CHAPTER 14 – GENERAL EMERGENCIES AND MAJOR TRAUMA First Nations and Inuit Health Branch (FNHIB) Clinical Practice Guidelines for Nurses in Primary Care. The content of this chapter was revised October 2011. Table of Contents RESPONDING TO GENERAL EMERGENCIES AND MAJOR TRAUMA ..............14–1 GENERAL EMERGENCY SITUATIONS ................................................................14–1 Anaphylaxis ......................................................................................................14–1 Shock ...............................................................................................................14–5 Coma (Not Yet Diagnosed) ..............................................................................14–7 Overdoses, Poisonings and Toxidromes ..........................................................14–9 Hypothermia ...................................................................................................14–14 MAJOR TRAUMA SITUATIONS ...........................................................................14–16 Head Trauma .................................................................................................14–16 Cervical Spine and Spinal Cord Trauma ........................................................14–19 Flail Chest ......................................................................................................14–21 Pelvic Fracture ...............................................................................................14–22 SOURCES ............................................................................................................14–25 Clinical Practice Guidelines for Nurses in Primary Care 2011 General Emergency and Major Trauma 14–1 RESPONDING TO GENERAL EMERGENCIES AND MAJOR TRAUMA For any emergency, always remember your ABCs The next priorities are as follows: (airway, breathing, circulation) as the priority. Primary – Adequate ventilation survey and resuscitation are followed by secondary survey, definitive care and, finally, transport. – Treatment of shock – Identification of life-threatening injuries The primary survey and resuscitation are done simultaneously. During this period, a patent airway See “Primary Survey” and “Resuscitation” sections is established while control of the cervical spine under “Responding to General Emergencies and is maintained. Maintenance of airway patency is Major Trauma” in the pediatric Chapter 20, “General obviously the most critical factor, and cervical spine Emergencies and Major Trauma” for a general injury should be assumed in every seriously injured approach to use with all clients in an emergency. individual, until proven otherwise. GENERAL EMERGENCY SITUATIONS ANAPHYLAXIS CAUSES Anaphylaxis is an acute hypersensitivity reaction The most common causes of fatal anaphylactic with multi-organ-system involvement that has a reactions are: rapid onset and may cause death.1,2 The symptoms – Drugs (for example, penicillin and cephalosporin develop over several minutes to several hours,3 may antibiotics, NSAIDs [nonsteroidal anti- involve multiple body systems (for example, skin inflammatory drugs] including ASA [90% of episodes], respiratory [70% of episodes], [acetylsalicylic acid], anesthetics)1 gastrointestinal [40% of episodes], circulatory [35% of – Foods (most common in children,5 for example, episodes]3) and may progress to unconsciousness as a peanuts, shellfish, nuts, sesame seeds, fish late event in severe cases. Rarely is unconsciousness products, eggs)5 the sole manifestation of anaphylaxis. The severity – Insect venom (for example, bees, wasps) and differentiation of an anaphylaxis reaction can be implied by the presence of cutaneous or multi- In contrast, fatal reactions to vaccines and latex rubber system findings, in addition to the involvement of are rare.6 cardiovascular and/or respiratory findings.4 HISTORY Anaphylaxis is a medical emergency and must be distinguished from fainting (vasovagal syncope), Most anaphylactic episodes involve an immediate which is more common and benign. Rapidity of onset hypersensitivity reaction following exposure to 1 is a key difference. When a person faints, the change an allergen. Symptoms often occur within 5–30 from a normal to an unconscious state occurs within minutes of exposure to trigger factor. Anaphylaxis seconds. Fainting is managed simply by placing the can be biphasic with recurrence of symptoms patient in a recumbent position and elevating the feet. occurring, usually within eight to ten hours, but Fainting is sometimes accompanied by brief clonic occasionally up to 72 hours after the resolution of 7 seizure activity, but this generally requires no specific the initial anaphylactic event. Anaphylaxis may be treatment or investigation. fatal within minutes, usually through cardiovascular orrespiratory compromise.1 Clinical Practice Guidelines for Nurses in Primary Care 2011 14–2 General Emergency and Major Trauma The signs and symptoms may include:8 SEVERE REACTION – Severe respiratory distress (lower respiratory Skin obstruction characterized by high-pitched – Flushing wheezing, upper airway obstruction characterized – Feeling of warmth by stridor) – Itching (may begin on palms and soles, may – Difficulty speaking, hoarseness include the external auditory canal) – Difficulty swallowing – Urticaria (hives) – Agitation – Angioedema (facial edema) – Shock – Morbilliform rash – Loss of consciousness – Piloerection (hair standing on end) PHYSICAL FINDINGS Oral – Tachycardia – Itching or tingling or edema of lips, tongue, – Tachypnea, laboured respiration palate or uvula – Blood pressure low-normal (client hypotensive if – Metallic taste in shock) – Pulse oximetry may show hypoxia Gastrointestinal – Client in moderate-to-severe distress – Nausea, vomiting, abdominal pain, diarrhea, – Use of accessory muscles of respiration difficulty swallowing – Chest: air entry reduced, mild-to-severe wheezing – Stridor, rapid or shallow breathing, cyanosis9 Respiratory – Client flushed and diaphoretic – Pruritus of the larynx and tightness in the throat – Generalized urticaria (hives) – Dysphagia, dysphonia or hoarseness – Facial edema, angioedema – Respiratory difficulties: shortness of breath, – Diminished level of consciousness wheezing, cough dyspnea, tightness of the chest – Confusion, anxiety, agitation (caused by hypoxia)9 – Nasal symptoms including, itching, congestion, – Skin feels cool and clammy sneezing, rhinorrhea DIFFERENTIAL DIAGNOSIS Ocular – Asthma – Periorbital itching, erythema, tearing or edema – Acute anxiety (panic attack), breath-holding – Red, itchy eyes5 episode in a child9 – Conjunctival erythema – Foreign-body aspiration Neurologic – Angioedema – Pulmonary embolism – Anxiety – Vasovagal syncope (fainting) (pulse and BP are – Apprehension, sense of impending doom generally normal, and there is usually no evidence – Confusion of airway symptoms)9 – Seizures 9 – Hypoglycemia – Headache 9 – Seizure disorder 9 Cardiovascular – Septic shock – Mastocytosis, carcinoid syndrome, scromboid – Feeling faint, dizziness, syncope poisoning9 – Palpitations, tachycardia Hypotension – Lower back pain due to uterine cramping in women – Cardiovascular collapse can occur without respiratory symptoms 2011 Clinical Practice Guidelines for Nurses in Primary Care General Emergency and Major Trauma 14–3 CASE DEFINITION Pharmacologic Interventions As anaphylaxis may present with a number of Epinephrine is the drug of choice for the treatment symptoms and/or signs, a case definition provides of anaphylaxis, and the IM route is preferred.11 a standard approach to describing the degree of There are no absolute contraindications to the use clinical severity and the level of diagnostic certainty. of epinephrine for the treatment of anaphylaxis.7,11 The case definition and guidelines for clinical application, including reporting adverse events, were Speedy intervention is of paramount importance. published by the Brighton Collaboration Anaphylaxis Failure to use epinephrine promptly is more Working Group in “Anaphylaxis: Case definition dangerous than using it quickly but improperly. and guidelines for data collection, analysis and Failure to administer epinephrine promptly and use of presentation of immunization safety data”.10 antihistamines and salbutamol rather than epinephrine are important errors in the treatment of anaphylaxis.7 COMPLICATIONS Promptly administer: – Hypoxia epinephrine 1 mg/mL solution (may be labelled – Shock 1:1000), 0.2–0.5 mg = 0.2–0.5 mL intramuscular – Airway obstruction due to edema of upper airway (IM)7,11 in the midanterolateral thigh to achieve peak – Convulsions plasma and tissue concentrations rapidly12 – Aspiration Repeat at 5–15 minute intervals, as necessary, – Death depending on the severity of the reaction, to control symptoms and to sustain or increase blood pressure.11 DIAGNOSTIC TESTS Published national anaphylaxis guidelines agree that 1 Diagnosis made on clinical findings. epinephrine is fundamental to acute management, although they do not agree on the initial dose or route MANAGEMENT of injection.12 The subcutaneous route and injecting Goals of Treatment in the opposite limb, when immunization is the cause, can also be used.13 – Improve oxygenation – Alleviate symptoms Epinephrine Dose in Children – Prevent complications Calculations based on body weight are preferred when – Prevent recurrence weight is known. When body weight is not known, – Treat as a medical emergency and manage airway, the dose of epinephrine (1:1000)