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E Cart
Located in designated areas where medical
emergencies and resuscitation is needed
Purpose: to maximize the efficiency in locating
medications/supplies needed for emergency
situations.
Drawer 5: Contains respiratory supplies
such as oxygen tubing, a flow meter, a face
shield, and a bag-valve-mask device for
delivering artificial respirations
Drawer 4: Contains suction supplies &
gloves
Drawer 3: Contains intravenous fluids
Drawer 2: Contains equipment for
establishing IV access, tubes for laboratory
tests, and syringes to flush medication lines.
Drawer 1: Contains medications needed
during a code such as epinephrine, atropine,
lidocaine, CaCl2 and NaHCO3
The back of the cart usually houses the cardiac
board.
Assessment and Intervention in the ER
The Primary Survey: Focuses on stabilizing lifethreatening conditions; employs the ABCD
Method
The ABCD Method
Airway - Establish the airway
Breathing - Provide adequate ventilation
Circulation - Evaluate & restore cardiac
output by controlling hemorrhage,
preventing & treating shock, and
maintaining or restoring effective
circulation
Disability - Determine neurologic disability
by assessing neuro function using the
Glasgow Coma Scale
Eye opening Spontaneous
response
To voice
To pain
None
4
3
2
1
Verbal
response
5
4
3
2
1
Oriented
Confused
Inappropriate words
Incomprehensible sounds
None
Motor
response
Obeys command
Localizes pain
Withdraws
Flexion
Extension
None
Clinical Manifestations
1. Choking
2. Apprehensive appearance
3. Inspiratory & expiratory stridor
4. Labored breathing
5. Flaring of nostrils
6. Use of accessory muscles (suprasternal &
intercostal retractions)
7. anxiety, restlessness, confusion
8. Cyanosis & loss of consciousness develops as
hypoxia worsens.
Assessment and Diagnostics
Involves simply asking whether the patient is
choking & requires help
If unconscious, inspection of the oropharynx
may reveal the object.
X-rays, laryngoscopy, or bronchoscopy may
also be performed.
For elderly patients, sedatives & hypnotic
medications, diseases affecting motor
coordination, & mental dysfunction are risk
factors for asphyxiation of food.
Victims cannot speak, breath or cough.
If victim can breathe spontaneously, partial
obstruction should be suspected; the victim is
encouraged to cough it out.
If the patient has a weak cough, stridor, DOB &
cyanosis, do the Heimlich.
After the obstruction is removed, rescue
breathing is initiated; if the patient has no
pulse, start cardiac compressions.
Head-Tilt-Chin-Lift Maneuver
Compiled Notes of Bernie C. Butac
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6
5
4
3
2
1
Jaw-Thrust Maneuver
1. Place the patient on a firm, flat surface.
2. Open the airway by placing one hand on
each side of the victims jaw, followed by
grasping and lifting the angles, thus
displacing the mandible forward.
Oropharyngeal Airway Insertion
A semicircular tube or tube-like plastic device
inserted over the back of the tongue into the lower
pharynx
Used in a patient who is breathing spontaneously
but unconscious.
ET Intubation: Indications
1. To establish an airway for patients who
cannot be adequately intubated with an
oropharyngeal airway.
2. To bypass an upper airway obstruction
3. To prevent aspiration
4. To permit connection of the patient to a
resuscitation bag or mech. ventilator
5. To facilitate removal of tracheobronchial
secretions
Cricothyroidotomy
Used in the following emergencies in w/c ET
intubation is contraindicated:
1. Extensive maxillofacial trauma
2. Cervical spine injuries
3. Laryngospasm
4. Laryngeal edema
5. Hemorrhage into neck tissue
6. Laryngeal obstruction
Nursing Diagnoses For Airway Obstruction
1. Ineffective airway clearance due to obstruction
of the tongue, object, or fluids (blood, saliva)
2. Ineffective breathing pattern due to
obstruction or injury
Hemorrhage
Assessment
Results in reduction of circulating blood
vol., w/c is the principal cause of shock
Signs and symptoms of shock:
1. Cool, moist skin
2.
3.
4.
5.
Hypotension
Tachycardia
Delayed capillary refill
Oliguria
Management
Fluid Replacement
Two large-bore intravenous cannulae are
inserted to provide a means for fluid and blood
replacement, and blood samples are obtained
for analysis, typing, & cross-matching.
Replacement fluids may include isotonic
solutions (LRS, NSS), colloid, and blood
component therapy.
Packed RBCs are infused when there is
massive hemorrhage
In emergencies, O(-) blood is used for women
of child-bearing age.
O(+) blood is used for men and
postmenopausal women.
Additional platelets and clotting factors are
give when large amounts of blood is needed.
Control of External Hemorrhage
Physical assessment is done to identify area of
the hemorrhage.
Direct, firm pressure is applied over the
bleeding area or the involved artery.
A firm pressure dressing is applied, and the
injured part is elevated to stop venous &
capillary bleeding if possible.
If the injured area is an extremity, it is
immobilized to control blood loss.
Control of Bleeding: Tourniquets
Applied only as a last resort just proximal to
the wound and tied tightly enough to control
arterial blood flow; tag the client with a T
stating the location and the time applied
Loosened periodically to prevent irreparable
vascular on neuro damage
If still with arterial bleeding, remove tourniquet
and apply pressure dressing
If traumatically amputated, the tourniquet
remains in place until the OR.
Control of Internal Bleeding
Watch out for tachycardia, hypotension, thirst,
apprehension, cool and moist skin, or delayed
capillary refill.
Packed RBC are administered at a rapid rate,
and the patient is prepped for OR.
Arterial blood is obtained to evaluate
pulmonary perfusion & to establish baseline
hemodynamic parameters
Patient is maintained in a supine position and
closely monitored.
Hypovolemic Shock
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Incised Wound
A clean cut by a sharp edged object such as
glass or metal.
As the blood vessels at the wound edges are
cut straight across, there may be profuse
bleeding
Laceration
Ripping forces or rough brushing against a
surface which can cause rough tears in the
skin or lacerations.
Laceration wounds are usually bigger and can
cause more tissue damage due to the size of
the wound.
Abrasion
Puncture Wound
Small entry site
Though not large in surface area, wounds are
deep and can cause great internal damage.
Gunshot Wound (GSW)
Caused by firing bullets or any other small
arms.
Have a clean entry site but a large and ragged
exit site.
Trauma
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PE for Internal Bleeding
Inspect body for bluish discoloration,
asymmetry, abrasion, & contusion
FAST (Focused Assessment for Sonographic
Examination of the Trauma Patient) exam
through CT scan to assess
hemodynamically unstable patients and
detect intraperitoneal bleeding
Pain in the left shoulder is common in a
patient with bleeding from a ruptured
spleen.
Pain in the right shoulder can result from a
laceration of the liver.
Administration of opioids is avoided during
the observation period.
Trauma: Genitourinary Injury
A rectal or vaginal exam is done to determine
any injury to the pelvis, bladder, and intestinal
wall.
To decompress the bladder & monitor urine
output, a Foley catheter is inserted AFTER DRE.
A high-riding prostate gland indicates a
potential urethral injury.
Trauma: Management of Intra-abdominal
Injuries
1. A patent airway is maintained.
2. Bleeding is controlled by applying direct
pressure to any external bleeding wounds & by
occlusion of any chest wounds.
3. Circulating blood vol. is maintained with
intravenous fluid replacement including blood
component therapy.
4. In blunt trauma, cervical spine immobilization
is maintained until cervical x-rays have been
obtained & injury is ruled out.
5. All wounds are located, counted &
documented.
6. If abdominal viscera protrude, the area is
covered with sterile, moist saline dressing to
prevent drying.
7. Oral fluids are withheld and stomach contents
are aspirated with an NGT in anticipation of
surgery.
Tetanus and broad-spectrum antibiotics are
given as prescribed.
8. If still with evidence of shock, blood loss, free
air under the diaphragm, evisceration,
hematuria or suspected abdominal injury,
transport to OR.
Trauma: Crushing Injuries
Occur when a person is caught between
objects, run over by a moving vehicle, or
compressed by machinery
Watch out for hypovolemic shock from
extravasation of blood & plasma into injured
tissues after compression has been released.
Crushing Injuries: Assessment
Watch out for paralysis of a body part,
erythema & blistering of skin, damaged part
appearing swollen, tense & hard.
Renal dysfunction is secondary to prolonged
hypotension.
Compiled Notes of Bernie C. Butac
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Management of Fractures
ABCD Method & evaluation for abdominal
injuries is performed BEFORE an extremity is
treated unless a pulseless extremity is seen.
If the extremity is pulseless, repositioning of
the extremity to proper alignment is required.
Pulseless Extremities
Management of Fractures
After the 1 survey, the 2 survey is done
using a head-to-toe approach.
Observe for lacerations, swelling & deformities
including angulation, shortening, rotation, &
symmetry.
Palpate all peripheral pulses.
Assess extremity for coolness, blanching,
decreased sensation & motor function.
Splinting of Extremities
Before moving the patient, a splint is applied
to immobilize the joint above & below the
fracture
Relieves pain, restores circulation, prevents
further tissue injury
Procedure:
1. One hand is placed distal to the fracture &
some traction is applied while the other
hand is placed beneath the fracture for
support.
2. The splint should extend beyond the joints
adjacent to the fracture.
3. Upper extremities must be splinted in a
functional position.
4. If a fracture is open, moist, sterile dressing
is applied.
5. Check the vascular status by assessing
color, temperature, pulse, and blanching of
the nail bed.
6. If there is neurovascular compromise, the
splint is removed and reapplied.
7. Investigate complaints of pain or pressure.
People at Risk:
those not acclimatized to heat
elderly and very young people
those unable to care for themselves
those w/ chronic & debilitating dse
those taking tranquilizers, diuretics,
anticholinergics, and beta blockers.
exertional heat stroke occurs in healthy
individuals during sports or work activities.
Heat Stroke
An acute medical emergency caused by failure
of the heat-regulating mechanisms.
Usually occurs during extended heat waves,
especially when accompanied by high humidity
Pathophysiology
Hyperthermia results because of inadequate
heat loss, which can also cause death.
Most heat-related deaths occur in the elderly,
because their circulatory systems are unable
to compensate for the stress imposed by heat
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Assessment
Causes thermal injury at the cellular level,
resulting to widespread damage to the heart,
liver, kidney, and blood coagulation
Watch out for profound CNS dysfunction
(confusion, delirium, bizarre behavior, coma),
body temperature (>40.6C), hot, dry skin,
anhidrosis, tachypnea, hypotension, and
tachycardia.
Management
The primary goal is to reduce the high
temperature as quickly as possible, because
mortality is directly related to the duration of
hyperthermia.
Simultaneous treatment focuses on stabilizing
oxygenation using the ABCs of basic life
support.
After clothing is removed, core temperature is
reduced to 39C ASAP by one or more of the ff
methods:
1. Cool sheets & towels or continuous
sponging with cool H2O
2. Ice applied to neck, groin, chest, &
axillae while spraying with tepid
water; cooling blankets
3. Iced saline lavage of stomach or
colon if temperature does not
decrease
4. Immersion in cold water bath
Nursing Interventions
Monitor vital signs, ECG, CVP and level of
responsiveness
Administer 100% oxygen to meet tissue needs
exaggerated by the hypermetabolic condition.
NSS or LRS is initiated to replace fluid losses
and maintain circulation
Urine output is monitored to detect acute
tubular necrosis from rhabdomyolysis.
Blood specimens are obtained to detect DIC
and to estimate thermal hypoxic injury to the
liver, heart, and muscle tissue
Dialysis is done for renal failure.
Give benzodiazepines or chlorpromazine for
seizures; K for hypokalemia; Na bicarbonate
for metabolic acidosis
Nurse Teachings
Advise client to avoid immediate exposure to
high temperature (10am-2pm).
FROSTBITE
Trauma from exposure to freezing
temperatures that results to actual freezing of
the tissue fluids in the cell and intracellular
spaces
Results in cellular and vascular damage
Body parts most frequently affected are the
feet, hands, nose and ears
Ranges from 1st (erythema) to 4th degree (fulldepth tissue destruction)
Assessment
Frozen extremity may be cold, hard, and
insensitive to touch
Appears white or mottled blue-white
Extent of injury from exposure to cold is not
initially known; assess for concomitant injury
History includes environmental temperature
duration of exposure, humidity, and presence
of wet conditions
Management
The goal is to restore normal body
temperature; controlled yet rapid rewarming is
instituted
Constrictive clothing and jewelry that could
impair circulation are removed.
Patient should NOT be allowed to ambulate if
the lower extremities are involved.
Place extremity in a 37 to 40C circulating
bath for 30- to 40-min.
Repeat treatment until circulation is effectively
restored.
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Hypothermia
A condition in which core temperature is 35C
or less as a result of exposure to cold
Occurs when patient loses ability to maintain
body temperature
Urban hypothermia is associated with a high
mortality rate affected are the elderly, infants,
patients with concurrent illnesses, and the
homeless.
Alcohol ingestion susceptibility due to
systemic vasodilation.
Trauma victims are at risk resulting from
treatment with cold fluids, unwarmed oxygen,
and exposure during examination.
Hypothermia takes precedence in treatment
over frostbite.
Assessment
Watch out for progressive deterioration, with
apathy, poor judgment, ataxia, dysarthria,
drowsiness, pulmonary edema, acid-base
abnormalities, coagulopathy & coma
Shivering may be suppressed below 32.2C
due to ineffective mechanism
Peripheral pulses are weak and become
undetectable; cardiac irregularities, hypoxemia
and acidosis may occur.
Management: Monitoring
VS, CVP, urine output, arterial blood gas levels,
blood chemistry and chest xray are frequently
evaluated.
Body temp is monitored with a rectal,
esophageal, or bladder thermometer.
Continuous ECG monitoring is done because
cold-induced myocardial irritability can lead to
v. fibrillation.
Near-Drowning
Survival for at least 24 hours after submersion
Most common consequence is hypoxemia
One of the leading causes of death in children
younger than 14 y/o; children younger than 4
y/o account for 40% of all drownings
Risk Factors
1. Alcohol ingestion
2. Inability to swim
3. Diving injuries
4. Hypothermia
5. Exhaustion
Rescue
Successful resuscitation with full neurologic
recovery has occurred in drowning victims
after prolonged submersion in cold water.
After surviving submersion, ARDS resulting in
hypoxia, hypercarbia, & respiratory or
metabolic acidosis can occur.
Pathophysiology
Fresh water aspiration results in loss of
surfactant, hence the inability to expand the
lungs.
Salt water aspiration leads to pulmonary
edema from the osmotic effects of the salt
within the lungs.
Treatment Goals
Maintaining cerebral perfusion and adequate
oxygenation to prevent further damage to vital
organs
Immediate CPR is the factor with the greatest
influence on survival
Prevention of hypoxia by ensuring an adequate
airway and respiration, thus improving
ventilation and oxygenation
Management
ABG analyses are performed to evaluate O2,
CO2, HCO3 and pH
If the patient is not breathing spontaneously,
ET intubation with positive-pressure ventilation
improves oxygenation, prevents aspiration,
and corrects intrapulmonary shunting and V-P
abnormalities
If the patient is breathing spontaneously,
supplemental O2 may be given by mask
Because of submersion, the patient is usually
hypothermic; use a rectal probe to assess
Prescribed warming procedures such as
corporeal rewarming, warmed PD, inhalation of
warmed aerosolized O2, and torso warming
Compiled Notes of Bernie C. Butac
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Antigen allergen
Antibody IgE previously sensitized basophils
and mast cells
Release of mediators like histamine and
prostaglandin cause the systemic reactions
Causes
Penicillins most common
Contrast media
Bee stings
Food
Anaphylaxis Signs and Symptoms
1. Respiratory Signs:
nasal congestion
itching, sneezing, coughing
bronchospasm & laryngeal edema
chest tightness, dyspnea
wheezing & cyanosis
2. Skin:
flushing with sense of warmth & diffuse
erythema;
generalized itching over entire body
(systemic reaction)
urticaria (hives);
massive facial angioedema (with
accompanying upper respiratory edema)
3. Cardiovascular:
Tachycardia or bradycardia
Peripheral vascular collapse
indicated by pallor, imperceptible
pulse, BP, circulatory failure,
coma & death
4. GIT:
nausea & vomiting
colicky abdominal pains, diarrhea
Anaphylaxis Management
Establish an airway & ventilation while another
gives epinephrine.
Early ET intubation avoids loss of the airway, &
oropharyngeal suction removes secretions.
If glottal edema occurs, a crico-thyroidotomy is
used to provide an airway.
Anaphylaxis: Epinephrine Administration
Subcutaneous injection for mild, generalized
symptoms
IM injection for more severe & progressive
reactions with the possibility of vascular
collapse
IV route for rare instances where there is LOC
& severe cardiovascular collapse; may cause
dysrhythmias
Anaphylaxis: Additional Treatments
Antihistamines are given to block further
histamine release
Aminophylline by slow IV trans-fusion for
severe bronchospasm & wheezing refractory to
treatment
Albuterol inhalers or humidified treatment to
bronchoconstriction
Compiled Notes of Bernie C. Butac
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Anaphylaxis Prevention
Be aware of the danger signs of anaphylaxis.
Ask the patient about previous allergies (e.g.
allergies to eggs)
Before giving antigenic agents, ask caregiver
whether agent was received at an earlier time.
Avoid giving medications to patients with
allergic disorders unless necessary.
Perform a skin test before administration of
certain agents; have epinephrine readily
available.
If dealing with outpatients, keep them in the
clinic for at least 30 min after injection of any
agent.
Caution patients who are highly sensitive to
carry medical kits.
Encourage wearing of medical IDs.
Poisoning: Ingested Poisons
May be corrosive (alkaline and acid agents that
cause tissue destruction)
Alkaline products: Lye, drain and toilet bowl
cleaners, bleach, non-phosphate detergents,
button batteries
Acid products: toilet bowl and metal cleaners,
battery acid
Poisoning Management
Control the airway, ventilation and
oxygenation.
ECG, VS, and neurologic status are monitored
for changes.
Shock resulting from the cardio-depressant
action of the ingested substance, or from
circulating blood volume due to capillary
permeability, is treated.
A Foley catheter is inserted to monitor renal
function and blood examinations are done to
test for poison concentration.
The amount, time since ingestion, signs and
symptoms, age and weight and health history
are determined.
Patient who ingested a corrosive poison is
given water or milk to drink for dilution (not
attempted if patient has acute airway
obstruction, or if with evidence of gastric or
esophageal burn or perforation.
The following procedures may be done:
Ipecac syrup to induce vomiting in the alert
patient
Gastric lavage for the obtunded patient;
aspirate is tested
Activated charcoal administration if poison can
be absorbed by it
Cathartic, when appropriate
Ingested Poison Warnings
Vomiting is NEVER induced after ingestion of
caustic substances or petroleum distillates.
The area poison control center should be called
if an unknown toxic agent has been taken or if
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CO Poisoning Management
Goal: to reverse cerebral and myocardial
hypoxia and hasten elimination of CO by:
1. Carrying the patient to fresh air
immediately and opening doors and
windows
2. Loosening all tight clothing
3. Initiate CPR if required; give O2.
4. Prevent chilling; wrap in blankets.
5. Keep patient as quiet as possible.
6. Do NOT give alcohol in any form.
7. Upon arrival at the ER, analyze
carboxyhemoglobin levels and give 100%
O2 until level is <5%.
8. Watch out for psychoses, spastic paralysis,
ataxia, visual disturbances, and
deterioration in mental status and behavior
which may be symptoms of brain damage.
9. If accidental poisoning occurs, the DOH
should be informed so that the dwelling
could be inspected.
Food Poisoning
A sudden illness that occurs after ingestion of
contaminated food or drink
Some of the most common diseases are
infections caused by bacteria, such as
Campylobacter, Salmonella, Shigella, E. coli
O157:H7, Listeria, and botulism
Campylobacter
A bacterium that causes acute diarrhea
Transmitted through ingestion of contaminated
food, water, or unpasteurized milk, or through
contact with infected infants, pets or wild
animals.
Salmonella
Transmitted by drinking unpasteurized milk or
by eating undercooked poultry and poultry
products such as eggs
Any food prepared on surfaces contaminated
by raw chicken or turkey can also become
tainted
May also stem from food contaminated by a
food worker
Shigella
Transmitted through feces. It causes
dysentery, an infection of the intestines
causing severe diarrhea. The disease generally
occurs in tropical or temperate climates,
especially under conditions of crowding, where
personal hygiene is poor
E. Coli O157:H7
Associated with eating undercooked,
contaminated ground beef. Drinking
unpasteurized milk and swimming in or
drinking sewage-contaminated water can also
cause infection
Listeria
found in many types of uncooked foods, such
as meats and vegetables, as well as in
processed foods that become contaminated
Botulism
Linked to home-canned foods with a low acid
content
Foods include asparagus, green beans, beets,
and corn.
Other sources include chopped garlic in oil,
chili peppers, tomatoes, improperly handled
baked potatoes cooked in aluminum foil, and
home-canned or fermented fish (such as
sardines)
Food Poisoning: MC Foods
Honey should NOT be given to children
younger than 12 months of age, as it can
contain spores of C. botulinum and is known to
cause infant botulism
Staphylococcus aureus in spaghetti
Bacillus cereus in fried rice
Toxins in mushrooms, shellfish, including the
puffer fish
Assessment
1. How soon after eating did the symptoms
occur?
2. What was eaten in the previous meal? Did
the food have an unusual odor or taste?
3. Did anyone else become ill from eating the
same food?
4. Did vomiting occur? What was the
appearance of the vomit?
5. Did diarrhea occur?
6. Any other neurologic symptoms?
7. Does the patient have a fever?
8. What is the clients appearance?
Management
Determine the source and type of food
poisoning.
Food, gastric contents, vomitus, serum and
feces are collected for examination.
Patients VS, sensorium and muscular activity
are closely monitored.
Support the respiratory system and assess
fluid and electrolyte balance; watch out for
lethargy, PR, fever, oliguria, anuria,
hypotension, and delirium.
Administer IV antiemetic medications for mild
nausea, give sips of weak tea, carbonated
drinks, or tap water.
Clear liquids for 12 to 24 hrs after nausea and
vomiting subside, and then progressed to a
low-residue bland diet.
Burns
Alteration in skin and underlying tissues as a
result of:
Too much exposure to sun and UV
Direct contact with heat and burning object
Hot water and liquids
Compiled Notes of Bernie C. Butac
12 | P a g e
Chemicals
Burn Management
Maintenance of Airway Patency
A. Assess the airway.
B. Auscultate the trachea, and monitor for
adventitious breath sounds or decreased
breath sounds.
C. If client is dyspneic or if there is carbon
monoxide poisoning, a high liter flow of 8
to 10 liters of oxygen is recommended.
D. If compromise is suspected, the victim may
be intubated and ventilated.
Indications for intubation are airway
obstruction and a PaO2 of less than
60 mm Hg.
The continuous monitoring by
means of a pulse oximeter assists in
assuring adequate oxygenation.
E. The client's level of consciousness should
be carefully monitored. Burn victims are
most often alert, oriented and cooperative
even with extensive injuries.
Fluid Resuscitation
The maximum loss of fluid occurs within 12 to
18 hours after the burn.
The total quantity of fluid required to correct
this volume deficit is replaced in the first 24
hours following the burn injury.
The amount of fluid required to correct the
deficit is calculated to be 2 to 4 mL per cent
burn per kilogram of body weight.
Administration of the fluids takes place over a
24-hour period with half the amount given in
the first 8 hours and the remainder over the
next 16 hours.
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Burn Management
Obtain laboratory data
Monitor urine output and vital signs
Administer tetanus antitoxin/toxoid
Hypertonic Saline Solution
Goal: to increase serum sodium level and
osmolarity to reduce edema and prevent
pulmonary complications
Concentrated solutions of sodium chloride
(NaCl) and lactate are given sufficiently to
maintain a desired volume of urinary output.
Phases of Burn Care: Emergent
1. Airway
2. Breathing
3. Circulation
4. Disability
5. Exposure
6. Fluid Resuscitation
Management
Determine the identity and characteristics of
the chemical agent for future treatment.
The standard burn treatment for the size &
location of the wound (antimicrobials,
debridement, tetanus toxoid) is instituted.
The patient may require plastic surgery for
further wound management
The patient is instructed to have the affected
area re-examined at 24 & 72 hours and in 7
days because of the risk of under-estimating
the extent & depth of these types of injuries.
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