NLE Emergency & Critical Care Nursing — Principles of Emergency & Critical Care NursingStudy Notes

Triage is the systematic process of sorting and prioritizing patients according to the severity and urgency of their condition so that those requiring immediate intervention receive care first. The word 'triage' comes from French (trier, meaning 'to sort'), and it answers a single critical question: who cannot wait? In the Philippine healthcare context, most emergency departments use triage protocols aligned with international standards to ensure equitable and efficient resource allocation during high-volume presentations. **Standard Three-Tier Triage Categories:** Emergency departments typically classify patients into three priority levels: **Priority 1 — Emergent (Immediate/Red):** Patients with immediate threat to life or limb require immediate evaluation and treatment, ideally within minutes. These are patients with conditions that will be fatal if not treated immediately. Examples include: complete airway obstruction (epiglottitis, severe angioedema), severe respiratory distress with SpO₂ <90% despite oxygen therapy, cardiac arrest requiring cardiopulmonary resuscitation (CPR), uncontrolled severe hemorrhage (arterial bleeding), acute myocardial infarction with hemodynamic compromise, status epilepticus (continuous or repeated seizures), severe head trauma with altered consciousness, tension pneumothorax, and acute stroke presenting within the thrombolytic window. These patients are seen immediately; no waiting is acceptable. **Priority 2 — Urgent (Semi-emergent/Yellow):** Patients with serious conditions that are not immediately life-threatening but require evaluation and treatment within 30 to 60 minutes. These patients have significant pathology but are hemodynamically stable or have compensatory mechanisms maintaining stability. Examples include: moderate to severe abdominal pain with stable vitals, closed fractures with intact circulation and sensation, fever >39°C in children or elderly, acute asthma exacerbation with SpO₂ 91-94%, lacerations requiring sutures without active heavy bleeding, acute coronary syndrome with stable rhythm, and moderate dehydration. The window for treatment is measured in tens of minutes rather than seconds. **Priority 3 — Non-urgent (Minor/Green):** Patients with stable, minor conditions that can safely wait for care, often 2-4 hours or longer depending on department census. These include: minor sprains and strains, chronic disease exacerbations in stable patients (e.g., well-controlled asthmatics), mild to moderate upper respiratory infections, prescription refill requests, minor lacerations without significant bleeding, and ankle sprains with normal neurovascular status. These patients have no immediate risk of deterioration. **Advanced Five-Level Triage Systems:** Many modern emergency departments, particularly tertiary centers in the Philippines, use five-level triage scales such as the Emergency Severity Index (ESI) developed by the American College of Emergency Physicians. This system adds nuance to the standard three-tier approach: - **Level 1 (Resuscitation):** Requires immediate, aggressive interventions; equivalent to Priority 1 - **Level 2 (Emergent):** High-risk situations or vital-sign abnormalities requiring immediate evaluation - **Level 3 (Urgent):** Stable but requiring prompt evaluation, often stratified by anticipated resource needs - **Level 4 (Semi-urgent):** Minor to moderate complaints with predictable resource needs - **Level 5 (Non-urgent):** Minor complaints requiring minimal resources **The Triage Nurse's Critical Role:** Under RA 9173, the registered nurse is responsible for performing initial triage assessments. This role demands clinical judgment, knowledge of early indicators of deterioration, and the ability to make quick decisions that may mean the difference between life and death. The triage nurse must also practice continuous re-triage: a patient's acuity can change while waiting, so reassessment at intervals (typically every 30-60 minutes in busy departments) is essential for patient safety and is part of the nursing accountability framework in Philippine healthcare settings. **Mass Casualty and Disaster Triage: The START System:** When multiple patients arrive simultaneously from a single incident (mass casualty) or during public health emergencies (typhoons, building collapses, transportation accidents common in the Philippines), the triage logic fundamentally shifts from individual survival to the greatest good for the greatest number. This utilitarian approach is codified in the START (Simple Triage And Rapid Treatment) system, which assigns color tags visible at a distance: - **RED (Immediate):** Serious, salvageable life-threatening conditions requiring immediate treatment. These patients have compromised airway, breathing, or circulation but are viable for recovery if treated urgently. - **YELLOW (Delayed):** Serious injuries or illness but with stable vitals or intact compensatory mechanisms; treatment can be delayed 1-4 hours without significant worsening. - **GREEN (Minor):** Minor injuries or no significant pathology; 'walking wounded' who require care but not urgently. - **BLACK (Expectant/Deceased):** Either deceased or so severely injured that survival is unlikely given available resources; comfort measures only. The critical and ethically challenging distinction in START triage is the classification of non-breathing patients. In routine ED care, a patient who is apneic receives immediate airway opening and resuscitation—full ACLS protocols apply. However, in a mass-casualty scenario where resources are severely limited, a patient who is non-breathing even after the airway is opened is tagged BLACK (expectant), acknowledging that salvaging this patient would consume resources needed for multiple salvageable patients. This shift in triage logic is difficult for Filipino nurses trained in always preserving life, but understanding this framework is critical for NLE examination success and for disaster response readiness. **Triage in the Philippine Healthcare Context:** Philippine hospital protocols for triage must align with Department of Health (DOH) guidelines and institutional policies. Most major hospitals use modified three or five-level systems. During typhoon season, flood events, or industrial accidents common in developing regions, emergency departments activate disaster protocols. Understanding when to shift from standard to mass-casualty triage, and how to explain this shift compassionately to families, is part of the nurse's ethical responsibility.

The primary survey is the rapid, systematic assessment performed in the first few minutes of emergency care designed to identify and immediately treat life-threatening conditions. It is not a comprehensive physical exam but rather a focused, urgent scan that follows the ABCDE sequence. The absolute rule of the primary survey is: do not advance to the next letter (A to B to C) until the threat at the current letter has been addressed or is being managed. This hierarchy reflects the harsh reality of physiology: a patient without an airway cannot breathe; a patient who cannot breathe cannot maintain circulation; a patient without circulation is dead within minutes. Disability and Exposure come after the life-sustaining priorities. **A — AIRWAY (with Cervical Spine Protection):** The airway is always assessed and managed first. The immediate question is: is the airway patent (open)? Assessment includes: - **Observation:** Can the patient speak in full sentences (indicating airway is patent and breathing adequate)? Is there stridor (high-pitched, musical breathing suggesting upper airway obstruction)? Is there gurgling (fluid in the airway)? Is there a gag reflex and cough (protective airway reflexes present)? - **Inspection:** Look inside the mouth for obstruction: is the tongue falling back (most common cause of airway loss in unconscious patients)? Are there secretions, blood, vomitus, or food particles? Is there visible swelling (angioedema, epiglottitis)? Is there a foreign body? - **Palpation:** Assess for tracheal deviation (suggesting tension pneumothorax on the opposite side); feel for subcutaneous emphysema (air in the subcutaneous tissue suggesting pneumothorax or tracheal injury). If the airway is obstructed or at risk of obstruction, immediate interventions include: 1. **Positioning:** Head-tilt/chin-lift maneuver opens the airway by moving the tongue away from the posterior pharynx. Technique: place one hand on the forehead and gently tilt the head back; place fingers under the bony part of the lower jaw and lift the chin. 2. **Jaw-thrust maneuver (cervical spine precaution):** Used when cervical spine (C-spine) injury is suspected (trauma, fall, mechanism suggesting neck injury). Technique: stand at the patient's head, place hands on both sides of the jaw, and thrust the jaw forward without extending the neck. This opens the airway while keeping the C-spine neutral. 3. **Suction:** Remove secretions, blood, or vomitus using a rigid (Yankauer) catheter to clear the airway. 4. **Airway devices:** - Oropharyngeal airway (OPA): inserted blindly; for unconscious patients; holds the tongue forward - Nasopharyngeal airway (NPA): passed through the nose; better tolerated in semi-conscious patients; contraindicated if basilar skull fracture suspected (avoid nasal airway) 5. **Definitive airway:** If the airway cannot be maintained with basic maneuvers, prepare for intubation (orotracheal tube), surgical airway (cricothyrotomy), or emergency transtracheal jet ventilation in cases of complete airway obstruction. **Cervical Spine Precautions:** In any trauma patient, assume C-spine injury until proven otherwise. Maintain cervical spine immobilization throughout the primary and secondary surveys: - Manual immobilization (in-line stabilization by holding the head) - Rigid cervical collar - Backboard with head blocks and straps (for transport) - Avoid log-rolling during initial assessment; use a scoop stretcher if moving is necessary **B — BREATHING (Ventilation and Oxygenation):** Once the airway is secured or being managed, assess breathing. The question is: is the patient ventilating (moving air in and out) and oxygenating (transferring oxygen into the blood)? Assessment includes: - **Respiratory rate:** Normal is 12-20 breaths/min; <8 or >30 suggests critical pathology - **Depth and effort:** Look for use of accessory muscles (indicates increased work of breathing, suggesting respiratory distress), paradoxical breathing (chest wall moving inward during inspiration, suggesting chest wall injury), or apnea (no breathing) - **Symmetry:** Unequal chest wall movement or unequal breath sounds suggest pneumothorax, hemothorax, or flail chest - **Breath sounds:** Are they present bilaterally? Diminished unilaterally suggests lung collapse or fluid; absent suggest pneumothorax - **Oxygen saturation (SpO₂):** Goal is ≥94% on room air; <90% indicates hypoxemia requiring supplemental oxygen - **Pulse oximetry, capnography (if available):** Confirm adequate ventilation If breathing is inadequate, immediate interventions include: 1. **Supplemental oxygen:** Start high-flow oxygen (10-15 L/min via non-rebreather mask, achieving SpO₂ >94%) 2. **Bag-valve-mask (BVM) ventilation:** If the patient is apneic or severely hypoventilating, use a BVM to deliver positive-pressure ventilation; ensure the mask seals well and the head is positioned in the sniffing position (for airway alignment) 3. **Needle decompression:** If tension pneumothorax is suspected (unilateral absent breath sounds, hypotension, JVD, tracheal deviation), perform needle decompression immediately: insert a 14-16 gauge needle into the 2nd intercostal space at the midclavicular line on the affected side. This is a life-saving procedure that converts tension pneumothorax (immediately fatal) into a simple pneumothorax (serious but survivable until chest tube is placed). 4. **Chest tube:** Definitive treatment for pneumothorax or hemothorax; usually placed in the ED or operating room 5. **Open chest wound management:** Cover with a three-sided dressing (occlusive on three sides, open on one to allow air escape) to prevent tension pneumothorax development **C — CIRCULATION (with Hemorrhage Control):** Once airway and breathing are addressed, assess circulation. The question is: is the heart beating and is blood reaching vital organs? Assessment includes: - **Pulse:** Check carotid or femoral pulse for at least 5-10 seconds (can be difficult to feel in a shocked patient). Presence = patient is not in cardiac arrest. - **Heart rate:** Bradycardia (<60) can indicate late shock or spinal cord injury; tachycardia (>100) typically indicates blood loss or compensatory response - **Blood pressure:** Systolic <90 mmHg indicates hypotension (shock) - **Skin:** Cool, clammy, pale, or mottled skin indicates poor perfusion - **Capillary refill:** Press the fingernail bed; color should return in <2 seconds. Delayed refill (>2 sec) suggests hypoperfusion - **Mental status:** Confusion or altered mental status can indicate inadequate cerebral perfusion **Hemorrhage Control:** Control external bleeding immediately: 1. **Direct pressure:** Apply firm, continuous pressure with sterile gauze; elevate the limb if possible 2. **Pressure dressing:** Apply gauze, then wrap with elastic bandage to maintain pressure 3. **Tourniquet:** If bleeding cannot be controlled with direct pressure (massive limb hemorrhage), apply a tourniquet proximal to the wound, between the wound and the heart. Write the time of application on the tourniquet. In modern trauma, early tourniquet application is favored for extremity hemorrhage. 4. **Hemostatic agents:** Gauze impregnated with hemostatic agents (e.g., QuikClot) can be packed into deep wounds to promote clotting **Fluid Resuscitation:** Establish IV access as early as possible: - **Two large-bore peripheral IVs (16-18 gauge):** Allows rapid fluid and blood product administration. Avoid the affected extremity in extremity trauma. - **Central venous access:** Considered if peripheral access cannot be obtained quickly, but should not delay resuscitation Initiate fluid resuscitation: - **Balanced crystalloid (Lactated Ringer's or Normal Saline):** First-line for trauma; administer rapidly (wide-open IV) for hemorrhagic shock - **Permissive hypotension in trauma:** Some protocols recommend maintaining a systolic BP of 80-90 mmHg until definitive hemorrhage control (operating room) is achieved, to minimize re-bleeding and dilution of clotting factors. Once bleeding is controlled, increase resuscitation to maintain MAP >65 mmHg. - **Blood products:** In massive hemorrhage, activate massive transfusion protocol; consider early packed RBCs, fresh frozen plasma (FFP), and platelets in a ratio approaching 1:1:1 (permissive hypotension and balanced resuscitation are standard in modern trauma) **Signs of Shock:** Recognize and respond to shock (inadequate tissue perfusion): - **Hypovolemic shock:** From hemorrhage; managed with hemorrhage control and fluid resuscitation - **Cardiogenic shock:** From cardiac dysfunction (MI, arrhythmia); managed with vasopressors and inotropes - **Distributive shock:** From sepsis or anaphylaxis; managed with antibiotics/vasopressors (sepsis) or epinephrine (anaphylaxis) - **Obstructive shock:** From tension pneumothorax, tamponade, or PE; managed by relieving the obstruction Classic signs: tachycardia, hypotension, cool clammy skin, delayed capillary refill, oliguria (urine output <0.5 mL/kg/hr), altered mental status. **D — DISABILITY (Neurologic Status):** Once airway, breathing, and circulation are addressed, perform a quick neurologic check. **AVPU Scale:** - **A (Alert):** Patient is awake and oriented - **V (Verbal):** Patient responds to voice - **P (Pain):** Patient responds only to painful stimulus - **U (Unresponsive):** Patient does not respond to any stimulus **Glasgow Coma Scale (GCS):** More detailed; assign points for eye opening, verbal response, and motor response. Total ranges from 3 (minimum) to 15 (maximum). GCS <8 generally indicates need for airway protection (intubation). **Additional disability assessment:** - **Pupils:** Are they equal and round? Reactive to light? A blown pupil (dilated, non-reactive) on one side suggests increased intracranial pressure (ICP) from bleeding or swelling on that side. - **Blood glucose:** Check immediately with a point-of-care device (glucometer). Hypoglycemia (<70 mg/dL) is a reversible cause of altered mental status and requires immediate dextrose IV. This is one of the first things you address in disability assessment. - **Gross motor function:** Can the patient move all four extremities? Any paralysis or weakness? Suggests spinal cord injury. **E — EXPOSURE/ENVIRONMENT:** After addressing A, B, C, and D, fully expose the patient to inspect for hidden injuries. Technique: - Undress the patient completely (respecting dignity when possible) to inspect for injuries not immediately visible: entrance and exit wounds from penetrating trauma, contusions, abrasions, lacerations, or deformities - Log-roll the patient (keeping the spine aligned) to inspect the back and buttocks - Immediately cover the patient with warm blankets after exposure **Preventing Hypothermia (The Lethal Triad):** A critical nursing responsibility during Exposure is preventing hypothermia, especially in trauma patients. The lethal triad is the combination of hypothermia, acidosis, and coagulopathy, which dramatically worsens outcomes: - **Hypothermia:** Core body temperature <35°C. Impairs clotting, increases arrhythmias, worsens shock. - **Acidosis:** From tissue hypoxia and anaerobic metabolism; impairs clotting further. - **Coagulopathy:** Dilutional (from IV fluids) and iatrogenic (dilution of clotting factors); combined with hypothermia-induced clotting impairment, creates a death spiral. Nursing interventions: - Remove wet clothing (evaporative heat loss) - Apply warm blankets - Use warm IV fluids (warm crystalloid to 37°C before administration) - Use radiant heaters if available - Avoid aggressive re-warming in the field (afterdrop risk); passive or gentle active re-warming is preferred until the patient reaches a trauma center - In severe hypothermia (core temp <30°C), the patient is not dead until they are warm and dead; do not pronounce until re-warming has been attempted **The Primary Survey Reassessment:** After completing the primary survey and beginning initial management, reassess frequently (every 1-5 minutes initially). If any deterioration occurs (loss of airway, respiratory distress, cardiac arrest, new bleeding), immediately return to the problem level in ABCDE and address it before moving on. This cyclical assessment is what distinguishes emergency nursing from routine nursing.

Once the primary survey is complete and life-threatening conditions are stabilized, the secondary survey begins. While the primary survey asks 'what will kill this patient in the next few minutes?', the secondary survey asks 'what else is wrong?' It is a systematic head-to-toe physical examination combined with a focused history. The secondary survey is more thorough but never takes priority over an uncorrected problem in the primary survey; if a patient's airway becomes obstructed while you are assessing their abdomen, immediately return to the airway. **Structured History: SAMPLE Mnemonic** Obtain a focused history using the SAMPLE framework: - **S — Signs and Symptoms:** What symptoms is the patient experiencing? What brings them to the ED? In trauma: mechanism of injury, loss of consciousness, entrapment. In medical emergencies: onset (sudden vs. gradual), severity, character, and associated symptoms. - **A — Allergies:** Ask specifically about drug allergies, food allergies, environmental allergies, and reaction type. Document clearly (e.g., 'PCN → anaphylaxis' vs. 'PCN → rash'). This is critical for medication selection and administration. - **M — Medications:** Current home medications. Can be obtained from patient, family, pharmacy records, or even an empty pill bottles from the patient's wallet. Medications provide clues: a patient on anticoagulants has bleeding risk; a patient on beta-blockers may not tachycardia even in shock; a patient on insulin could have had hypoglycemia episode. - **P — Past Medical History:** Chronic diseases, surgeries, previous hospitalizations. Can reveal risk factors: diabetes → higher infection risk; COPD → baseline higher respiratory rate; coronary artery disease → higher MI risk; liver disease → bleeding tendency. - **L — Last Oral Intake:** When did the patient last eat or drink? Important for anesthesia risk (NPO status for surgery), hypoglycemia assessment, and aspiration precautions. In trauma, assume full stomach regardless of report. - **E — Events Leading to Presentation:** For trauma, detailed mechanism. For medical emergencies: what was the patient doing when symptoms started, progression, what they've already taken or done about it. Establish timeline: often the most recent event is causative. **Head-to-Toe Physical Examination** Systematically inspect, auscultate, palpate, and percuss each body region: **Head:** Inspect scalp for lacerations, contusions, skull deformities. Palpate for step-offs or crepitus (broken bone). Look for Battle's sign (bruising behind ear, suggests basilar skull fracture) or raccoon eyes (periorbital ecchymosis, also basilar skull fracture). Check for cerebrospinal fluid (CSF) leakage from ears or nose (clear, glucose-positive fluid); if present, use a 'halo test'—CSF on gauze creates a characteristic ring as it spreads around blood. Check eardrums for hemotympanum (blood behind drum, suggests basilar skull fracture). **Neck:** With C-spine precautions still in place, inspect for tracheal deviation (tension pneumothorax), JVD (elevated central venous pressure or right heart failure), and neck veins. Palpate for tracheal deviation, subcutaneous emphysema (crepitus suggesting air leak), and lymphadenopathy. In cardiac assessment, carotid pulses should not be distended more than 2 cm above the sternal angle; excessive JVD suggests fluid overload or right heart failure. **Chest:** Inspect for movement symmetry, use of accessory muscles, entrance/exit wounds, contusions, or flail segments. Palpate for rib tenderness, crepitus (rib fractures), or subcutaneous emphysema. Auscultate breath sounds bilaterally at the apexes and bases; compare left to right. Percuss for hyper-resonance (pneumothorax) or dullness (hemothorax or consolidation). In cardiac exam, palpate the point of maximal impulse (PMI, normally at 5th ICS midclavicular line), listen for heart sounds (S1, S2, murmurs, rubs), check for pericardial friction rub (suggests pericarditis or tamponade). **Abdomen:** Inspect for distension, bruising (Grey Turner's sign—flank bruising suggests retroperitoneal bleeding; Cullen's sign—periumbilical bruising suggests intra-abdominal bleeding). Auscultate for bowel sounds (present = some perfusion and motility, absent = possible ileus). Palpate gently beginning in quadrants away from tenderness, progressing to tender areas, assessing for guarding (voluntary muscle tensioning) vs. rigidity (involuntary, suggests peritonitis). Assess for rebound tenderness (pain when you release pressure, suggests peritoneal inflammation/bleeding). Palpate for hepatomegaly (liver edge below costal margin), splenomegaly (left upper quadrant mass), or aortic pulsation (aortic aneurysm). Insert Foley catheter and assess urine color (dark = dehydration, brown/red = hemoglobinuria, black = myoglobinuria suggesting rhabdomyolysis). **Pelvis:** Palpate the iliac crests and pubic symphysis; gently compress the pelvis from front and sides to elicit instability (suggests pelvic fracture with bleeding into the retroperitoneal space—a major source of occult blood loss in trauma). Insert a rectal exam: assess sphincter tone (normal, lax suggesting spinal cord injury), presence of blood (indicates lower GI pathology), and prostate position (high-riding or absent prostate suggests urethral injury in males). **Extremities:** Inspect all four limbs and compare left to right. Assess for swelling, deformity, color changes, and wounds. Palpate for crepitus (bone fracture), deformity, and tenderness. Assess distal neurovascular status: is the limb warm or cold? Sensation intact? Motor function intact? Capillary refill <2 sec? Peripheral pulses present? Any paresthesia or weakness? Document baseline status before splinting or applying traction, as this becomes the standard against which later assessment is compared. Perform the Ottawa Ankle Rules (ankle fracture risk) or Ottawa Knee Rules if indicated. Assess for compartment syndrome risk (pain out of proportion to injury, pain with passive stretch of muscles in the compartment, swelling, tense compartments). **Spine:** Logroll the patient (keeping spine aligned) to inspect the posterior surfaces of the head, neck, back, and buttocks for wounds, bruising, or deformity. Palpate the spinous processes along the thoracic and lumbar spine for step-offs (vertebral displacement) or tenderness. Perform a detailed neurologic exam: is sensation intact in all dermatomes? Can the patient move all four extremities equally? Any focal weakness or paralysis? Assess for priapism (penile erection from spinal cord injury, suggests spinal shock). Check rectal tone (spinal injury → lax tone). **Neurologic Exam:** Expanded version of the D assessment. Mentation: alert, oriented to person, place, time, situation? Cranial nerves: pupils, eye movements, facial symmetry, tongue midline, gag reflex. Motor: strength 0-5 in all major muscle groups bilaterally. Sensory: intact to light touch and pinprick in upper and lower extremities. Reflexes: normal, brisk, or diminished. Coordination: ask patient to touch their nose and your finger alternately (dysmetria suggests cerebellar injury). Gait: if patient is safe to stand, assess balance and gait pattern. **Vital Signs (Complete Set):** Obtain full vital signs if not already done: temperature (core if possible), heart rate, respiratory rate, blood pressure (both arms if trauma), oxygen saturation. Trends matter more than single values; repeat vitals at frequent intervals (every 5-15 minutes in acute settings) to detect improvement or deterioration. **Pain Assessment and Management** Assess pain using an appropriate scale (0-10 numeric, FLACC for children, verbal descriptors). Identify the location, character, onset, and aggravating/alleviating factors. Document pain score. Pain never takes priority over airway/breathing/circulation, but untreated pain increases catecholamine release, increases myocardial oxygen demand, and impairs healing. Administer analgesia as ordered (NSAIDs, opioids, local/regional anesthesia) and reassess effectiveness. **Diagnostic Studies** Order indicated imaging and laboratory tests based on chief complaint and findings: - **X-rays:** Chest (assess for pneumothorax, hemothorax, rib fractures, mediastinal shift), pelvis (assess for fractures), extremities, or C-spine if trauma - **CT scans:** Head (trauma, suspected intracranial injury), chest, abdomen/pelvis (evaluate solid organs, bleeding) - **Focused Assessment with Sonography in Trauma (FAST):** Rapid bedside ultrasound assessing for free fluid in pericardium (tamponade), right upper quadrant (liver bleeding), left upper quadrant (splenic bleeding), and pelvis (free blood). Done in emergency department, guides need for operating room. - **Laboratory tests:** Complete blood count (CBC), comprehensive metabolic panel (CMP), coagulation studies (PT, PTT), arterial or venous blood gas (assess pH, oxygenation, ventilation, lactate), troponin (cardiac), urinalysis, and type and crossmatch for blood products if hemorrhage suspected - **12-lead ECG:** For chest pain, assess for STEMI, arrhythmias - **Pregnancy test:** In any woman of childbearing age before X-ray, CT, or medication administration **Reassessment After Secondary Survey** The secondary survey is not the end of assessment. Continue to monitor and reassess: - Vital signs: at least every 15-30 minutes in critical patients, more frequently if unstable - Repeat primary survey elements if any change in status - Reassess pain and medication effectiveness - Monitor for deterioration: any change in level of consciousness, respiratory distress, hemodynamic instability should prompt immediate reevaluation

The intensive care unit (ICU) is a specialized environment designed to concentrate the sickest patients and the advanced technology necessary to support or replace failing organ systems. In the Philippine healthcare system, ICUs exist in most tertiary and secondary hospitals, from the Philippine General Hospital (a teaching institution) to regional medical centers. The ICU environment is governed by different principles than the general ward: the ratio of nurses to patients is much lower (often 1:1 or 1:2 compared to 1:5-6 on a general ward), advanced monitoring is continuous, and nursing roles expand significantly to include autonomous decision-making in monitoring for complications and initiating emergency interventions. **ICU Defining Characteristics** **Continuous Monitoring:** - **Cardiac monitoring (telemetry):** All ICU patients have continuous ECG monitoring; alarms alert staff to arrhythmias - **Pulse oximetry:** Continuous oxygen saturation monitoring; alarms if SpO₂ drops below set threshold - **Arterial line:** Continuous blood pressure monitoring (see hemodynamic monitoring section) - **Central venous pressure (CVP) monitoring:** Assesses intravascular volume and right heart function - **Capnography:** In intubated patients, continuous measurement of end-tidal CO₂ (PetCO₂) confirms tube placement and monitors ventilation adequacy - **Frequent laboratory monitoring:** Serial blood work (every 4-6 hours initially), blood cultures, arterial blood gases **Advanced Life Support Capabilities:** - **Mechanical ventilation:** Positive-pressure ventilation for patients who cannot breathe adequately on their own - **Vasoactive infusions:** Medications (epinephrine, norepinephrine, dopamine, vasopressin) that support blood pressure and tissue perfusion in shock states - **Continuous renal replacement therapy (CRRT):** For patients with acute kidney injury (AKI); continuously removes fluid and waste products - **Extracorporeal membrane oxygenation (ECMO):** Advanced life support for respiratory or cardiac failure; blood is circulated outside the body through an oxygenator - **Intraaortic balloon pump (IABP):** Mechanical circulatory support in cardiogenic shock - **Sedation and paralysis protocols:** Medications to keep mechanically ventilated patients from fighting the ventilator **High Acuity Nursing Role:** ICU nurses are responsible for: 1. **Continuous assessment:** Monitoring trends in vital signs, urine output, mental status, and organ function; recognizing early signs of deterioration 2. **Rapid intervention:** Initiating emergency procedures (CPR, defibrillation), adjusting medications and ventilator settings (within protocols), obtaining vascular access 3. **Medication management:** Administering and titrating vasoactive infusions (dosing often based on blood pressure and urine output targets), sedatives, paralytics, and prophylactic medications 4. **Device management:** Maintaining arterial lines, central venous catheters, endotracheal tubes, chest tubes, and urinary catheters; recognizing complications 5. **Infection prevention:** Implementing strict aseptic technique, recognizing signs of line-related infections, and supporting antibiotic therapy 6. **Comfort and safety:** Preventing self-extubation, managing pain and anxiety, maintaining proper positioning, preventing pressure injuries 7. **Family support:** Communicating complex information, supporting decision-making, and facilitating end-of-life discussions **Prevention of Iatrogenic Complications** One of the core nursing functions in critical care is preventing complications that arise from the intensive interventions themselves. These 'iatrogenic' (caused by medical care) complications are leading sources of morbidity in ICU patients. Key prevention strategies: **Ventilator-Associated Pneumonia (VAP) Prevention Bundle:** - **Head elevation:** Maintain the head of the bed (HOB) at 30-45 degrees elevation (unless contraindicated by hemodynamic instability); reduces aspiration of contaminated oral secretions into the lungs - **Sedation interruption:** Daily interruption of sedation allows assessment of readiness to extubate and reduces the duration of mechanical ventilation (shorter ventilation time = lower VAP risk) - **Spontaneous breathing trial:** Daily assessment of whether the patient can breathe spontaneously (with minimal ventilator support) without respiratory distress allows early extubation - **Oral hygiene:** Regular mouth care with chlorhexidine (an antimicrobial rinse) reduces bacterial colonization of the oropharynx - **Subglottic secretion removal:** Endotracheal tubes with a suction port above the cuff allow removal of secretions that accumulate above the cuff; when the cuff is deflated during extubation, these secretions can fall into the lungs and cause VAP **Central-Line Associated Bloodstream Infection (CLABSI) Prevention:** - **Strict aseptic technique:** Maintain sterile fields during catheter insertion and dressing changes - **Hand hygiene:** Vigorous hand hygiene before touching central lines or the insertion site - **Catheter site care:** Use sterile gauze or transparent dressing; change dressing if soiled, wet, or loose; chlorhexidine-based site preparation reduces infection risk - **Daily line necessity review:** Remove lines as soon as they are no longer needed (e.g., switch from central line to peripheral IV once patient can tolerate oral intake and peripheral access is adequate) - **Prompt recognition of infection:** Monitor for signs of line infection: fever, local warmth/erythema/drainage at the site, positive blood cultures. If CLABSI is suspected, obtain blood cultures (from the line and from peripheral puncture), remove the catheter, and initiate empiric antibiotics **Venous Thromboembolism (VTE) Prevention:** - **Early mobilization:** Sitting up in bed, standing, and walking (even if limited) as soon as hemodynamically stable reduces clot risk - **Sequential compression devices:** Intermittent compression boots on the lower extremities promote venous return; often used in patients who cannot mobilize - **Pharmacologic prophylaxis:** Subcutaneous low-molecular-weight heparin (enoxaparin, dalteparin) or unfractionated heparin is given to prevent clot formation in high-risk patients - **Assessment for DVT/PE:** Assess for unilateral calf swelling (DVT), sudden respiratory distress or pleuritic chest pain (PE); order compression ultrasound or CT pulmonary angiography (CTPA) if suspected **Pressure Injury Prevention:** - **Frequent repositioning:** Change patient position every 2 hours if bed-bound (or use a pressure-relieving bed) - **Skin inspection:** Assess skin daily, especially over bony prominences (sacrum, heels, elbows, occiput) - **Moisture management:** Keep skin clean and dry; manage incontinence promptly - **Nutritional support:** Adequate protein and calories support skin integrity - **Use of pressure-relieving devices:** Foam overlays, gel pads, or dynamic air mattresses reduce pressure on vulnerable areas **Stress Ulcer Prophylaxis:** - **H2 blockers or proton pump inhibitors:** In critical illness, gastric acid production increases and ulceration risk rises; prophylactic acid suppression is standard in many ICU settings - **Early enteral nutrition:** Feeding (even small amounts) protects the gastric mucosa better than H2 blockade alone **ICU Delirium Prevention:** - **Orientation and familiar faces:** Explain where the patient is, what day/time it is, and who is caring for them; involve family to provide familiar voices - **Minimizing sedation:** Use sedation only when necessary; excessive sedation increases delirium risk - **Sleep-wake cycle:** Minimize noise/light at night; maximize during the day - **Cognitive stimulation:** Encourage conversation, memory exercises, reading familiar materials - **Pain control:** Untreated pain worsens delirium - **Early mobilization:** See VTE prevention above; activity improves mental status **Family Communication and Support** The ICU environment is frightening: beeping alarms, mechanical ventilation sounds, intravenous infusions, and critically ill patients can overwhelm families. Nursing communication is essential: 1. **Explain the environment:** Describe what monitors are measuring, what alarms mean, and why tubes and lines are necessary 2. **Realistic expectations:** Clarify the prognosis (if known) and the goals of care 3. **Involve in care:** Encourage family presence, participation in comfort measures (hand-holding, reading aloud), and involvement in decision-making 4. **Discuss code status:** Clarify whether the patient is a full code (all resuscitation measures) or has a do-not-resuscitate (DNR) order 5. **Support end-of-life care:** If the patient is dying, facilitate peaceful passing, allow time for goodbyes, and honor cultural and spiritual practices 6. **Use standardized handover:** SBAR (Situation, Background, Assessment, Recommendation) format ensures critical information is communicated to the next shift or to physicians **Common ICU Diagnoses and Presentations** **Acute Respiratory Distress Syndrome (ARDS):** - Sudden onset of severe hypoxemia (PaO₂/FiO₂ ratio <300) with bilateral infiltrates on chest X-ray - Caused by sepsis, aspiration, trauma, pancreatitis, or transfusion - Requires mechanical ventilation with lung-protective strategy (low tidal volumes 6-8 mL/kg of ideal body weight, plateau pressures <30 cm H₂O) - Prognosis: ~40% mortality **Sepsis and Septic Shock:** - Systemic inflammatory response to infection; organ dysfunction (altered mental status, prolonged capillary refill, lactate >2, oliguria) - Septic shock adds hypotension (MAP <65) unresponsive to fluid resuscitation - Requires rapid cultures, empiric antibiotics, aggressive fluid resuscitation, vasopressors if fluid-refractory hypotension - Per Surviving Sepsis Campaign: blood cultures before antibiotics, broad-spectrum antibiotics within 1 hour, fluid 30 mL/kg for hypotension, lactate measurement **Acute Kidney Injury (AKI):** - Sudden loss of renal function; classified as pre-renal (hypovolemia), intrinsic (direct kidney damage), or post-renal (obstruction) - Presents with rising creatinine, oliguria (<0.5 mL/kg/hr), and hyperkalemia (dangerous) - Managed with fluid optimization (if pre-renal), nephrotoxin avoidance, and CRRT if severe or unresponsive **Multiple Organ Failure (MOF):** - Dysfunction of two or more organ systems; often follows sepsis or major trauma - Respiratory failure (ventilator dependence), renal failure (oliguria, hyperkalemia), hepatic failure (coagulopathy, encephalopathy), cardiac failure (hypotension, arrhythmias) - Mortality increases dramatically with each additional organ system affected **Status Asthmaticus:** - Life-threatening asthma exacerbation unresponsive to standard therapy - Presents with severe dyspnea, silent chest (little/no air movement on exam, signifying severe obstruction), hypercapnia (CO₂ >45), and hypoxemia - Requires aggressive bronchodilators, systemic corticosteroids, and often mechanical ventilation with permissive hypercapnia (allowing higher CO₂ to avoid excessive airway pressures) **Cardiogenic Shock:** - Heart cannot generate adequate cardiac output; usually from acute MI - Presents with hypotension, cool skin, elevated JVD, and pulmonary edema (crackles on lung auscultation, pink frothy sputum) - Managed with revascularization (PCI or thrombolytics), afterload reduction (nitroprusside, milrinone), and/or mechanical circulatory support (IABP, ECMO) **Summary of ICU Nursing Priorities (in order of Maslow's hierarchy and ABCDE logic):** 1. Maintain airway, breathing, circulation (ABC support with mechanical ventilation, vasoactive drugs, fluids) 2. Prevent iatrogenic complications (VAP, CLABSI, VTE, pressure injuries, delirium) 3. Manage pain and anxiety (comfort enables healing, reduces catecholamine surge) 4. Support organ function (renal replacement, hepatic support, nutritional support) 5. Facilitate communication with family and support decision-making 6. Promote psychological well-being and earliest possible recovery (mobilization, orientation, hope)

Hemodynamic monitoring measures the pressures and flows within the cardiovascular system. These numbers guide fluid and medication therapy, helping clinicians distinguish between different types of shock and optimize treatment. For the NLE examination, understanding the key parameters, normal values, and what abnormalities mean is essential for both emergency and critical care nursing. **The Concept of Afterload, Preload, and Contractility** Before diving into specific monitoring devices, understand three fundamental concepts: **Preload:** The amount of stretch on the ventricular myocardium at end-diastole (before contraction). Think of it as how full the ventricle is. Increased preload (from fluid overload or a failing heart retaining fluid) causes the ventricle to be overstretched; decreased preload (from hemorrhage or dehydration) means the ventricle starts with less blood to pump. The Frank-Starling law describes this: within limits, more stretch leads to more forceful contraction and greater cardiac output. However, overstretched muscle contracts poorly (like an overstretched rubber band). **Afterload:** The resistance the ventricle must overcome to eject blood. Imagine a dam holding back water; the water pressure is the afterload. High afterload (from vasoconstriction in shock, or high blood pressure) means the heart must work harder to pump. Low afterload (from vasodilation) means easier pumping. In septic shock, vasodilation reduces afterload; in cardiogenic shock, vasoconstriction increases afterload to maintain blood pressure at the cost of worsening cardiac efficiency. **Contractility:** The intrinsic ability of the heart muscle to contract. A healthy heart with good contractility can eject ~60% of the blood in the ventricle (ejection fraction). Damage to the heart muscle (myocardial infarction, viral cardiomyopathy, chronic heart failure) reduces contractility. Medications like inotropes (epinephrine, dobutamine) artificially increase contractility; beta-blockers and calcium-channel blockers decrease it. **Cardiac Output and Organ Perfusion** Cardiac output (CO) = Heart Rate × Stroke Volume. Stroke volume is the amount of blood ejected per beat; it depends on preload, afterload, and contractility. Cardiac output = (Preload - Afterload) × Contractility × Heart Rate All organs (brain, kidneys, heart, liver) require minimum perfusion to function. The key concept is not absolute blood pressure, but rather adequate perfusion—i.e., is blood reaching tissues and is oxygen being extracted and utilized? **Mean Arterial Pressure (MAP): The Critical Number** MAP is the average pressure in the arterial system throughout the cardiac cycle. It is calculated as: **MAP = Diastolic + (1/3 × Pulse Pressure)** or more simply **MAP ≈ DBP + 1/3(SBP - DBP)** For example: if BP is 120/80, MAP = 80 + 1/3(120 - 80) = 80 + 13.3 = 93 mmHg. **Critical MAP values:** - MAP ≥ 65 mmHg: Generally required to perfuse vital organs (brain, kidneys, heart). Below this, organ damage occurs. - MAP ≥ 75-80 mmHg: Preferred in septic shock and some critical conditions - MAP <50 mmHg: Severe hypotension; brain and heart are at immediate risk However, a single MAP value is less informative than the trend. A patient with MAP 70 and rising is improving; a patient with MAP 75 and falling is deteriorating. The clinical exam (warm skin, good urine output, clear mentation) confirms that pressure is translating into perfusion. **Peripheral Perfusion Indicators:** Always correlate hemodynamic numbers with the clinical picture: - **Skin temperature and color:** Warm, pink skin indicates good perfusion; cool, pale, mottled (blotchy) skin indicates poor perfusion despite what numbers might show - **Urine output:** Should be at least 0.5 mL/kg/hr (e.g., 35 mL/hr for a 70 kg adult). Oliguria (low urine output) suggests inadequate renal perfusion - **Mental status:** Confusion or altered consciousness in the setting of hemodynamic instability suggests inadequate cerebral perfusion - **Capillary refill:** Pressing the fingernail should return color in <2 seconds; delayed refill suggests poor peripheral perfusion - **Lactate level:** Tissues that are underperfused switch to anaerobic metabolism, producing lactate. Elevated lactate (>2 mmol/L) suggests tissue hypoperfusion despite normal blood pressure ('cryptic shock'). Persistently elevated lactate despite treatment indicates poor prognosis. **Arterial Line Monitoring** An arterial line (A-line) is a thin catheter placed in a peripheral artery (usually radial, femoral, or axillary) connected to a pressure transducer and monitor. It provides continuous, beat-to-beat blood pressure measurement and allows easy sampling of arterial blood without repeated needle sticks. **Insertion and Maintenance:** - **Location:** Radial artery most common (Allen's test performed first to ensure collateral ulnar blood flow); femoral or axillary used if radial unavailable - **Transducer placement:** Must be leveled at the **phlebostatic axis** (4th intercostal space, midaxillary line, approximately at the level of the right atrium). This is critical for accuracy: - **Transducer too high:** Reads falsely LOW (gravity pulls the reading down) - **Transducer too low:** Reads falsely HIGH (gravity adds to the reading) - **Zeroing:** After placing the transducer at the phlebostatic axis, "zero" the transducer to atmospheric pressure. This establishes the baseline. If the transducer drifts, re-zero. - **Flushing:** The line is kept patent with continuous heparin infusion (0.5-1 U/mL saline at 3 mL/hr) or intermittent flushes. Never inject air into an arterial line (air embolism risk). **Waveform Interpretation:** The arterial waveform shows distinct phases: - **Systolic upstroke:** Rapid rise as the left ventricle ejects blood - **Dicrotic notch:** A small dip in the waveform as the aortic valve closes; indicates the end of systole - **Diastolic downslope:** Gradual fall as the heart relaxes and peripheral vessels absorb the pressure Abnormal waveforms suggest pathology: - **Dampened waveform:** Flat, indistinct waveform; suggests air in the line, clot in the catheter, or transducer malfunction. Troubleshoot: check for air bubbles, flush the line, re-level transducer. - **Pulsus paradoxus:** Systolic pressure drops >10 mmHg with inspiration; seen in pericardial tamponade, severe asthma, or COPD exacerbation **Complications of Arterial Lines:** - **Ischemia:** Check the distal limb regularly (hand if radial line) for signs of poor perfusion: pallor, cold, paresthesia. If present, remove the line immediately. - **Hemorrhage:** Accidental disconnection can lead to rapid bleeding. All connections must be taped securely; alarms should alert staff to line disconnection. - **Thrombosis:** Clot formation in the artery can occlude flow. Regular flushing and early line removal when no longer needed reduce risk. - **Infection:** Line-related bloodstream infection is possible; maintain sterile technique during placement and dressing changes. - **Pseudoaneurysm:** After line removal, bleeding into the surrounding tissue can form a false aneurysm. Femoral lines have higher risk. **Central Venous Pressure (CVP) Monitoring** A central venous catheter (CVC) is a line placed in a large central vein (internal jugular, subclavian, or femoral) with the tip positioned in the superior vena cava (or inferior vena cava if femoral). The CVP is the pressure in the central veins, which reflects right-heart filling and intravascular volume status. **Normal CVP:** - **2-6 mmHg** (in mmHg) or **3-8 cm H₂O** (if measured with a water manometer) - Represents the pressure needed to fill the right ventricle adequately **Interpretation:** - **Low CVP (<2 mmHg):** Suggests hypovolemia (dehydration, hemorrhage). Treatment: fluid resuscitation - **High CVP (>8 mmHg):** Suggests fluid overload or right-heart dysfunction (right ventricular infarction, acute pulmonary embolism, ARDS, or pulmonary hypertension). Treatment: fluid restriction, diuretics, or inotropes (depending on the cause) - **CVP trends matter:** A CVP of 5 that was previously 3 suggests improving volume status; a CVP of 7 that was previously 5 suggests worsening fluid overload **CVP as a Fluid Responsiveness Indicator:** In a hypotensive patient, does the patient need more fluid (hypovolemic shock) or is the problem a weak heart (cardiogenic shock)? CVP helps distinguish: - **Low CVP + hypotension:** Patient is hypovolemic; give fluid bolus; repeat CVP assessment - **High CVP + hypotension:** Fluid won't help; the problem is heart function (cardiogenic shock). Consider inotropes (dobutamine, milrinone) or vasopressors (dopamine, norepinephrine) - **Normal CVP + hypotension:** Could be distributive shock (sepsis, anaphylaxis); give fluid cautiously and add vasopressors if needed **Complications of Central Venous Catheters:** - **Placement complications:** Pneumothorax (if subclavian placement), hemothorax, artery puncture, tamponade (if catheter perforates the right atrium). Check chest X-ray after placement. - **Infection (CLABSI):** Central-line bloodstream infection is a major ICU complication. Follow strict aseptic technique, maintain site care, remove line when no longer needed. - **Thrombosis:** Clot can form around the catheter; risk increases with duration of catheterization. - **Arrhythmias:** If the tip advances too far into the right ventricle, irritation can cause ectopic beats or atrial fibrillation. Withdraw the catheter slightly. **Pulmonary Artery (Swan-Ganz) Catheter** A pulmonary artery catheter (PAC) is an advanced monitoring device passed through the right heart into the pulmonary artery. While its use has declined (many prefer echocardiography for similar information), it remains an examinable concept for the NLE. **What it measures:** - **Right atrial pressure (RAP):** Similar to CVP; reflects right-heart filling - **Right ventricular pressure (RVP):** Normally <25 mmHg systolic - **Pulmonary artery pressure (PAP):** Normally 20-30 mmHg systolic, 8-15 mmHg diastolic; elevated in pulmonary hypertension or left-heart failure - **Pulmonary artery wedge pressure (PAWP):** Obtained by floating a balloon at the catheter tip into a small pulmonary artery until blood flow is occluded ("wedged"). PAWP approximates left-heart filling pressure (left ventricular end-diastolic pressure). Normal is 5-12 mmHg. High PAWP suggests left-heart failure or fluid overload; low PAWP suggests hypovolemia. - **Cardiac output (CO):** Measured by thermodilution method (cold saline injected, temperature change detected, CO calculated) - **Cardiac index (CI):** CO adjusted for body surface area; normal is 2.5-4.2 L/min/m² **Interpretation:** The PAC helps distinguish shock types by examining hemodynamics: - **Hypovolemic shock:** Low CVP, low PAWP, low CO, high systemic vascular resistance (body vasoconstricts to maintain pressure) - **Cardiogenic shock:** High CVP, high PAWP, low CO, high SVR (weak heart with fluid backup and systemic vasoconstriction) - **Distributive shock (sepsis/anaphylaxis):** Low CVP initially (if fluid loss) or normal/high (with fluid resuscitation), low PAWP, variable CO (often low), low SVR (vasodilation) - **Obstructive shock (tamponade, PE, tension pneumothorax):** High CVP, high right-ventricular pressure, low CO, elevated SVR **Critical Nursing Intervention: Balloon Management** The PAC has a balloon that is inflated to obtain the wedge pressure. **Never inflate the balloon for more than a few seconds**. Prolonged inflation occludes blood flow to that area of lung, risking: - **Pulmonary infarction:** Tissue death from lack of blood flow - **Pulmonary artery rupture:** A catastrophic complication causing massive hemorrhage into the lungs (hemoptysis, shock) After obtaining the wedge reading, **immediately deflate the balloon**. The catheter should always be in the PA pressure reading (not wedged) during normal use. **Echocardiography as Alternative** Transesophageal echocardiography (TEE) or bedside transthoracic echocardiography (TTE) provides real-time visualization of heart structure and function. Many institutions now prefer echo over PAC for assessing cardiac function, fluid responsiveness, and pericardial effusion (tamponade). **Putting It Together: A Practical Example** A 65-year-old patient with acute MI develops cardiogenic shock: BP 85/55 (MAP = 62), heart rate 110, respiratory distress (crackles on lung exam). Hemodynamic profile: - **Arterial line:** BP 85/55 (MAP 62, below target of 65) - **CVP:** 12 mmHg (high, suggesting volume overload from failing left heart) - **Urine output:** 200 mL/4 hours for a 70 kg patient (oliguria; should be 140+ mL/4 hours) - **Lactate:** 3.2 mmol/L (elevated, suggesting tissue hypoperfusion) Assessment: Cardiogenic shock with pulmonary edema and inadequate perfusion. Nursing actions: 1. Position patient upright to reduce pulmonary edema (orthopnea precaution) 2. Administer high-flow oxygen to improve SpO₂ 3. Prepare for urgent revascularization (catheterization lab for PCI—angioplasty) 4. If hypotension persists, administer inotrope (dobutamine or milrinone) to improve heart contractility; may add vasopressor (norepinephrine) if inotrope alone insufficient 5. Diuretics contraindicated (dehydration will worsen cardiac output); focus on improving heart function 6. Reassess MAP, urine output, and lactate after interventions; goal is MAP >65, urine output >0.5 mL/kg/hr, lactate normalizing This approach differs from hypovolemic shock, where the treatment is fluid boluses and pressors only if fluid-refractory; here, the problem is too much fluid and a weak heart, so the treatment focuses on improving cardiac function and reducing afterload. **Summary Table: Hemodynamic Parameters and Normal Values** | Parameter | Normal Value | High | Low | |-----------|--------------|------|-----| | MAP (Mean Arterial Pressure) | 70-100 mmHg | Hypertension, pain, anxiety | Shock, hypotension | | CVP (Central Venous Pressure) | 2-6 mmHg (3-8 cm H₂O) | Fluid overload, right heart failure | Hypovolemia, dehydration | | Systolic BP | 90-120 mmHg | Hypertension | Shock | | Diastolic BP | 60-80 mmHg | Hypertension | Shock | | Heart Rate | 60-100 bpm | Tachycardia (pain, anxiety, fever, shock) | Bradycardia (athletic, hypothermia, AV block) | | PAWP (Pulmonary Artery Wedge Pressure) | 5-12 mmHg | Left heart failure, fluid overload | Hypovolemia | | Cardiac Output | 4-8 L/min | (Usually not reported as 'high') | Cardiogenic shock, severe sepsis | | Cardiac Index | 2.5-4.2 L/min/m² | Hyperthermia, anxiety | Cardiogenic shock, sepsis | | Urine Output | ≥0.5 mL/kg/hr | Fluid overload, diuretic use | Dehydration, AKI, shock | | Lactate | <2 mmol/L | Tissue hypoperfusion, anaerobic metabolism | Good perfusion, aerobic metabolism | | Capillary Refill | <2 seconds | Poor (vasoconstriction) | Good perfusion | **The Bottom Line:** Hemodynamic numbers are tools, not the goal. The goal is adequate tissue perfusion: warm skin, good urine output, normal lactate, clear mentation, and adequate MAP. Numbers that don't match the clinical picture should prompt investigation (dampened waveform from line problems, transducer position error, etc.). Treat the patient, not the numbers.

Emergency and critical care nursing is defined by rapid decision-making and decisive action. While comprehensive knowledge of diseases is important, the ability to prioritize and act decisively on the most life-threatening problem is what saves lives. This section consolidates the principles into actionable nursing priorities that apply across every emergency scenario. **The Hierarchy of Nursing Priorities: ABCDE + Maslow** The ABCDE sequence is absolute. When two problems compete for your attention, the one higher in the sequence always wins: 1. **Airway always comes before Breathing** - Example: A patient has both airway obstruction and respiratory distress. You establish the airway first (with positioning, suctioning, airway device, or intubation). Only after airway patency is secured do you address the breathing problem. 2. **Breathing always comes before Circulation** - Example: A patient has both respiratory distress (SpO₂ 80%) and chest pain (possible MI). You provide oxygen and support ventilation first; then you address the chest pain and start MI protocols. 3. **Circulation always comes before Disability** - Example: A trauma patient has both uncontrolled hemorrhage (shock) and a decreased consciousness level (disability). You control the bleeding and resuscitate first; then you assess and protect the airway (disability assessment comes after circulation stabilization). 4. **Disability always comes before Exposure** - Example: During a complete assessment, you notice the patient is hypothermic while exposed. You complete the disability assessment; then you cover the patient with warm blankets (Exposure component). This hierarchy reflects physiology: a patient without an airway is dead within minutes; a patient without breathing is dead within minutes; a patient without circulation is dead within 5 minutes; disability and exposure, while important, are secondary priorities. **Five Principles of Emergency/Critical Care Nursing** **Principle 1: Stabilize Before Diagnosing** The temptation in emergency medicine is to run every test, make a diagnosis, then treat. Instead, emergency nursing reverses this logic: treat what you know is wrong, diagnose while treating. **Example:** A patient arrives with severe respiratory distress, stridor, and cyanosis. You don't wait for a chest X-ray or CT to diagnose the problem; you immediately assume airway obstruction, suction secretions, insert an airway device, prepare for intubation. Only after the airway is patent and oxygenation is restored do you obtain imaging to determine the cause (epiglottitis? angioedema? foreign body?). **Principle 2: Establish Access Early** Vascular access is needed to administer medications, fluids, and blood products rapidly. In unstable patients: - Establish two large-bore peripheral IVs (16-18 gauge) in the upper extremities - If peripheral access is difficult or the patient is in profound shock, obtain central venous access - Do not delay resuscitation while struggling with IV placement; use the first successful access to start fluids while trying for a second line **Principle 3: Monitor Continuously** Any unstable patient gets: - Continuous cardiac monitoring (ECG telemetry) to detect arrhythmias - Pulse oximetry (SpO₂ monitoring) to detect hypoxemia - Frequent or continuous blood pressure monitoring (automatic BP cuff, arterial line if available) - Core temperature monitoring (especially in trauma) Alarms are set at critical thresholds (e.g., SpO₂ <90%, HR <40 or >120, MAP <65) and staff respond immediately to alarms. **Principle 4: Reassess After Every Intervention** Do not assume an intervention worked; verify it: - After giving high-flow oxygen, check SpO₂ (should increase within minutes) - After a fluid bolus, reassess blood pressure, urine output, and perfusion - After endotracheal intubation, verify tube placement with capnography and chest X-ray - After chest decompression for tension pneumothorax, reassess breath sounds and vital signs If an intervention did not achieve the expected result, immediately consider why (is the tube kinked? Is the IV infiltrated? Is the problem something else?) and adjust. **Principle 5: Document and Communicate: SBAR Handover** In a fast-paced emergency, critical information can be lost. Structured communication prevents errors. Use **SBAR**: - **Situation:** Brief statement of the patient and chief complaint. "Mr. Santos is a 65-year-old man with acute MI." - **Background:** Relevant history. "He has diabetes, hypertension, prior MI five years ago. He took aspirin at home. Wife says he was fine this morning, collapsed with chest pain 30 minutes ago." - **Assessment:** Current status and your clinical impression. "He is hypotensive (85/55), tachycardic (115), has pulmonary crackles, troponin elevated. I believe he is in cardiogenic shock with pulmonary edema." - **Recommendation:** What you need. "He needs urgent catheterization, and I recommend starting an inotrope to improve his BP while we arrange transport to the cath lab." This format takes 30-60 seconds but ensures nothing critical is missed. Use SBAR in handoffs to the next shift, when calling the physician, or when transferring the patient to the ICU. **Specific Nursing Interventions by Priority** **A — Airway Interventions (In Priority Order)** 1. **Assess patency:** Can the patient speak? Is there stridor? Inspect inside the mouth for obstruction. 2. **Position:** Head-tilt/chin-lift or jaw-thrust (if C-spine injury suspected) 3. **Suction:** Clear secretions, blood, or foreign material with a rigid catheter 4. **Insert airway device:** Oropharyngeal airway (OPA) if unconscious; nasopharyngeal airway (NPA) if semi-conscious (but no basilar skull fracture) 5. **Prepare for intubation:** If airway cannot be maintained with basic measures, prepare equipment (endotracheal tube, laryngoscope, suction, sedatives) and notify the physician/provider **B — Breathing Interventions** 1. **Assess adequacy:** Rate, depth, effort, symmetry, and breath sounds 2. **Supplemental oxygen:** Start high-flow oxygen (10-15 L/min via non-rebreather mask), aiming for SpO₂ >94% 3. **Bag-valve-mask ventilation:** If apneic or severely hypoventilating, assist breathing with BVM 4. **Needle decompression:** If tension pneumothorax suspected (absent breath sounds unilaterally, hypotension, JVD), insert 14-16 gauge needle into 2nd ICS at midclavicular line 5. **Chest tube preparation:** After needle decompression, prepare for definitive chest tube placement 6. **Support ventilation:** Prepare for mechanical ventilation if needed (intubation and ventilator setup) **C — Circulation Interventions** 1. **Check for pulse:** Assess carotid or femoral pulse for 5-10 seconds 2. **If no pulse → CPR:** Start chest compressions (100-120 per minute), rescue breathing or BVM, defibrillation if indicated 3. **If pulse present:** - Control external bleeding: Direct pressure, tourniquet if needed - Establish IV access: Two large-bore IVs (16-18G), higher if central access needed - Initiate fluid resuscitation: Balanced crystalloid (Lactated Ringer's or Normal Saline) at wide-open rate initially; target MAP >65, urine output >0.5 mL/kg/hr - Prepare for blood products: Type and crossmatch; in massive hemorrhage, activate massive transfusion protocol - Prepare for pressors: If hypotension persists after fluids, prepare vasopressors (norepinephrine, dopamine, epinephrine) **D — Disability Interventions** 1. **AVPU assessment:** Alert, Verbal, Pain, Unresponsive 2. **Check pupils:** Size, equality, reactivity (blown pupil suggests increased ICP) 3. **Blood glucose:** Check immediately with glucometer; if <70 mg/dL, give 50 mL D50 IV push 4. **Protect airway:** If GCS <8 (severely altered), prepare for intubation to protect airway **E — Exposure/Environment Interventions** 1. **Inspect:** Fully undress and visually inspect for hidden injuries 2. **Log-roll:** With spine precautions, assess back and buttocks 3. **Prevent hypothermia:** Remove wet clothing, apply warm blankets, use warm IV fluids, apply radiant heater **Common Medication Interventions in Emergency/Critical Care** While specific drug protocols vary by institution and physician order, nurses should be familiar with common emergency medications: **For Airway/Breathing:** - **Epinephrine (1:1000):** For anaphylaxis (0.3-0.5 mg IM); for cardiac arrest (1 mg IV push Q3-5 min) - **Albuterol:** Beta-2 agonist; for asthma/COPD exacerbation (nebulized 2.5-5 mg or MDI 4-8 puffs) - **Ipratropium:** Anticholinergic; paired with albuterol for COPD (0.5 mg nebulized) - **Magnesium sulfate:** For severe asthma/COPD (2 g IV over 20 min) **For Circulation:** - **Atropine:** For bradycardia/heart block (0.5-1 mg IV push, repeat Q3-5 min up to 3 mg total) - **Amiodarone:** For ventricular fibrillation or ventricular tachycardia (300 mg IV push first, 150 mg second); also for SVT/AFib rate control (loading doses, then infusion) - **Adenosine:** For stable SVT (6 mg IV rapid push, then 12 mg if needed); given as fast IV flush - **Isoproterenol:** For severe bradycardia unresponsive to atropine (1-5 mcg/min infusion); rarely used now **For Shock/Hypotension:** - **Norepinephrine (Levophed):** Alpha + beta agonist; first-line vasopressor for septic shock (0.1-0.5 mcg/kg/min, titrate to MAP >65) - **Dopamine:** Dose-dependent effects: low (<5 mcg/kg/min) for renal perfusion, moderate (5-10) inotropic, high (>10) vasoconstrictive - **Epinephrine:** High-dose inotrope/vasopressor; for cardiogenic shock or refractory hypotension (0.1-0.5 mcg/kg/min) - **Dobutamine:** Inotrophic agent for cardiogenic shock; increases contractility but can lower BP (2.5-10 mcg/kg/min) - **Milrinone:** Inodilator (increases contractility, lowers afterload); for cardiogenic shock (0.25-0.75 mcg/kg/min) **For Anaphylaxis:** - **Epinephrine:** 0.3-0.5 mg IM (0.3 mg for adults, smaller doses for children); repeat every 5-15 min if needed - **Diphenhydramine:** H1 receptor antagonist (25-50 mg IV/IM) for itching and urticaria - **Cimetidine or ranitidine:** H2 receptor antagonist (300 mg IV) to reduce gastric acid production - **Methylprednisolone or dexamethasone:** Corticosteroid to prevent biphasic anaphylaxis (125 mg IV) **CPR and ACLS Protocol (Brief Overview)** Cardiopulmonary resuscitation (CPR) is initiated for cardiac arrest (no pulse, no breathing). Current guidelines emphasize: 1. **Check responsiveness and breathing:** Tap and shout; if unresponsive and not breathing, activate emergency response (call code) 2. **Start chest compressions:** 100-120 compressions per minute, pushing hard and fast on the lower half of the sternum, depth at least 2 inches (5 cm) 3. **Airway and breathing:** After 30 compressions, deliver 2 breaths (mouth-to-mouth, BVM, or other device) 4. **Defibrillation:** If the rhythm is ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), defibrillate early (apply pads, charge to 360 J or manufacturer-recommended, deliver shock, resume compressions) 5. **Medications every 3-5 minutes:** Epinephrine 1 mg IV push Q3-5 min; Amiodarone 300 mg first, 150 mg second for VF/VT 6. **Consider reversible causes:** The H's and T's: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hyperkalemia, Hypothermia, Tension pneumothorax, Tamponade, Thrombosis (MI), Thromboembolism (PE), Toxins 7. **Continue until:** Spontaneous return of circulation (ROSC), termination by provider, or family requests cessation **Post-Resuscitation Care (Post-Cardiac Arrest Care):** After ROSC is achieved, focus immediately shifts to: - **Optimize oxygenation and ventilation:** Target SpO₂ 94-98% (avoid hyperoxia), target PetCO₂ 35-45 mmHg if intubated - **Therapeutic hypothermia:** Cool the patient to 32-34°C core temperature for 12-24 hours to improve neurologic outcomes. Use ice packs, cold IV saline, or cooling blankets. - **Identify and treat the cause:** If MI, prepare for urgent catheterization. If PE, prepare for thrombolytics or embolectomy. - **Monitor for complications:** Arrange ICU admission; monitor for organ failure, arrhythmias, and other post-arrest complications **Ethical and Communication Challenges** **Do-Not-Resuscitate (DNR) Orders:** A patient or their healthcare proxy may request DNR status (no CPR if cardiac arrest occurs). Nurse responsibilities: - Verify DNR order is current and properly documented - Communicate DNR status to all team members at shift change - If DNR status is questioned or unclear, default to FULL code (resuscitate) until clarified - If the patient codes and DNR is confirmed, activate comfort care measures (pain relief, positioning, family presence) rather than CPR **Withdrawal of Life Support:** If the patient is dying despite maximal support and the family wishes to withdraw life support, the nurse's role is to facilitate a peaceful death: - Discontinue monitors, alarms, and painful interventions - Provide comfort medications (morphine for pain/dyspnea, anticholinergics to dry secretions) - Maintain dignity: allow family presence, facilitate spiritual practices, provide quiet environment - Provide post-mortem care with respect and cultural sensitivity **RA 9173 and Nursing Accountability:** Under the Philippine Nursing Practice Law (RA 9173), nurses in emergency and critical care settings have defined responsibilities: - Perform initial triage and assessment - Implement protocols and standing orders - Initiate emergency interventions (airway management, CPR, fluid resuscitation) - Monitor and report patient status - Collaborate with physicians and other members of the healthcare team - Advocate for patient safety and rights - Maintain accurate documentation Nurses work within their scope of practice as defined by the law, institutional protocols, and their education level. Advanced practice nurses (APNs) with specialized training may have expanded roles. **Common Pitfalls and Preventive Strategies** **Pitfall 1: Tunnel Vision** - **Definition:** Focusing so intently on one problem (e.g., a wound) that other critical issues are missed - **Prevention:** Follow ABCDE systematically; even if you identify a dramatic problem (e.g., a laceration), complete the full primary survey before focusing on treatment **Pitfall 2: Anchoring Bias** - **Definition:** Settling on an initial diagnosis and missing new information that contradicts it - **Example:** A patient is labeled "anxiety" based on the first evaluation, so when they truly develop MI symptoms, it's dismissed as anxiety. - **Prevention:** Reassess continuously; treat the patient in front of you, not the label from an hour ago **Pitfall 3: Over-Reliance on Monitors** - **Definition:** Trusting monitor readings when the patient looks unstable, or vice versa - **Example:** A monitor shows normal BP, but the patient is cool, clammy, and confused (cryptic shock with actually inadequate perfusion). - **Prevention:** Always correlate monitors with the clinical picture (skin, urine output, mentation, lactate) **Pitfall 4: Delayed Intervention** - **Definition:** Spending time gathering information when immediate action is needed - **Example:** Waiting for a CT before securing an airway in a patient with epiglottitis. - **Prevention:** "Stabilize before diagnosing." Act on what you know is wrong; gather information while treating. **Pitfall 5: Communication Gaps** - **Definition:** Failing to hand off critical information or not clarifying orders - **Example:** Assuming the physician knows the patient's allergy because it's in the chart, so you don't mention it. - **Prevention:** Use SBAR; verbally confirm allergies and critical information; if an order seems unsafe, clarify before executing **Pitfall 6: Inadequate Reassessment** - **Definition:** Assuming an intervention worked without verifying - **Example:** Giving fluid for hypotension, then never rechecking BP or reevaluating if fluids helped. - **Prevention:** After every intervention, assess response within minutes. Adjust or escalate if no improvement.