Clinical Practice Guidelines for Nurses in Primary Care
Chapter 14 - General Emergencies and Major Trauma
General Emergency Situations
Overdoses, Poisonings and Toxidromes
Definition
Ingestion of a substance in sufficient quantity to induce symptom complexes
associated with toxic effects.
Specific Poisonings and Clinical Toxidromes
Opiates
- Examples: heroin, morphine, clonidine, codeine, diphenoxylate (Lomotil)
- Toxidrome characterized by sedation, hypotension, bradycardia, respiratory
depression, usually pinpoint pupils (may not be present with mixed overdose)
Petroleum Distillates
- Examples: gasoline, fuel oil, model airplane glue
- Main toxic effect: pulmonary (from inhalation)
Tricyclic Antidepressants
- Main toxic effects: cardiac arrhythmias, anticholinergic effects (see toxidrome
for opiate poisoning, above), vomiting, hypotension, confusion and seizures
- Cardiac complications: prolonged QRS and QT intervals, other arrhythmias
- Neurologic complications: agitation, seizures
- Hypotension: Treat initially with IV fluids (see "Shock," above,
this chapter)
The client may appear fine and then rapidly deteriorate. He or she will need
to be admitted to a monitored unit. Be prepared to manage the client's
airway. Even if the client is asymptomatic 6 hours after ingestion, he
or she must be admitted to hospital for psychiatric examination.
Salicylates (e.g., Aspirin)
- Main toxic effects: tinnitus, nausea, vomiting, hyperventilation (primary
respiratory alkalosis), metabolic acidosis, fever, hypokalemia, hypoglycemia,
seizures and coma
Many patients are misdiagnosed on initial presentation as having sepsis or
gastroenteritis (because of fever, acidosis, vomiting and other symptoms).
This misdiagnosis is particularly common in the elderly.
Acetaminophen (Tylenol )
- Main toxic effects: hepatic, occurring 24-72 hours after ingestion
- Client may also have nausea and vomiting
Caustic Agents
- Examples: alkaline (drain cleaner), bleach and battery acid (household
bleach is usually not a problem, except for superficial burns)
- Main toxic effects: local tissue necrosis of the esophagus with alkali
and of the stomach with acids, as well as respiratory distress; obvious facial
or oral burns and emesis; hoarseness and stridor reflecting epiglottic edema
(especially with acids)
Carbon Monoxide
- Main toxic effects: central nervous system effects, including confusion,
coma, seizures, headache, fatigue and nausea; arrhythmias or cardiac ischemia
possible
- Diagnosis: clinical background (e.g., exposure to furnace or car exhaust
[especially in children who have been riding in the back of pick-up trucks]);
level of carboxyhemoglobin needed to confirm
Arterial oxygen saturation as measured by pulse oximetry
is frequently normal in cases of carbon monoxide poisoning.
Cocaine
- Main toxic effects: seizures, hypertension, tachycardia, paranoid behavior
or other alterations in mentation, rhabdomyolysis, myocardial infarction
and stroke (CVA)
Assessment and Management: General Approach
Remember: your first priority is ABC
- Remember to decontaminate gut (see procedure below), clothing, skin and
environment
- If client is unconscious, see "Coma (Not Yet Diagnosed)," above,
this chapter
- Determine to the best of your ability what was ingested
- For any client with overdose, draw blood sample for determination of serum
acetaminophen level (see "Acetaminophen (Tylenol)," above, this section)
- Contact the nearest poison control center for further information about
the toxin in question
Appropriate Consultation
Consult a physician as soon as you are able after the initial assessment and
stabilization of ABC.
Gut Decontamination
Activated Charcoal
- Treatment of choice in most overdoses involving ingestion
- May be indicated for overdose with theophylline, tricyclic antidepressants,
phenobarbital, phenytoin, digoxin
- Does not work for metals such as iron or lithium
- Administer 10-25 g for children, 50-100 g for adults (1 g/kg)
- A sorbitol mixture reduces transit time but should be used only with the
first dose if multiple doses of charcoal will be used
- If client will drink the mixture, this mode of administration is acceptable;
otherwise, administer by nasogastric tube
- 30% of clients will vomit after administration of charcoal; in this case,
charcoal can be administered again
- Use of multiple-dose charcoal is still controversial
Ipecac
Ipecac is not very useful. It is only partially effective
in emptying gastric contents and may propel pills beyond the pylorus. Because
of the risk of aspiration, ipecac is contraindicated in obtunded patients and
those unable to protect the airway, in cases of ingestion of caustic materials
or petroleum distillates, and in cases of overdose with tricyclic antidepressants,
theophylline or any agent that might cause a change in mental status.
Ipecac inhibits retention of charcoal and thus delays administration of charcoal.
The dose is 30 mL for an adult, followed with water.
Gastric Lavage
- May remove more stomach contents than ipecac
- Not effective beyond 1.5 hours after ingestion, but you may want to try
it in severely ill clients
- Use largest nasogastric tube available or orogastric tube
- Most effective if charcoal is given 20-30 minutes before lavage; repeat
charcoal when lavage is finished
- Airway protection is recommended (client should be fully conscious)
- Instill 300-mL aliquots of saline, then remove until saline is clear on
removal or until 5 L of fluid has been used for irrigation
- Lavage alone is not adequate for gastric emptying and delays administration
of charcoal
Management of Specific Overdoses and Toxidromes
Opiates
Use the following drug with caution in those who are narcotic addicts, as
it may precipitate acute opiate withdrawal. If this is a concern, the client's
airway must be supported until the narcotic wears off.
Always observe the client until there is no chance of
further respiratory depression. This is especially important with naloxone,
which has a relatively short half-life.
naloxone (Narcan) (D class drug), 5 g/kg
IV (usually start with 0.4-2 mg in adults); dose may be repeated if needed,
up to a maximum of 10 mg
This is a short-acting drug (half-life 1.1 hours).
Client may have recurrent narcotization when naloxone
wears off.
Petroleum Distillates
- Do not perform lavage or induce vomiting if swallowed
- If no symptoms within 6 hours, no need for further observation
Tricyclic Antidepressants
- Avoid emesis (client may aspirate)
- Charcoal and lavage are mainstays of treatment (see "Gut Decontamination," above,
this section)
- Client may appear fine and then rapidly deteriorate
- Client should be admitted to a monitored unit
- Be prepared to manage client's airway
- If client is asymptomatic 6 hours after ingestion, he or she should still
be admitted to hospital for psychiatric evaluation and care
- Cardiac complications: prolonged QRS, QT interval, other arrhythmias
- Neurologic complications: agitation, seizures
- Seizures usually brief and self-limited; treat as outlined in "Status
Epilepticus (Acute Grand Mal Seizure)," in chapter 8, "Central Nervous
System"
- Avoid phenytoin
- If hypotension occurs, treat initially with IV fluids (see "Shock," above,
this chapter)
Salicylates (e.g., Aspirin)
- Toxic dose: 150 mg/kg (300 mg/kg is highly toxic)
- IV administration of normal saline to maintain blood pressure (see "Shock," above,
this chapter)
- Urine alkalinization (to promote excretion of salicylates)
Acetaminophen (Tylenol)
- Toxic dose: 140 mg/kg or >10 g in adults (in alcoholic clients, the
toxic dose is often much less if the client is taking acetaminophen regularly,
even as little as 4 g/day)
- vomiting and unable to keep down charcoal, consider metoclopramide (Maxeran)
(B class drug)
- If ingestion is in toxic range, treat with:
N -acetylcysteine (Mucomyst) (D class drug), 20%,
140 mg/kg PO or IV and then 70 mg/kg every 4 hours for 17 doses; repeat
any doses vomited within 1 hour of administration
- Do not withhold N-acetylcysteine even if 24-26 hours after ingestion;
late administration, though not as effective as early administration, still
reduces mortality
- Charcoal use is acceptable in acetaminophen overdose and only minimally
interferes with N-acetylcysteine; charcoal should be given early
and N-acetylcysteine at least 4 hours later
Caustic Materials
- Do not induce emesis or perform lavage
- Charcoal is not indicated
- If the client has visible burns, he or she has a 50% chance of lower burns
of significance; however, absence of visible lesions does not rule out significant
injury (10% to 30% will have burns beyond the mucosa)
Carbon Monoxide
- Administration of 100% oxygen (to displace carbon monoxide from hemoglobin)
- Even if client seems well when seen or is recovering from the CNS insult,
hyperbaric oxygen has been shown to reduce long-term sequelae; therefore
transfer client to hospital
Cocaine
- Cocaine has a relatively short half-life, so most symptoms are self-limited
- For coronary vasospasm, hypertension or tachycardia, observation is probably
adequate, because of the short half-life
- For other cases, treat as for myocardial infarction
- Myocardial infarction and CVA may occur up to 72 hours after cocaine use
- Concurrent use of alcohol increases the likelihood of cardiac vasospasm
Not all chest pain represents myocardial infarction (e.g.,
pneumomediastinum in crack use, bronchospasm).
Monitoring and Follow-Up
Monitor ABC, level of consciousness, vital signs, oxygen saturation, intake
and urine output frequently until the client is stable.
Referral
Medevac as soon as possible.
Hypothermia
Definition
Core temperature of ≤ 35°C (95°F).
Risk Factors
- Endocrine or metabolic derangements (e.g., hypoglycemia)
- Infection (e.g., meningitis, sepsis)
- Intoxication
- Intracranial pathology (e.g., head trauma)
- Submersion
- Environmental exposure
- Major burns
- Iatrogenic (cold IV fluids, exposure during treatment)
History
The evaluation and treatment of hypothermia is essentially
the same whether the client is wet or dry, on land or in water.
- One or more of above risk factors
- The hypothermic client should be assessed carefully for coexisting injury
or illness
- Signs and symptoms of hypothermia may be mimicked by alcohol, diabetes
mellitus, altitude sickness, overdose and other conditions; therefore, thorough
assessment is imperative
- Associated significant illness or injury may exacerbate hypothermia
The hypothermic client may appear "beyond help" because
of skin color, pupil dilatation and depression of vital signs. However, people
with severe hypothermia have been resuscitated. Therefore, be cautious about
assuming that the client cannot be resuscitated. It is also wise to be cautious
about what you say during the resuscitation. Seemingly unconscious patients
frequently remember what is said and done.
Physical Findings
In the cold client, rectal temperature is one of the vital
signs.
In terms of the "ABCs," think A, B, C and D for hypothermic clients:
A for airway
B for breathing
C for circulation
D for degrees (body-core temperature)
In the cold client, body-core temperature is an important sign. Although obtaining
the body-core temperature is useful for assessing and treating hypothermia,
there is tremendous variability in individual physiologic responses at specific
temperatures.
Assessment of Temperature
Axillary and oral measurements are poor measures of core temperature. Rectal
temperature more closely approximates the core temperature and is a practical
method for use in the field.
For clients with cold skin, rectal temperature should be determined with a
low-reading thermometer (i.e., capable of measuring temperatures as low as
21°C).
Core Temperature 35°C to 36°C
- Client feels cold, is shivering
Core Temperature 32°C to 35°C
- Slowing of mental faculties
- Slurred speech
- Mild incoordination
- Muscle stiffness
- Inappropriate judgment
- Irritability
- Shivering apparent
Core Temperature 32°C
Core Temperature ≤ 31°C
- Semi-comatose
- Progressive decrease in level of consciousness
- Coma likely at temperatures ≤ 30°C
- Cyanosis
- Tissue edema
Core Temperature 29°C
- Respiratory activity slow, may be difficult to detect
- Heart rate slow; pulse may be difficult to palpate
Core Temperature ≤ 28°C
- Vital signs absent
- Pupils dilated and unresponsive
- Respiratory arrest
- Ventricular fibrillation
Management
Goals of Treatment
- Rewarm core
- Prevent or manage complications
General Principles
The client with severe hypothermia must be handled very
gently. The cold heart is highly prone to cardiac arrest, and even cautious
movement of the client may induce cardiac arrest.
- Ensure that any items, oxygen or fluids (both oral and IV) coming into
contact with the client are warmed beforehand
- Oxygen should be heated to 105°F to 108°F (40.5°C to 42.2°C)
and humidified, if possible
- Because cold skin is easily injured, avoid direct application of hot objects
or excessive pressure (e.g., uninsulated hot water bottles)
- The inside of a vehicle and any rooms where hypothermic clients are treated
should be warm enough to prevent further heat loss (ideally above 80°F
[26.7°C])
- Splinting should be performed, when indicated and with caution, to prevent
additional injuries to frostbitten tissues
- Do not give caffeine or alcohol
Cardiopulmonary resuscitation (CPR) has no significant effect on survival
of hypothermic clients in the following situations and should not be
initiated:
- Cold-water submersion for > 1 hour
- Core temperature < 15.5°C (60°F)
- Obvious fatal injuries
- Client frozen (e.g., formation of ice in airway)
- Chest wall so stiff that compression is impossible
- Rescuers are exhausted or in danger
Rise in core temperature may lag behind change in skin
temperature and may continue to drop, so monitor rectal temperature frequently.
Basic Treatment for All Cases of Hypothermia
Prevent further heat loss: insulate from the ground, protect from the wind,
eliminate evaporative heat loss by removing wet clothing or by covering client
with a vapor barrier (such as a plastic garbage bag), cover the head and neck,
and move the client to a warm environment; consider covering client's mouth
and nose with light fabric to reduce heat loss through respiration.
Mild Hypothermia
Rewarm passively and gradually:
Step 1: Place client in as warm an environment as possible
Step 2: Increase heat production through exercise (without sweating)
and fluid replacement with high-calorie, warm, sweet fluid; this method of
adding heat is particularly important when emergency care is not readily available,
as in remote or prolonged-transport environment
Step 3: Rewarm passively through application of insulated heat packs
to high heat transfer-loss areas such as the head, neck, underarms, sides of
the chest wall and groin; apply heavy insulation to the same areas to prevent
further heat loss (goal is to increase temperature by 1°C to 2°C per
hour)
Step 4: Consider warm shower or bath if the client is alert
Do not leave client alone.
Severe Hypothermia with Signs of Life (e.g., Pulse and Respiration)
Treat the client as outlined in steps 2 and 3 above, with the following exceptions:
- Do not put a severely hypothermic client in a shower or bath
- Do not give a client fluids by mouth unless he or she is capable of swallowing
and protecting the airway
- Treat hypothermic clients very gently (do not rub or manipulate or apply
direct heat to extremities)
In addition, the following measures should be taken:
- Reassess ABC and vital signs frequently
- Give warm, humidified oxygen at 10-12 L/min or more
- Administer warmed (to 37°C) normal saline by IV
- Clients with moderate-to-severe hypothermia may have a large amount of
fluid sequestration and may need aggressive fluid resuscitation; an initial
bolus of 20 mL/kg is indicated; repeat as necessary, but do not overload
with IV fluids
Severe Hypothermia with No Signs of Life
- If no pulse (after checking for up to 45 seconds), no respiration and no
contraindications, start CPR unless contraindicated
- Ventilate with Ambu bag with 50% warm, humidified oxygen; aim for 12-15
ventilations and 80-100 compressions; continue as long as you can
- Administer warmed (to 37°C) normal saline by IV
- Clients with moderate-to-severe hypothermia may have large amount of fluid
sequestration and may need aggressive fluid resuscitation; an initial bolus
of 20 mL/kg is indicated; repeat as necessary
- Rewarm passively as outlined above
No drugs are used in resuscitation unless core temperature > 32°C
and drugs are ordered by a physician.
Consultation
If resuscitation has been provided in conjunction with rewarming techniques
for more than 60 minutes without the return of spontaneous pulse or respiration,
continue efforts but contact the physician for recommendations.
Referral
Medevac as soon as possible.
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