilopoulos, G. (2020). Boerhaave syndrome: Effort rupture of the esophagus. UpToDate. https://www.uptodate.com/contents/ boerhaave-syndrome-effort-rupture-of-the-esophagus?search=boerhaave&source=search_result&selectedTitle=1~17&usage_type =default&display_rank=1#H111872787

CHAPTER 13 Jeffries, D., & Visser, L. (2022). Rapid access guide for pediatric emergencies. Springer Publishing.

CHAPTER 14 American College of Obstetricians and Gynecologists. (2018). ACOG Committee opinion 736: Optimizing postpartum care. Obstetrics and Gynecology, 131(5), e140–e150. Centers for Disease Control and Prevention. (2021). Fast facts: Preventing intimate partner violence. https://www.cdc.gov/violencepreve ntion/intimatepartnerviolence/fastfact.html Centers for Disease Control and Prevention. (2021). Preventing intimate partner violence. https://www.cdc.gov/violenceprevention/pdf/ ipv/IPV-factsheet_2021.pdf

Additional Reading 423

424 Additional Reading Centers for Disease Control and Prevention. (2021). Sexual assault and abuse and STIs. https://www.cdc.gov/std/treatment-guidelines/ sexual-assault.htm Centers for Disease Control and Prevention. (2017). Injury prevention and control: Division of violence prevention. https://vetoviolence .cdc.gov/apps/connecting-the-dots/node/5 National Domestic Violence Hotline. (n.d). Power and control: Break free from abuse. https://www.thehot line.org/identify-abuse/ power-and-control/ National Domestic Violence Hotline. (n.d). Warning signs of abuse: Know what to look for. https://www.thehotline.org/identify-abuse/ domestic-abuse-warning-signs/ Rape, Abuse, & Incest National Network [RAINN]. (2022). Warning signs for college-age adults. https://www.rainn.org/articles/ warning-signs-college-age-adults Victim Rights Law Center. (2021). The victim rights law center. https://www.victimrights.org

CHAPTER 15 Emergency Nurses Association. (2018). Emergency nursing core curriculum (7th ed.). Elsevier. The American College of Obstetrics and Gynecologists. (2022). Health care for transgender and gender diverse individuals. https://www. acog.org/clinical/clinical-guidance/committee-opinion/articles/2021/03/health-care-for-transgender-and-gender-diverse-individuals Shea, S. S., & Hoyt, K. S. (2016). Family emergent/urgent and ambulatory care: The pocket NP. Springer Publishing.

CHAPTER 16 Emergency Nurses Association. (2020). Sheehy’s emergency nursing principles and practice (7th ed.). Elsevier. Emergency Nurses Association. (2018). Emergency nursing core curriculum (7th ed.). Elsevier. Morey, A. F., Brandes, S., & Dugi, D. D. (2020). Urotrauma guideline. 2020 https://www.auanet.org/guidelines/guidelines/ urotrauma-guideline

National Organization for Rare Disorders. (2021). Fournier gangrene. https://rarediseases.org/rare-diseases/fournier-gangrene/ Shah, A. (2019, June). Priapism. Merck Manual Professional Version. Priapism. https://www.merckmanuals.com/professional/ genitourinary-disorders/symptoms-of-genitourinary-disorders/priapism?query=priapism Shenot, P. (2019, August). Testicular torsion. Merck Manual Professional Version. https://www.merckmanuals.com/professional/ genitourinary-disorders/penile-and-scrotal-disorders/testicular-torsion?query=testicular%20torsion Wu, H., Wang, F., Tang, D., & Han, D. (2021). Mumps orchitis: Clinical aspects and mechanisms. Frontiers in Immunology, 12, 582946. https://doi.org/10.3389/fimmu.2021.582946

CHAPTER 17 American Academy of Ophthamology [AAOa]. (2021, November). Cellulitis. https://www.aao.org/eye-health/diseases/cellulitis-treatment American Academy of Ophthamology [AAOb]. (2022, January 7). What is a corneal ulcer (keratitis)? https://www.aao.org/eye-health/ diseases/corneal-ulcer American Optometric Association. (2019). Preschool vision: 3 to 5 years of age. https://www.aoa.org/patients-and-public/good-vision -throughout-life/childrens-vision/preschool-vision-3-to-5-years-of-age American Optometric Association. (2017). Evidence-based clinical practice guideline: Comprehensive pediatric eye and vision exam. https://www.aoa.org/AOA/Documents/Practice%20Management/Clinical%20Guidelines/EBO%20Guidelines/Comprehensive%20 Pediatric%20Eye%20and%20Vision%20Exam.pdf American Optometric Association. (n.d). Pediatric eye and vision examination. https://www.aoa.org Boyd, K. (2021, September 14). Detached retina https://www.aao.org/eye-health/diseases/detached-torn-retina Cleveland Clinic. (2019, August 15). Children’s eye care. https://my.clevelandclinic.org/health/articles/5445-childrens-eye-care Emergency Nurses Association. (2020). Sheehy’s emergency nursing principles and practice (7th ed.). Elsevier. Emergency Nurses Association. (2018). Emergency nursing core curriculum (7th ed.). Elsevier. Emergency Nurses Association. (2020). Provider manual ENPC emergency nursing pediatric course. (5th ed.). Gilboy, N., Tanabe, P., Travers, D., & Rosenau, A. M. (2012). Emergency Severity Index (ESI): A triage tool for emergency department care, version 4, implementation handbook 2012 edition. Agency for Healthcare Research and Quality.

Additional Reading 425

426 Additional Reading MacGrory, B., Schrag, M., Biousse, V., Furie, K. L., Gerhard-Herman, M., Lavin, P. J., Sobrin, L., Tjoumakaris, S. I., Weyand, C. M., Yaghi, S., & on behalf of the American Heart Association Stroke Council; Council on Arteriosclerosis, Thrombosis and Vascular Biology. (2021, March). Management of central retinal artery occlusion: A scientific statement from the American Heart Association. Stroke, 52, e282–e294. https://doi.org/10.1161/STR.0000000000000366 Shea, S. S., & Hoyt, K. S. (2016). Family emergent/urgent and ambulatory care: The pocket NP. Springer Publishing. Sim, S., & Ting, S. W. (2017, August). Diagnosis and management of central retinal artery occlusion. Eye Net Magazine, 33–35. https:// www.aao.org/eyenet/article/diagnosis-and-management-of-crao Visser, L., & Montejano, A. (2019). Fast facts for the triage nurse: An orientation and care guide. Springer Publishing.

CHAPTER 18 Broering, B. (2010). Head trauma. In K. P. Howard & R. Steinmann (Eds.), Sheehy’s emergency nursing principles and practice (6th ed., pp. 254–271). Elsevier. Children’s Hospital of Philadelphia. (2021). Laryngeal trauma. https://doi.org/10.1016/j.radcr.2021.01.002 Chow, A. (2021). Submandibular space infections (Ludwig’s angina). UpToDate. https://www.uptodate.com/contents/ submandibular-space-infections-ludwigs-angina Emergency Nurses Association. (2020). Sheehy’s emergency nursing principles and practice (7th ed.). Elsevier. Emergency Nurses Association. (2018). Emergency nursing core curriculum (7th ed.). Elsevier. Galioto, N. (2017, April 15). Peritonsillar abscess. American Family Physician, 95(8), 501–506. https://www.aafp.org/afp/2017/0415/p50 1.html Rai, S., & Anjum, F. (2021, August 30). Laryngeal fracture. https://www.ncbi.nlm.nih.gov/books/NBK562276/ Shea, S. S., & Hoyt, K. S. (2016). Family emergent/urgent and ambulatory care: The pocket NP. Springer Publishing. Tsur, N., Amitai, N., S, Shoffel-Havakuk, Abuhasira, & Hamzany, Y. (2021, March). Forceful sneeze: An uncommon case of laryngeal fracture. Radiology Case Reports, 16(3), 742–743. https://doi.org/10.1016/j.radcr.2021.01.002

CHAPTER 19 American Association of Neurological Surgeons. (2022). Cauda equine syndrome. https://www.aans.org/en/Patients/ Neurosurgical-Conditions-and- Treatments/Cauda-Equina-Syndrome Jeffries, D., & Visser, L. (2022). Rapid access guide for pediatric emergencies. Springer Publishing.

CHAPTER 20 Centers for Disease Control and Prevention. (2022, April 29). Healthcare workers: Information on COVID-19 https://www.cdc.gov/corona virus/2019-ncov/hcp/index.html Centers for Disease Control and Prevention. (2011). TB elimination: Diagnosis of tuberculosis disease. https://www.cdc.gov/tb/ publications/factsheets/testing/diagnosis.pdf Gilboy, N., Tanabe, P., Travers, D., & Rosenau, A. M. (2012). Emergency Severity Index (ESI): A triage tool for emergency department care, version 4, implementation handbook 2012 edition. Agency for Healthcare Research and Quality. Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & Healthcare Infection Control Practices Advisory Committee. (2017, October). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. CDC. https://www.cdc .gov/infectioncontrol/pdf/guidelines/isolation-guidelines.pdf Sweet, V (Ed.). (2018). Emergency nursing core curriculum (7th ed.). Elsevier.

CHAPTER 21 Adeyinka, A. (2021). Tumor lysis syndrome. StatPearls. https://www.statpearls.com/articlelibrary/viewarticle/30680/ Emergency Nurses Association. (2020). Sheehy’s emergency nursing principles and practice (7th ed.). Elsevier. Kaplow, R. (2016). Understanding spinal cord compression. Nursing, 46(9), 44–51. Punnipuzha, S., Edemobi, P., & Elmoheen, A. (2021). Febrile neutropenia. StatPearls.

Additional Reading 427

428 Additional Reading

CHAPTER 22 Boyer, E., & Weibrecht, K. (2021, June 23). Salicylate (aspirin) poisoning in adults. UpToDate. https://www.uptodate.com/contents/ salicylate-aspirin-poisoning-in-adults?search=salicylate%20overdose&source=search_result&selectedTitle=1~118&usage_type=de fault&display_rank=1#H3130958597 Jeffries, D., & Visser, L. (2022). Rapid access guide for pediatric emergencies. Springer Publishing. Sturt, P. (2010). Toxicologic emergencies. In P. K. Howard & R. A. Steinmann (Eds.), Sheehy’s emergency nursing: Principles and practice (6th ed., pp. 564–577). Elsevier. World Health Organization. (2019). Worldwide poison centers. http://globalcrisis.info/poisonemergency.html#AAA

CHAPTER 23 Arnold, T. C. (2017). Brown recluse spider envenomation. J. Alcock (Ed.), Medscape http://emedicine.medscape.com/article/ 772295-overview#a3 Auerbach, P. S. (2007). Envenomation by aquatic vertebrates. In Wilderness medicine (5th ed., p. 1732). Elsevier. Bush, S. P., & Cohen, J. P. (2017). Widow spider envenomation. J. Alcock (Ed.), Medscape http://emedicine.medscape.com/article/ 772196-overview Centers for Disease Control and Prevention. (2021, June 28). Rattlesnakes. https://www.cdc.gov/niosh/topics/snakes/types.html Centers for Disease Control and Prevention. (2018, May 31). Brown recluse. https://www.cdc.gov/niosh/topics/spiders/types.html Dart, R., & White, J. (2007). Snakebite: A brief medical guide. 3–28–79–26.46.95. Hodge, D. (2010). Bites and stings. In G. R. Fleisher & S. Ludwig (Eds.), Textbook of pediatric emergency medicine (6th ed., p. 671). Lippincott Williams and Wilkins. Isbister, G. K. (2018). Marine envenomation’s from corals, sea urchins, fish or stingrays. UpToDate. https://www.uptodate.com/contents/ marine-envenomations-from-corals-sea-urchins-fish-or-stingrays#H21432535

Lavonas, E. J., Ruha, A.-M., Banner, W., Bebarta, V., Bernstein, J. N., Bush., P. S., Kerns, W. P., Richardson, H. W., Seifert., A. S., Tanen, D. A., Curry, S. C., & Dart, R. C. (2011). Unified treatment algorithm for the management of crotaline snakebite in the United States. BMC Emergency Medicine, 11(2).https://doi.org/10.1186/1471-227X-11-2 Morrissey, J., & Johnson, D. (2008). The field guide to wilderness and rescue medicine (4th ed., pp. 55–59). Wilderness Medical Associates. Norris, R. L., & Bush, S. P. (2007). North American venomous reptile bites. In P. S. Auerbach (Ed.), Wilderness medicine (5th ed.). Elsevier. Winter, K. L., Isbister, G. K., Schneider, J. J., Konstantakopoulos, N., Seymour, J. E., & Hodgson, W. C. (2008). An examination of the cardiovascular effects of an “Irukandji” jellyfish, Alatinanr mordens. Toxicology Letters, 179, 118–123. https://doi.org/10.1016/j. toxlet.2008.04.011 World Health Organization. (2013). Animal bites fact sheet. http://www.who.int/mediacentre/factsheets/fs373/en

CHAPTER 24 Arnold, T. C. (2017). Brown recluse spider envenomation. J. Alcock (Ed.), Medscape http://emedicine.medscape.com/article/ 772295-overview#a3 Auerbach, P. S. (2007). Envenomation by aquatic vertebrates. In Wilderness medicine (5th ed., p. 1732). Elsevier. Bush, S. P., & Cohen, J. P. (2017). Widow spider envenomation. J. Alcock (Ed.), Medscape http://emedicine.medscape.com/article/ 772196-overview Centers for Disease Control and Prevention. (2018, May 31). Brown recluse. https://www.cdc.gov/niosh/topics/spiders/types.html Centers for Disease Control and Prevention. (2021, June 28). Rattlesnakes. https://www.cdc.gov/niosh/topics/snakes/types.html Dart, R., & White, J. (2007). Snakebite: A brief medical guide. 3–28–79–26.46.95. Hodge, D. (2010). Bites and stings. In G. R. Fleisher & S. Ludwig (Eds.), Textbook of pediatric emergency medicine (6th ed., p. 671). Lippincott Williams and Wilkins. Isbister, G. K. (2018). Marine envenomation’s from corals, sea urchins, fish or stingrays. UpToDate. https://www.uptodate.com/contents/ marine-envenomations-from-corals-sea-urchins-fish-or-stingrays#H21432535 Jeffries, D., & Visser, L. (2022). Rapid access guide for pediatric emergencies. Springer Publishing.

Additional Reading 429

430 Additional Reading Lavonas, E. J., Ruha, A.-M., Banner, W., Bebarta, V., Bernstein, J. N., Bush., P. S., Kerns, W. P., Richardson, H. W., Seifert., A. S., Tanen, D. A., Curry, S. C., & Dart, R. C. (2011). Unified treatment algorithm for the management of crotaline snakebite in the United States. BMC Emergency Medicine, 11.https://doi.org/10.1186/1471-227X-11-2 Morrissey, J., & Johnson, D. (2008). The field guide to wilderness and rescue medicine (4th ed., pp. 55–59). Wilderness Medical Associates. Norris, R. L., & Bush, S. P. (2007). North American venomous reptile bites. In P. S. Auerbach (Ed.), Wilderness medicine (5th ed.). Elsevier. Winter, K. L., Isbister, G. K., Schneider, J. J., Konstantakopoulos, N., Seymour, J. E., & Hodgson, W. C. (2008). An examination of the cardiovascular effects of an “Irukandji” jellyfish. Alatinanr mordens. Toxicology Letters, 179, 118–123. https://doi.org/10.1016/j. toxlet.2008.04.011 World Health Organization. (2013). Animal bites fact sheet. http://www.who.int/mediacentre/factsheets/fs373/en

CHAPTER 25 Centers for Disease Control and Prevention. (2021). Fast facts: Preventing intimate partner violence. https://www.cdc.gov/ violenceprevention/intimatepartnerviolence/fastfact.html Centers for Disease Control and Prevention. (2021). Preventing intimate partner violence. https://www.cdc.gov/violenceprevention/pdf/ ipv/IPV-factsheet_2021.pdf Centers for Disease Control and Prevention. (2021). Sexual assault and abuse and STIs. https://www.cdc.gov/std/treatment-guidelines/ sexual-assault.htm Centers for Disease Control and Prevention. (2017). Injury prevention and control: Division of violence prevention. https://vetoviolence .cdc.gov/apps/connecting-the-dots/node/5 National Domestic Violence Hotline. (n.d). Power and control: Break free from abuse. https://www.thehotline.org/identify-abuse/ power-and-control/ National Domestic Violence Hotline. (n.d). Warning signs of abuse: Know what to look for. https://www.thehotline.org/identify-abuse/ domestic-abuse-warning-signs/ Rape, Abuse, & Incest National Network (RAINN).

Victim Rights Law Center. (2021). The victim rights law center. https://victimrights.org

CHAPTER 26 Anti-slavery International. (2019). What is human trafficking? https://www.antislavery.org/slavery-today/human-trafficking/ Byrne, M., Parsh, S., & Parsh, B. (2019). Human trafficking: Impact, identification, and intervention. Nursing Management, 50(8), 18–24. https://doi.org/ 10.1097/01.NUMA.0000575304.15432.07 De Chesnay, M. (2013). Sex trafficking: A clinical guide for nurses. Springer Publishing. Emergency Nurses Association. (2018). Emergency nursing core curriculum (7th ed.). Elsevier. Emergency Nurses Association. (2020). Emergency nurse pediatric course: Provider manual (5th ed.). Jones and Bartlett. Emergency Nurses Association. (2020). Sheehy’s emergency nursing principles and practice (7th ed.). Elsevier. Homeland Security. (n.d). Indicators of human trafficking. https://www.dhs.gov/blue-campaign/indicators-human-trafficking Homeland Security. (n.d). What is human trafficking? https://www.dhs.gov/blue-campaign/what-human-trafficking International Labour Organization. (2017, September 19). 40 million in modern slavery and 152 million in child labour around the world. https://www.ilo.org/global/about-the-ilo/newsroom/news/WCMS_574717/lang--en/index.htm Jeffries, D., & Visser, L. (2022). Rapid access guide for pediatric emergencies. Springer Publishing. Konstantopoulos, W. on behalf of the ACEP Work Group. (2018, May 25). The complexities of recognizing and responding to trafficked patients in the ED. https://www.acepnow.com/article/the-complexities-of-recognizing-and-responding-to-trafficked-patients-in -the-ed/ Lamb-Susca, L., & Clements, P. T. (2018, November). Intersection of human trafficking and the emergency department. Journal of Emergency Nursing, 44(6), 563–569. https://doi.org/ 10.1016/jen.2018.06.001 National Human Trafficking Hotline. (n.d). What is human trafficking? https://humantraffickinghotline.org/what-human-trafficking National Human Trafficking Resource Center. (n.d). Identifying victims of human trafficking: What to look for in a healthcare setting. ​​​​​​​ https://humantraffickinghotline.org/sites/default/files/What%20to%20Look%20for%20dur ing%20a%20Medical%20Exam%20-%2 0FINAL%20-%202-16-16.docx.pdf

Additional Reading 431

432 Additional Reading National Human Trafficking Resource Center [NHTRC]. (2016). Framework for a human trafficking protocol in healthcare settings. https:// humantraffickinghotline.org/resources/framework-human-trafficking-protocol-healthcare-settings Normandin, P. (2017). Child human trafficking: See, pull, cut the threads of abuse. Journal of Emergency Nursing, 43(6), 588–590. https:// www.jenonline.org/article/S0099-1767(17)30416-6/references Oldham, J. (2018, March). Human Trafficking. Journal of Psychiatric Patients, 24(2), 71. https://journals.lww.com/practicalpsychiatry/fullt ext/2018/03000/human_trafficking.1.aspx Ramnauth, T., Benitez, M., Logan, B., Abraham, S., & Gillum, D. (2018, May 29). Nurses’ awareness regarding human trafficking. International Journal of Studies in Nursing, 3(2). http://journal.julypress.com/index.php/ijsn/article/view/389 https://doi.org/10.20849/ ijsn.v3i2.389 Tracy, E. E., & Macias-Konstantopoulos, W. (2021). Human trafficking: Identification and evaluation in the health care setting. UpToDate. https://www.uptodate.com/contents/human-trafficking-identification-and-evaluation-in-the-health-care-setting United Nations Office on Drugs and Crime. (2016). Global report on trafficking in persons 2016. https://www.unodc.org/documents/ data-and-analysis/glotip/2016_Global_Report

CHAPTER 27 American College of Emergency Physicians. (2017). EMS management of patients with potential spinal injury. https://www.acep.org/clini cal—practice-management/ems-management-of-patients-with-potential-spinal-injury American College of Surgeons. (2018). Advanced trauma life support. (10th ed.). Author Emergency Nurses Association. (2020). Trauma nursing core course provider manual (8th ed.). Jones and Bartlett. Slota, M.C. (Ed.). (2019). Pediatric high acuity, progressive, and critical care nursing, (3rd ed.). Springer Publishing.

CHAPTER 28 American Burn Association (ABA). (2018). Chapter 8: Pediatric burns. In Advanced burn life support course: Provider manual (2018 update), (pp. 59–67). Author. American Burn Association. (2017). Burn center referral criteria. http://ameriburn.org/wp-content/uploads/2017/05/ burncenterreferralcriteria.pdf Briggs, J. K., & Grossman, V. A. (2020, Ed 2). Emergency nursing 5-tier triage protocols. Springer Publishing. https://doi .org/10.1891/9780826137913 Emergency Nurses Association (ENAb). (2020). Trauma nursing core course provider manual, (8th ed.). Jones and Bartlett. Gilboy, N., Tanabe, P., Travers, D., & Rosenau, A. M. (2012). Emergency Severity Index (ESI): A triage tool for emergency department care, version 4, implementation handbook 2012 edition. Agency for Healthcare Research and Quality. Jeffries, D., & Visser, L. (2022). Rapid access guide for pediatric emergencies. Springer Publishing.

CHAPTER 29 Active Shooter Incidents 20-Year Review, 2000-2019. https://www.fbi.gov/file-repository/active-shooter-incidents-20-year-review2000-2019-060121.pdf/view FBI Active Shooter Incidents in the United States in 2020. https://www.fbi.gov/file-repository/active-shooter-incidents-in-the-us2020-070121.pdf/view

CHAPTER 30 Altered Standards of Care in a Mass Casualty Event. http://www.ahrq.gov/research/altstand/ ATSDR - Health Risk Communication Primer. http://www.atsdr.cdc.gov/HEC/primer.html

Additional Reading 433

434 Additional Reading California Department of Public Health Standards and Guidelines for Healthcare Surge During Emergencies. (2013). https://www.calhosp italprepare.org/sites/main/files/file-attachments/volume1_hospital_final.pdf California Emergency Medical Services Agency (EMSA. (2014). HICS http://www.emsa.ca.gov/disaster_medical_services_division_hospi tal_incident_command_system Carbine, D., Cohen, R., Hopper, A., Murphy, B., Phillips, P., & Powers, R. (2015). Neonatal disaster preparedness toolkit. N.p. California Association of Neonatologists. https://www.cpqcc.org/sites/default/files/DP_Toolkit_-_final__2-5-15.pdf\ Centers for Disease Control and Prevention. (2020). Crisis and emergency risk communication. Author. https://emergency.cdc.gov/cerc/ Center for HICS - Emergency Preparedness (calhospitalprepare.org) Code of Federal Regulations: 42 CFR §482.15 Condition of participation. Emergency Preparedness. Harvard Medical International Ltd. (2014). Advanced disaster medical response for providers. The Joint Commission. (2022). Standards on emergency management: EM 09.01.01 – EM 17.01.01. Lin, A., Taylor, K., & Cohen, R. S. (2018). Triage by resource allocation for in-patients: A novel disaster triage tool for hospitalized pediatric patients - Los Angeles county emergency operations plan - Civil disturbance annex. https://emergency.lacity.org/sites/g/files/wph49 6/f/Civil%20Disturbance%20Annex%202018_1.pdf National Fire Protection Agency. (2006). Emergency evacuation planning guide for people with disabilities; FEMA emergency support function #8. In Public Health and Medical Services (pp. IS–808). National Incident Management System: Command and Coordination and Appendix A: Incident Command System and Appendix B: EOC Organization. (2017). https://www.fema.gov/sites/default/files/2020-07/fema_nims_doctrine-2017.pdf National Incident Management System (NIMS) Compliance Guidance for Healthcare Organizations. http://www.fema.gov/ implementation-and-compliance-guidance-stakeholders Occupational Safety and Health Administration. (2020). Guidance on Preparing Workplaces for Pandemic Influenza. https://www.osha .gov/Publications/influenza_pandemic.htmlState Preparing for Civil Unrest National Fire Academy. (2019). https://nfa.usfa.fema.gov/pdf/efop/efo248668.pdf PRISM: Primary Response Incident Scene Management. https://www.medicalcountermeasures.gov/barda/cbrn/prism// Public Health Emergency Preparedness and Response Capabilities. https://www.cdc.gov/cpr/readiness/00_docs/CDC_PreparednesRes ponseCapabilities_October2018_Final_508.pdf

Satellite Broadcast: Preparing for Radiological Population Monitoring & Decontamination. http://www.phppo.cdc.gov/PHTN/Radiologica l2006/default.asp Standardized Emergency Management System (SEMS) Guidelines, Part I. System Description Section A. http://www.caloes.ca.gov/ cal-oes-divisions/planning-preparedness/standardized-emergency-management-system Substance Abuse and Mental Health Services Administration. (2019). Communicating in a crisis: Risk communication guidelines for public officials. https://store.samhsa.gov/product/communicating-crisis-risk-communication-guidelines-public-officials/ pep19-01-01-005 World Health Organization. (2020). Who pandemic phase descriptions and main actions by phase. Author. https://www.who.int/influenza/ resources/documents/pandemic_phase_descriptions_and_actions.pdf

Additional Reading 435

INDEX A-B-C-D-E of the pediatric patient, 27 abdominal emergencies, 37–38 abdomen, diagnostic considerations based on anatomy of, 139 abdominal/flank pain, 129 chief complaints, 125 foreign body, 131 heartburn/epigastric pain, 132 hiccups, 133 key tips, 127, 128 nausea/vomiting/diarrhea, 134 older adult considerations, 53 persistent hiccups, emergency causes of, 140 red flags, 126 triage considerations, 126 urinary catheter problems, 135 urinary problems, 136 worst-case scenarios, 137–138 abdominal/flank pain abdominal emergencies, 129 stool and/or vomit, blood in, 130

abdominal pain, 161–162 abnormal movement, 239 abruptio placentae, 170 ACE inhibitors, 57 across-the-room assessment, 1 active shooter/active threat active shooter/active violence, incident response for, 374–377 critical first minutes postinjury, 378 definitions, 372 department and potential direct threat, incident, 376 department/unit, incident, 376 facility grounds or parking areas, incident, 375 law enforcement response, prepare for, 377–378 “life-threatening” bleeding, identifying and treatment, 378 potential threat, recognition of, 373 resource numbers, 372 situational awareness, 374 suspicious package or improvised explosive device discovered, 376 treatment, 378

437

438 Index activities of daily living (ADL), 65 acute angle closure glaucoma, 206 acute chest syndrome (ACS), 264 acute coronary syndrome (ACS), 95, 102 Addisonian crisis, 147 Adult Glasgow Coma Scale, 123, 352 against medical advice (AMA), 72 aggression, 312 aggressive behavior, 305 agitated behavior, 305 agitation, 312 airway, 27 airway compromise, 368 alcohol, 269–271, 273 alcohol withdrawal, 317 alcohol withdrawal delirium (AWD), 312 alkaline burns, 368 altered mental status (AMS), 113–114 alternating current (AC) exposure, 368 amputation, 226, 228–229, 340 anger pathway, 318 ankle, amputation proximal to, 341–342 anorexia nervosa, 312 anticipated orders, 4 antihistamines, 269–270

anxious behavior, 305 aortic aneurysm/dissection, 102 APGAR score, 160 appendicitis, 137 atypical acute myocardial infarction, signs and symptoms of, 105 auditory hallucinations, 311 auto collision, 366–367 AVPU mnemonic, level of consciousness assessment using, 123

back pain, 154, 161–162 cardiac emergencies, 97–98 musculoskeletal emergencies, 230 bee, 295–296, 299 behavioral health emergencies, 46 alcohol withdrawal, signs and symptoms of, 317 anger pathway, 318, 319 change in behavior, 305–306 chief complaints, 301 key tips, 303–304 older adult considerations, 64 red flags, 301–302 suicidal attempt, 307–309

suicidal or homicidal thoughts with or without intent, 310 suicide risk, degree/severity of, 317 visual and auditory hallucinations, 311 warning signs of suicide, 316 worst-case scenarios, 302, 312–315 Bell’s palsy, 112 benzodiazepines, 269–270 bilious emesis, 38 binge eating, 312 bite and sting emergencies, 46 cat, dog, other non-human mammals and human, 288–289 chief complaints, 286 key tips, 287 marine animal injuries, 290–291 older adult considerations, 64 red flags, 286 snake bites, 291–292 spider bites, 293–294 stings, 295–296 worst-case scenarios, 287, 296–300 bites, 296 bizarre behavior, 305 black widow, 293–295, 298 bleeding hematologic and oncologic emergencies, 257

uncontrolled, 231–232 vagina from, 164–165 blunt trauma, 340–341, 343–344 blurred vision, 166 Boerhaave syndrome, 137 bowel obstruction, 137 breathing, 27 breech fetal presentation, 170 brief resolved unexplained event (BRUE), 33 brown recluse, 293–294, 299 bruising, 146 hematologic and oncologic emergencies, 257 bulimia nervosa, 312 burn emergencies, 49 chemical burns, 361–362 chief complaints, 357 electrical burns, 364–365 key tips, 360 older adult considerations, 65 Parkland Burn Resuscitation Formula, 370 red flags, 358 thermal burns, 366–367 worst-case scenarios, 358, 368–369 burn table, 371 for infants and children, 50

Index 439

440 Index caffeine/energy drinks, 271–272 carbon monoxide (CO) poisoning, 369 cardiac emergencies, 35–36 atypical acute myocardial infarction, signs and symptoms of, 105 cardiac and respiratory high acuity conditions, 104 chest, jaw, neck, back, epigastric, and/or scapular pain, 97–98 chief complaints, 93 dyspnea, 98–99 fatigue/weakness, 99–100 heart, leads representative of different areas of, 108 key tips, 95–96 older adult considerations, 58 palpitations, 100–101 red flags, 94 right-sided 12-lead EKG electrode placement, 107 standard left-sided 12-lead EKG electrode placement, 106 syncopal episode, 101–102 thrombolytics, absolute and relative contraindications to, 108 triage considerations, 94–95 worst-case scenarios, 102–104 cardiac tamponade, 351 cardiomyopathy, 170 cauda equina syndrome, 240 central retinal artery occlusion, 206

cerebrovascular accident, 119 chemical exposure/burn, 195–196, 206, 359, 361–362 types of, 211, 363 CHEMPACK, 382 chest pain, cardiac emergencies, 97–98 chief complaints, 5 child maltreatment, 49, 51 circulation, 27 circumferential burns, 369 CNS depressants, 269–270 CNS stimulants, 271–272 cobras, 291–292 cocaine, 271–272 Color-Coded Triage System, 394–395 Command Section, 384–385 communication, 33 older adult considerations, 56 compartment syndrome, 240 comprehensive triage assessment, 13–14 concussion, 119 contact, 361–364 with power lines, 364–365 copperheads, 291–292 coral snake, 291–292, 298 cotton mouths, 291–292

coup-contrecoup injury, 120 COVID-19, 248 critical first minutes postinjury, 378 critical incident stress management, during and after disaster, 397 critical triage concept, 7 crush injury, to extremity, 233 crying behavior, 305 Cushing’s disease/syndrome, 147

decontamination CBRN, donning/doffing of level C, 391–393 personal protective equipment for, 391 recommended control zones for, 390 dehydration, 154 delirium, 59–65 dementia, 60 dental, ear, nose, throat, and facial emergencies, 40–41 chief complaints, 212 dysphagia, 215–216 facial swelling/injury, 217–218 foreign body, 219 key tips, 214–215 older adult considerations, 62–63 red flags, 213

sore throat, 220 tooth avulsion/dental pain, 221–222 worst-case scenarios, 213, 222–223 dental pain, 221–222 depressed behavior, 305 diabetes insipidus, 147 diabetic ketoacidosis (DKA), 147 diarrhea, 134 difficulty breathing, 88 hematologic and oncologic emergencies, 256 difficulty urinating, 186–187 diphtheria, 249 disability, 27 disaster, 381 emergency management during CBRN decontamination, donning/doffing of level C, 391–393 contact numbers, 379–380 critical incident stress management during and after, 397 decontamination, recommended control zones for, 390 definitions, 380–382 hospital incident command system, 384–385 incidents and response, 386 multicasualty/mass casualty incident triage, 394–395 natural disasters, 386 occurs during your shift, 383–384

Index 441

442 Index disaster (cont.) personal protective equipment, for decontamination, 391 state and regional disaster medical resources, 398–400 vulnerable populations, disaster response for, 396–397 disaster (and multicasualty) triage, 382 disaster medical assistance team (DMAT), 381 dislocation/fracture, suspected, 234–235 dissecting aneurysm, 120 disseminated intravascular coagulation (DIC), 170, 264 dizziness, hematologic and oncologic emergencies, 258 dysphagia, 215–216 dyspnea, 98–99

eating disorders, 312 eclampsia, 171 ectopic pregnancy, 171, 180 ED metrics, 15 elapids, 291–292 electrical burns, 364–365 electrical lightning strike, 364–365 electrical shock, 359 emergency management, 380 during disaster CBRN decontamination, donning/doffing of level C, 391–393 contact numbers, 379–380

critical incident stress management during and after, 397 decontamination, recommended control zones for, 390 definitions, 380–382 hospital incident command system, 384–385 incidents and response, 386 multicasualty/mass casualty incident (MCI) triage, 394–395 natural disasters, 386 occurs during your shift, 383–384 personal protective equipment, for decontamination, 391 state and regional disaster medical resources, 398–400 vulnerable populations, disaster response for, 396–397 emergency medical condition (EMC), 72 Emergency Medical Treatment and Active Labor Act (EMTALA), 72 emergency operations plan (EOP), 381 endocarditis, 102 endocrine emergencies, 38 chief complaints, 142 key tips, 144 lab values seen in, 150 older adult considerations, 61 polyuria, polydipsia, and polyphagia, 145 red flags, 143 skin hyperpigmentation, bruising, unusual fat deposits, expothalmos, and neck swelling, 146

triage considerations, 143 worst-case scenarios, 143, 147–149 endophthalmitis, 206 epididymitis, 190 epigastric pain, 132 cardiac emergencies, 97–98 epiglottitis, 91 epistaxis, 222 esophageal varices, 138 expose/environment, 28 exposure issues, 68 expothalmos, 146 extremity crush injury to, 233 temperature regulation to, 237 eye(s) infection, 198–199 pain, 200–201 treatment for, 211

fatigue/weakness, 99–100 febrile neutropenia, 264 fetal demise, 171 fetal movement, absence of, 163–164 fever, 244–245 hematologic and oncologic emergencies, 259 rash with, 247–248 finance/administration section, 385 fire ant, 295–296, 299 five-level triage scale, 9–10 flank pain, abdominal emergencies, 129 foreign body abdominal emergencies, 131 dental, ear, nose, throat, and facial emergencies, 219 ingestion/aspiration, 90 ocular emergencies, 197–198 Fournier’s gangrene, 190 fractured penis, 191 fractures, types of, 42

facial swelling/injury, 217–218 facial/tongue swelling, 89 falls, 345–347 FAST (stroke) assessment, neurologic emergencies, 121

general staff section, 385 guide, 1 goal of, 1 layout, 2–5

Index 443

444 Index gunshot/projectile, 349 gynecologic emergencies, 39 abdomen, lower abdominal diagnostic considerations, 182 chief complaints, 174 older adult considerations, 61 pelvic pain/lower abdominal pain, 177–178 red flags, 174 vaginal bleeding, 178–179 worst-case scenarios, 175, 180–181

headache, 166 hematologic and oncologic emergencies, 260 neurologic emergencies, 116–117 head injury, 345–346 heartburn, 132 hematologic and oncologic emergencies, 44–45 bleeding/bruising, 257 chief complaints, 253 difficulty breathing, 256 dizziness/syncope, 258 fever, 259 headache, 260 infection, 261 key tips, 255 older adult considerations, 64

pain, 262 red flags, 254 weakness, 263 worst-case scenarios, 254, 264–266 Hemolysis, Elevated Liver Enzymes, and Low Platelets (HELLP) Syndrome, 171 hemophilia (A&B), 265 hemorrhagic fever, 249 hemothorax, 351 hiccups, 133 high-pressure injury, 235–236, 349–350 high-risk presentations, 81–82 A-B-C-D-E assessment, 80–81 advanced triage protocols/standardized orders, 83 PQRST questions, 83 reassessment, 83 vital signs, 82 homicidal ideation or attempt, 313 hornet, 295–296, 299 hospital incident command system (HICS), 381, 384–385 house fire, 366–367 human, 297 human trafficking, 48 chief complaints, 329 key tips, 332–333

questions to ask, 335 red flags, 330 risk factors for, 334 triage considerations, 331 hyperemesis gravidarum, 172 hyperosmolar hyperglycemic state (HHS), 148 hypertension, 95 hypertensive crisis, 103 hyphema, 207 hypoglycemia, 148 hypoperfusion, 54 hypothermia, 32

idiopathic thrombocytopenia, 265 imminent or precipitous delivery, 156–158 incarcerated inguinal hernia, 191 incident action plan (IAP), 381 incident commander (IC), 384 infection eye(s), 198–199 hematologic and oncologic emergencies, 261 infectious and communicable disease emergencies, 44

chief complaints, 241 fever, 244–245 isolation precaution guidelines, 251 key tips, 243 older adult considerations, 63 rash, rapidly progressing, 245–246 rash with fever, 247–248 red flags, 241 worst-case scenarios, 242, 248–250 ingestion, 361–362 CNS depressants, 269–270 CNS stimulants, 271–272 inhalation, 361–362 injection, 361–362 intimate partner violence (IPV), 48 chief complaints, 320 collection of evidence, 327 key tips, 324–326 red flags, 321–322 sexual assault, risk factors for, 328 triage considerations, 323 iron toxicity, stages of, 285 ischemic optic neuropathy, 207 isolated eye injury, 202–203

Index 445

446 Index isolation precautions, types of, 70–71 IV fluid bolus, 38

jaw pain, cardiac emergencies, 97–98 jellyfish, 290–291, 297

kidney stones, 128

large BSA burns, 368 laryngeal fracture, 223 law enforcement response, prepare for, 377–378 left without being seen (LWBS), 72 legal issues concepts and definitions, 72 minimizing risk at triage, 73–75 assessment, 73 documentation, 75 nurse behaviors, 73–74 patient leaving without treatment, 76 reportable conditions and events, 77 risk management, report to, 78 length-based tape, 19 liaison officer, 384

limb deformity, 226 logistics section, 385 loss of control, 136 loss of function, 237 lower abdominal pain, gynecologic emergencies, 177–178 Ludwig’s angina, 86, 91, 215, 223

male reproductive emergencies, 39 chief complaints, 183 difficulty urinating, 186–187 key tips, 185 older adult considerations, 62 pain or penile discharge, 187–188 red flags, 184 urinary catheter problems, 189–190 worst-case scenarios, 184, 190–191 maltreatment, older adult considerations, 65 mambas, 291–292 mania, 313 manic behavior, 305 Marfan syndrome, 95 marine animal injuries, 290–291, 297–298 mass casualty incident (MCI), 381 trauma incidents, 387–388 maternal fever, 155

measles, 249 medical screening exam (MSE), 72 medical-technical specialists, 385 meningitis, 249 methamphetamine, 271–272 miscarriage, 167 mnemonic, delirium, 59–65 mnemonics, 30–31 multicasualty/mass casualty incident (MCI) triage, 394–395 multiple casualty incident, 381 musculoskeletal emergencies, 41–44 amputation, 228–229 amputation/limb deformity considerations, 226 back pain, 230 bleeding, uncontrolled, 231–232 chief complaints, 224 dislocation/fracture, suspected, 234–235 extremity, crush injury to, 233 high-pressure injury, 235–236 key tips, 227 loss of function/sensation/temperature regulation to extremity, 237 neck pain/injury, 238 older adult considerations, 63

pain, severe with deformity, numbness, abnormal movement, and/or color, 239 red flags, 225 spinal cord considerations, 225 worst-case scenarios, 225, 240 wound and treatment considerations, 226 myasthenic crisis, 91 myocarditis, 103 myxedema crisis, 148

narcotics, 269–270 natural disasters, 386 nausea, 134 neck pain/injury cardiac emergencies, 97–98 musculoskeletal emergencies, 238 neck swelling, 146 neonatal care post-delivery, 158 neurologic emergencies, 36 Adult Glasgow Coma Scale, 123 altered mental status, 113–114 AVPU mnemonic, level of consciousness assessment using, 123 chief complaints, 109 consciousness, causes of altered level of, 122

Index 447

448 Index neurologic emergencies (cont.) face and/or arm numbness/weakness, slurred speech/difficulty speaking, 114–115 FAST (stroke) assessment, 121 headache, 116–117 key tips, 111–112 older adult considerations, 57–59 red flags, 110 seizure, suspected, 118–119 thrombolytic therapy, 124 triage considerations, 110 worst-case scenarios, 110, 119–120

obstetric emergencies, 39 abdominal, back, and/or pelvic pain, 161–162 absence of fetal movement, 163–164 APGAR score, 160 chief complaints, 152 headache/blurred vision, 166 imminent or precipitous delivery, 156–158 key tips, 155 miscarriage, 167 neonatal care post-delivery, 158 red flags, 153

seizure, 168 vagina, bleeding/passing clots from, 164–165 vomiting, 169 worst-case scenarios, 154, 170–173 ocular emergencies, 39 chemical burns, types of, 211 chemical exposure/burn to eye(s), 195–196 chief complaints, 192 foreign body, 197–198 infection, eye(s), 198–199 key tips, 194 Morgan lens, tips for inserting, 210 older adult considerations, 62 pain, eye(s), 200–201 red flags, 193 trauma (isolated eye injury), 202–203 treatment for eyes, 211 vision loss, 204–205 visual acuity tests, types of, 209 worst-case scenarios, 193, 206–208 older adult considerations abdominal emergencies, 60 adult maltreatment, 65 behavioral health emergencies, 64 bite and sting emergencies, 64

burn emergencies, 65 cardiac emergencies, 58 communication, 56 dental, ear, nose, throat, and facial emergencies, 62 endocrine emergencies, 61 gynecologic emergencies, 61 hematologic and oncologic emergencies, 64 infectious and communicable disease emergencies, 63 initial assessment, 55 key tips, 57 male reproductive emergencies, 62 musculoskeletal emergencies, 63 neurologic emergencies, 58 ocular emergencies, 62 quick assessment, 54 vital sign, 54 red flags, 53 respiratory emergencies, 57 toxicology emergencies, 64 trauma emergencies, 65 triage considerations, 55–56 open/ruptured globe, 207 operations section, 385 orbital cellulitis, 207 orbital fracture, 208

ovarian torsion, 180 overdose, 307–308

pain eye(s), 200–201 hematologic and oncologic emergencies, 262 penile discharge, 187–188 palms, rule of, 50 palpitations, 100–101 pancreatitis, 138 panic disorder, 313 passing clots, vagina from, 164–165 patient arrival, 10 patient reassessments, 68 pediatric assessment A-B-C-D-E of the pediatric patient, 27 “across-the-room” or “quick look,” 26 components, 26 secondary assessment, 29 Pediatric Assessment Triangle (PAT), 16–18, 26 components of, 26 pediatric considerations abdominal emergencies, 37–38 behavioral health emergencies, 46

Index 449

450 Index pediatric considerations (cont.) bite and sting emergencies, 45–46 burn emergencies, 49 cardiac emergencies, 35–36 child maltreatment, 51 communication, 33 dental, ear, nose, throat, and facial emergencies, 40–41 endocrine emergencies, 38 gynecologic emergencies, 39 hematologic and oncologic emergencies, 44–45 infectious and communicable disease emergencies, 44 initial assessment, 31–32 key tips, 33 male reproductive emergencies, 39 mnemonics, 30–31 musculoskeletal emergencies, 41–44 neurologic emergencies, 36 obstetric emergencies, 38 ocular emergencies, 39 pediatric triage pearls, 31–33 quick assessment, 26 red flags, 25 respiratory emergencies, 33–35 sexual assault and intimate partner violence, child maltreatment, and human trafficking, 47

toxicology emergencies, 45 trauma emergencies, 47–48 triage considerations, 32–33 vital sign tips, 29–30 Pediatric Glasgow Coma Scale, 37, 353 pediatric triage, 10 pelvic inflammatory disease (PID), 180 pelvic pain, 161–162 gynecologic emergencies, 177–178 penetrating object to eye(s), 208 penetrating trauma, 341, 349–350 perforated bowel, 138 pericardial tamponade, 103 pericarditis, 104 peritonsillar abscess, 91, 223 permanent tooth avulsion, 223 persistent hiccups, emergency causes of, 140 personal protective equipment (PPE), 249 pertussis, 250 placenta previa, 172 planning section, 385 pneumonia, 92 pneumothorax, 92 polydipsia, 145 polyphagia, 145 polyuria, 145

postpartum complications, 172 pre-eclampsia, 173 premature rupture of membranes, 173 priapism, 191 prolapsed cord, 173 pseudoephedrine, 271–272 psychotic depression, 314 psychotic episode, 314 public information officer (PIO), 384 pulmonary contusion, 351 pulmonary embolus, 92 pyelonephritis, 138

radiation exposure, 359 rapid triage assessment, 12 rash rapidly progressing, 245–246 with fever, 247–248 rattlesnakes, 291–292 red flags, 4, 25 abdominal emergencies, 126 behavioral health emergencies, 301 bite and sting emergencies, 286 burn emergencies, 358

cardiac emergencies, 94 dental, ear, nose, throat, and facial emergencies, 213 endocrine emergencies, 143 gynecologic emergencies, 174 hematologic and oncologic emergencies, 254 human trafficking, 330 infectious and communicable disease emergencies, 241 male reproductive emergencies, 184 musculoskeletal emergencies, 225 neurologic emergencies, 110 obstetric emergencies, 153 ocular emergencies, 193 older adult considerations, 53 respiratory emergencies, 85 sexual assault and intimate partner violence, 321 toxicology emergencies, 267 trauma emergencies, 337 rehydration, 38 resources, 7 respiratory distress, 28 respiratory emergencies, 33–35 apnea, event witnessed or reported, 87 chief complaints, 84 difficulty breathing, 88

Index 451

452 Index respiratory emergencies (cont.) facial/tongue swelling, 89 foreign body ingestion/aspiration, 90 key tips, 86 older adult considerations, 57 red flags, 85 triage considerations, 85 worst-case scenarios, 85, 91–92 respiratory failure, 28 retention, 136 retinal detachment, 208 retrobulbar hematoma, 208 risk, 381 rule of palms, 371

safety and security issues, 67 safety officer, 385 scapular pain, cardiac emergencies, 97–98 scorpion, 295–296, 300 screening tools, 20 ST-elevation myocardial infarction checklist, 20–21 suspected severe sepsis screening and treatment checklist, 22–24 suspected stroke checklist, 21–22 seatbelt sign, 340

sea urchins, 290–291, 298 seizure, 120, 168 suspected, neurologic emergencies, 118–119 sensation, 237 sexual assault, 48 chief complaints, 320 collection of evidence, 327 key tips, 324–325 red flags, 321–322 risk factors for, 328 triage considerations, 323 sexually transmitted infection (STI), 181 simple triage and rapid treatment (START), 382 skin hyperpigmentation, 146 snake bites, 291–292, 298 sore throat, 220 sort, assess, lifesaving interventions, treatment/transport (SALT), 382 spider bites, 293–294, 298–299 spinal cord compression, 265 injury, 240, 345–346 musculoskeletal emergencies, 225 splenic injury, 351 stab wound, 349–350 ST-elevation myocardial infarction (STEMI) checklist, 20–21 stingrays, 290–291, 297

stings, 299–300 substance information, toxicology emergencies, 277 suicidal ideation or attempt, 307–309, 314 suicide risk, degree/severity of, 317 suicide, warning signs of, 316 superior vena cava syndrome, 265 surge capacity, 382 suspected severe sepsis, screening and treatment checklist, 22–24 suspected stroke checklist, 21–22 syncopal episode, 101–102 syncope, hematologic and oncologic emergencies, 258 syndrome of inappropriate antidiuretic hormone (SIADH), 149 systematic approach, 10 systematic triage assessment process, 10–12

taipans, 291–292 tension pneumothorax, 351 testicular torsion, 191 thermal burns, 366–367 third nerve palsy, 208 throat, 219–220 thrombolytics, absolute and relative contraindications to, 108 thrombolytic therapy, 124

thyroid storm, 149 tooth avulsion, 221–222 toxic alcohols, 284 toxicology emergencies, 45 chief complaints, 267 ingestion CNS depressants, 269–270 CNS stimulants, 271–272 key tips, 268–269 medication/drug ingestions, rapid and comprehensive triage assessment for, 275–276 older adult considerations, 64 red flags, 267 stages of iron toxicity, 285 substance information, 277–283 toxic alcohols, 284 withdrawal alcohol, 273 opioids, 274 worst-case scenarios, 268 toxic shock syndrome, 181 trauma, 202–203 trauma emergencies, 47–48, 173 Adult Glasgow Coma Scale, 352 amputation, 340

Index 453

454 Index trauma emergencies (cont.) anatomic trauma triage criteria, 338 blunt trauma, 340–341, 343–344 chief complaints, 336 considerations for trauma triage criteria, 338 falls, 345–348 Glasgow Coma Scale Children 95% on Room Air >95% on Room Air >95% on Room Air >95% on Room Air

Normal Normal cry or speech Responds to parents or to environmental stimuli Good muscle tone Moves extremities well

Abnormal Abnormal or absent cry or speech Decreased response to parents or environmental stimuli Floppy or rigid muscle tone/head bobbing Not moving

Normal Respirations are quiet, easy, and unlabored Breathing at a normal rate No central cyanosis

Abnormal Increased work of breathing Nasal flaring, retractions or abdominal muscle use/tracheal tug Noisy breathing Decreased/absent respiratory effort

Normal Color appears normal for racial group Capillary refill at palms, soles, forehead, or central body ≥2 sec Strong peripheral and central pulses with regular rhythm No significant bleeding

Abnormal Cyanosis, mottling, or pallor Absent or weak pulses Pulse outside normal range Capillary refill >2 sec with other abnormal findings Obvious significant bleeding

Pediatric Assessment Triangle (For details see Chapter 2, Triage)

457

APPENDIX B THE A-B-C-D-E ASSESSMENT: A REVIEW During the across-the-room and rapid triage assessment, observe for A-B-C-D-E abnormalities that could indicate the patient requires immediate intervention.

Assessment Airway—Obstruction (tongue, teeth, blood, emesis, foreign body), swelling, abnormal airway sounds (grunting, stridor, wheezing); unable to speak/cry ** Tip: If the patient is talking normally, a severe airway issue is unlikely. If the patient is talking, the airway is open. Breathing—Work of breathing (labored, accessory muscle use, nasal flaring, retractions), rate (slow/fast), rhythm (irregular), depth (deep/shallow), positioning (tripod), chest rise and fall (unequal), speech patterns (number of words able to speak), tracheal position (deviated) ** Tip: If the patient is speaking in full sentences, breathing is likely sufficient. Circulation—Pulse rate (slow, fast), quality (bounding, weak, absent), capillary refill (delay >2 seconds), skin color (cyanosis, pallor, mottling) and condition (moist, diaphoretic, turgor, tenting), bleeding (absent, uncontrolled) ** Tip: If a pulse is present and capillary refill is