NLE Emergency & Critical Care Nursing — Trauma, Poisoning & Environmental EmergenciesRevision Notes

Exam Tips

• NLE PRIORITY: If a trauma question asks 'what is the FIRST action?' — the answer is almost always A (Airway with C-spine), then B, then C.
• Hemorrhage control hierarchy: Direct pressure → Tourniquet (limb bleeding) → IV access + fluids.
• If GCS is dropping, think: rising ICP from intracranial hemorrhage — priority is to notify physician and prepare for possible intubation.
• Lethal triad mnemonic: 'HAC' — Hypothermia, Acidosis, Coagulopathy.
• Mechanism of injury guides your suspicion for hidden injuries: high-speed MVA → suspect aortic injury; fall from height → suspect spinal and pelvic fractures.

Key Points

• Multiple trauma means injury to more than one body region or organ system. The danger is that a visible but survivable injury distracts the team from a silent, lethal one.
• The PRIMARY SURVEY follows ABCDE: Airway (with C-spine control), Breathing, Circulation, Disability, Exposure/Environment.
• A — Airway with Cervical Spine Control: Assume spinal injury in any significant blunt trauma. Use a jaw-thrust (NOT head-tilt chin-lift) to open the airway while keeping the cervical spine neutral. Apply a cervical collar.
• B — Breathing: Identify and immediately treat the 3 life-threatening chest injuries: (1) Tension pneumothorax → needle decompression at 2nd intercostal space, midclavicular line; (2) Open pneumothorax → occlusive dressing (3 sides sealed); (3) Massive hemothorax → chest tube insertion.
• C — Circulation with Hemorrhage Control: Hemorrhage is the LEADING CAUSE of preventable trauma death. Priority actions: direct pressure → tourniquet for uncontrolled limb bleeding → two large-bore IVs → balanced resuscitation with blood products. Check for occult (hidden) bleeding in chest, abdomen, pelvis, and thighs.
• D — Disability: Assess Glasgow Coma Scale (GCS) and pupil response. A falling GCS may signal rising intracranial pressure (ICP) — notify physician immediately.
• E — Exposure/Environment: Fully undress the patient to find all wounds. Then PREVENT HYPOTHERMIA aggressively — warm blankets, warm IV fluids, warm environment.
• The TRAUMA LETHAL TRIAD is: Hypothermia + Acidosis + Coagulopathy. These three findings are self-reinforcing and can lead to irreversible shock and death. Preventing hypothermia is a TRUE resuscitation priority.
• The SECONDARY SURVEY (head-to-toe assessment) follows the primary survey and is guided by mechanism of injury.
• Reassessment is constant — a 'stable' trauma patient can decompensate suddenly from ongoing internal bleeding.
• Top NANDA nursing diagnoses in multiple trauma: Ineffective Airway Clearance, Deficient Fluid Volume (hemorrhage), Impaired Gas Exchange, Risk for Infection, Acute Pain.

Definitions

Section Title

Multiple Trauma (Polytrauma): Primary Survey and Priorities

Common Mistakes

• Using head-tilt chin-lift in a trauma patient — always use jaw-thrust to protect the cervical spine.
• Skipping the primary survey because the wound looks minor — always do ABCDE first regardless of appearance.
• Forgetting occult bleeding sites: chest, abdomen, pelvis, thighs can each hold liters of blood silently.
• Treating hypothermia as an afterthought rather than a resuscitation priority — this leads to the lethal triad.
• Moving to the secondary survey before the primary survey is complete and life threats are addressed.

Formulas

Exam Tips

• NLE FAVORITE: 'A nurse is caring for a burn patient. Which finding requires the MOST immediate action?' Answer: Hoarseness or stridor — indicates impending airway closure → prepare for intubation.
• Parkland formula shortcut: Memorize '4-kg-%TBSA-LR-24hr-half first 8'.
• 8-hour clock starts at TIME OF INJURY — always ask/document exact time of burn.
• CO poisoning clue words in NLE scenarios: 'enclosed space,' 'house fire,' 'normal SpO2 but confused' → give 100% O2.
• Full-thickness burns are PAINLESS (nerve ends destroyed) but partial-thickness burns are VERY PAINFUL — this distinction appears in depth-identification questions.

Key Points

• Burns threaten life through TWO main mechanisms: (1) Airway compromise from inhalation injury and (2) Massive fluid loss leading to distributive/hypovolemic shock.
• PRIORITY #1 IN BURNS = AIRWAY. Signs of inhalation injury: facial burns, singed nasal hair, soot in mouth/nose, hoarseness, stridor, carbonaceous sputum. Airway edema develops RAPIDLY — intubate EARLY before the airway closes.
• STOP THE BURNING PROCESS first: remove clothing and jewelry. Do NOT peel off adherent material.
• Burn depth classification: (1) Superficial/1st degree — epidermis only, red, painful, no blisters (e.g., sunburn); (2) Partial-thickness/2nd degree — epidermis + dermis, blisters, VERY painful, moist; (3) Full-thickness/3rd degree — all layers, leathery, painless (nerve destruction), waxy/charred.
• Extent of burns is estimated using the RULE OF NINES in adults: Head & neck = 9%, Each arm = 9%, Anterior trunk = 18%, Posterior trunk = 18%, Each leg = 18%, Perineum = 1%. Total = 100%.
• Fluid resuscitation for major burns (≥20% TBSA in adults): Use the PARKLAND FORMULA.
• PARKLAND FORMULA: Total fluid = 4 mL × body weight (kg) × %TBSA burned. Use Lactated Ringer's solution. Give HALF in the FIRST 8 HOURS (from time of injury, not arrival). Give the remaining HALF over the next 16 hours.
• Urine output is the best indicator of adequate fluid resuscitation: target 0.5 mL/kg/hr in adults; 1 mL/kg/hr in children; 1–1.5 mL/kg/hr in electrical burns.
• CARBON MONOXIDE (CO) POISONING: Suspect in enclosed-space fires. CRITICAL: Pulse oximetry reads FALSELY NORMAL because it cannot distinguish carboxyhemoglobin (COHb) from oxyhemoglobin (HbO2). Treat with 100% high-flow oxygen via non-rebreather mask. Symptoms: headache, confusion, cherry-red skin (late sign).
• Wound care: Cover with clean dry dressings. Provide analgesia (burns are extremely painful). Maintain warmth — burned patients lose heat rapidly and are prone to the lethal triad.
• NANDA diagnoses: Risk for Deficient Fluid Volume, Impaired Skin Integrity, Acute Pain, Risk for Infection, Impaired Gas Exchange (inhalation injury).

Definitions

Section Title

Emergency Burn Care

Common Mistakes

• Timing the 8-hour half from ARRIVAL at hospital, not from TIME OF INJURY — this is incorrect and leads to under-resuscitation.
• Including superficial (1st degree) burns in the TBSA calculation — only partial-thickness and full-thickness burns are counted.
• Trusting pulse oximetry in CO poisoning — it reads falsely normal; always treat with 100% O2 in enclosed-space fires.
• Waiting too long to intubate with signs of inhalation injury — by the time stridor is severe, intubation may be impossible.
• Applying ice or cold water to burn wounds — this worsens hypothermia and tissue injury; use cool (not cold) running water for 20 minutes only for minor burns.

Exam Tips

• Memorize the antidote pairings as a table — NLE frequently asks 'which antidote is used for [toxin]?'
• SLUDGE mnemonic = Organophosphate → give Atropine (reverses SLUDGE) + Pralidoxime.
• Opioid overdose hallmark = 'triad of miosis, respiratory depression, decreased LOC' → Naloxone.
• Activated charcoal contraindication: 'protected airway?' If no (unconscious, no intubation) → DO NOT give AC.
• Acetaminophen: 'looks fine but NAC must be given within 8 hours' — do not delay treatment based on normal appearance.
• Beta-blocker toxicity (bradycardia, hypotension, bronchospasm) → antidote = Glucagon (not atropine alone).

Key Points

• Universal approach to ALL poisoning: (1) Support ABCs first, (2) Identify the toxin, (3) Decontaminate when appropriate, (4) Give specific antidote if available, (5) Enhance elimination if indicated.
• MOST IMPORTANT RULE: The majority of poisoned patients are managed with SUPPORTIVE CARE. Antidotes are the exception, not the routine.
• ACTIVATED CHARCOAL (AC): Most effective when given within 1 hour of ingestion. Adsorbs (binds) many toxins in the GI tract. CONTRAINDICATED when airway is unprotected (decreased consciousness without a secured airway) due to aspiration risk. Does NOT bind: alcohols, iron, lithium, potassium, corrosives.
• GASTRIC LAVAGE and INDUCED EMESIS (ipecac) are NO LONGER RECOMMENDED as routine decontamination methods.
• NEVER induce vomiting after ingestion of: CAUSTIC/CORROSIVE substances (acids, alkalis — causes re-injury to esophagus) or HYDROCARBONS (gasoline, kerosene — aspiration risk causes chemical pneumonitis).
• KEY ANTIDOTES to memorize: (1) Opioids → Naloxone (Narcan); (2) Acetaminophen/Paracetamol → N-Acetylcysteine (NAC, Mucomyst); (3) Organophosphates → Atropine + Pralidoxime; (4) Digoxin → Digoxin-specific Fab antibody fragments; (5) Benzodiazepines → Flumazenil (USE WITH CAUTION); (6) Beta-blockers → Glucagon; (7) Heparin → Protamine sulfate; (8) Warfarin → Vitamin K; (9) Iron → Deferoxamine; (10) Methanol/Ethylene glycol → Fomepizole; (11) Cyanide → Hydroxocobalamin.
• OPIOID TOXIDROME: Miosis (pinpoint pupils), respiratory depression, decreased LOC (the triad). Treatment: Naloxone — titrate to restore breathing, not to full wakefulness. Anticipate re-dosing because naloxone's duration is SHORTER than most opioids.
• ORGANOPHOSPHATE/CHOLINERGIC TOXIDROME (SLUDGE/DUMBELS): Salivation, Lacrimation, Urination, Defecation, GI distress, Emesis (plus Bradycardia, Bronchospasm, Bronchorrhea). Caused by anticholinesterase poisoning (pesticides, nerve agents). Atropine reverses muscarinic effects; Pralidoxime reactivates cholinesterase IF given early (before 'aging').
• ACETAMINOPHEN OVERDOSE: May appear asymptomatic initially, then progress to fulminant hepatic failure in 72–96 hours. NAC is most effective within 8 hours of ingestion. This is why ALL acetaminophen overdose patients need urgent treatment even if they feel fine.
• FLUMAZENIL caution: Can precipitate SEIZURES in chronic benzodiazepine users or in mixed overdoses (especially with TCAs). NOT given routinely.
• NANDA diagnoses in poisoning: Risk for Aspiration, Ineffective Breathing Pattern, Decreased Cardiac Output (dysrhythmia), Risk for Injury, Deficient Knowledge (prevention).

Definitions

Section Title

Poisoning and Overdose: Universal Approach and Key Antidotes

Common Mistakes

• Inducing vomiting in caustic or hydrocarbon ingestion — causes additional esophageal injury or aspiration pneumonitis.
• Giving activated charcoal to a drowsy, unresponsive patient without a secured airway — major aspiration risk.
• Expecting naloxone to work for hours — its duration is shorter than most opioids; repeat dosing or infusion may be needed.
• Thinking NAC is only needed if the patient looks sick — acetaminophen overdose is silent initially; treat early regardless of symptoms.
• Using flumazenil routinely in all suspected benzodiazepine overdoses — can trigger life-threatening seizures in certain patients.

Exam Tips

• Snakebite 'do not' list is frequently tested: No ice, No cut-and-suck, No tourniquet.
• Anaphylaxis from sting: FIRST action = IM epinephrine (anterolateral thigh preferred for faster absorption).
• Dog bite in the Philippines → always think RABIES PEP referral to nearest ABTC.
• Bee stinger removal: scrape, don't squeeze — 'scrape not squeeze' is a common NLE distractor.

Key Points

• SNAKEBITE MANAGEMENT: (1) Immobilize the bitten limb at or BELOW heart level to slow venom spread; (2) Keep the patient calm and still; (3) Mark the advancing edge of swelling with the time every 15–30 minutes to monitor progression; (4) Transport urgently to a facility with antivenom; (5) Give ANTIVENOM for signs of envenomation (systemic symptoms, progressive swelling).
• SNAKEBITE — WHAT NOT TO DO: Do NOT apply ice (worsens tissue damage); Do NOT cut and suck (ineffective, causes infection); Do NOT apply an arterial tourniquet (causes ischemia and worsens tissue necrosis); Do NOT apply constriction bands.
• INSECT STINGS (Bee/Wasp): Remove a retained stinger by SCRAPING (not pinching/squeezing — squeezing injects more venom). Monitor for anaphylaxis. Systemic allergic reaction = give intramuscular (IM) EPINEPHRINE (1:1000, 0.3–0.5 mg IM in anterolateral thigh). Have diphenhydramine, corticosteroids, and IV fluids ready.
• ANIMAL/HUMAN BITES: (1) Irrigate wound COPIOUSLY with clean water under pressure; (2) Assess for tendon and nerve injury; (3) Update TETANUS prophylaxis status; (4) Consider RABIES post-exposure prophylaxis (PEP) for mammalian bites (dog, bat, cat — especially stray animals); (5) Antibiotics for high-risk wounds (deep puncture, hand bites, human bites).
• In the Philippine context, dog bites are the leading source of rabies exposure. The nurse should facilitate prompt wound care AND referral for Rabies PEP per the Philippine Animal Bite Treatment Center (ABTC) protocol.
• Anaphylaxis is the primary life threat in insect stings — assess airway (stridor), circulation (hypotension), skin (urticaria, angioedema). IM epinephrine is the FIRST and most important treatment.

Definitions

Section Title

Bites and Stings

Common Mistakes

• Applying a tourniquet to a snakebite — causes limb ischemia and is strongly contraindicated.
• Cutting and sucking the venom — ineffective and introduces infection; wastes critical transport time.
• Squeezing a bee stinger — injects more venom; always scrape it off instead.
• Giving antihistamines (diphenhydramine) as the first-line treatment for anaphylaxis — IM epinephrine is ALWAYS first.
• Forgetting to assess tetanus status in ALL bite/wound patients.

Exam Tips

• NLE KEY DIFFERENTIATOR: 'Normal/intact mental status = heat exhaustion; Altered mental status + temp >40°C = heat stroke = emergency.'
• Heat stroke treatment: 'ABC first, then COOL NOW — every minute counts.'
• Antipyretics question trap: 'Nurse will give paracetamol for heat stroke' — this is INCORRECT.
• Cooling target: stop at 39°C to prevent over-cooling.
• Prevention teaching is also tested: hydration, time of day avoidance (10am–2pm), acclimatization.

Key Points

• CRITICAL DISTINCTION: Heat Exhaustion vs. Heat Stroke — the key differentiator is MENTAL STATUS.
• HEAT EXHAUSTION: Heavy sweating, weakness, headache, nausea, dizziness, pale cool clammy skin. Core temperature NORMAL or MILDLY ELEVATED (<40°C). MENTAL STATUS IS INTACT (alert and oriented). Treatment: rest in cool place, remove excess clothing, oral hydration if conscious, IV fluids (normal saline) if needed. NOT immediately life-threatening.
• HEAT STROKE: MEDICAL EMERGENCY. Core temperature >40°C (104°F) WITH ALTERED MENTAL STATUS (confusion, agitation, seizures, coma). Classic heat stroke: hot, DRY skin (anhidrosis — sweating mechanism fails). Exertional heat stroke: may still have sweating. Organ damage: rhabdomyolysis, acute renal failure, coagulopathy, hepatic injury.
• HEAT STROKE TREATMENT PRIORITY = IMMEDIATE, AGGRESSIVE COOLING. Do not delay cooling for any reason (transport, labs, IV access). Methods: (1) Remove all clothing; (2) Evaporative cooling — mist with water + fan; (3) Cold-water or ice-water immersion (most effective); (4) Ice/cold packs to neck, axillae, and groin (areas of large blood vessels); (5) Cooled IV fluids.
• Target core temperature for cooling: 39°C — stop active cooling at 39°C to prevent overshoot hypothermia.
• ANTIPYRETICS (paracetamol/aspirin) DO NOT WORK in heat stroke. The mechanism is NOT a raised hypothalamic set point (as in fever from infection) — it is a failure of thermoregulation from heat overload. Antipyretics are USELESS and should NOT be given.
• Time at high temperature determines extent of organ damage and survival — every minute matters.
• Prevention (patient teaching): hydration before/during activity, avoid outdoor activity during peak heat hours (10am–2pm), light clothing, gradual acclimatization, recognize early warning signs.
• NANDA diagnoses: Hyperthermia, Deficient Fluid Volume, Risk for Injury (seizures, falls from altered LOC).

Definitions

Section Title

Heat-Related Illness: Exhaustion vs. Heat Stroke

Common Mistakes

• Giving antipyretics (paracetamol) for heat stroke — completely ineffective and wastes time; the cause is not a reset hypothalamic thermostat.
• Delaying cooling to obtain IV access or transport — cooling is THE priority; begin immediately.
• Confusing heat exhaustion with heat stroke — remember MENTAL STATUS is the key differentiator.
• Continuing active cooling below 39°C — risks overshoot hypothermia; stop at 39°C.
• Giving oral fluids to a heat stroke patient with altered LOC — aspiration risk; use IV route.

Exam Tips

• 'Handle gently' — appears frequently as a priority action for hypothermia (prevents VF).
• 'Not dead until warm and dead' — expect NLE scenarios asking when to stop CPR: NEVER stop before warming.
• Rewarming method depends on severity: Mild = passive; Moderate-Severe = active external + internal.
• Warmed humidified oxygen and warmed IV fluids are INDEPENDENT NURSING ACTIONS within ordered protocols.
• Remove wet clothing and blanket immediately — basic first step always expected in NLE scenarios.

Key Points

• DEFINITION: Core body temperature BELOW 35°C (95°F). Can be mild (32–35°C), moderate (28–32°C), or severe (<28°C).
• Progression: As temperature drops — shivering occurs then CEASES (bad sign: shivering stops at ~32°C), consciousness progressively declines, bradycardia, atrial fibrillation, then ventricular fibrillation in severe hypothermia.
• HANDLE GENTLY: Rough handling or sudden movement of a hypothermic patient can trigger VENTRICULAR FIBRILLATION due to a cold, irritable myocardium. Move the patient carefully and minimize unnecessary repositioning.
• REWARMING METHOD depends on severity: (1) MILD — Passive External Rewarming: warm blankets, warm environment, remove wet clothing; (2) MODERATE TO SEVERE — Active External Rewarming: warming blankets, radiant heat sources; PLUS Active Internal Rewarming: warmed humidified oxygen via ventilator, warmed IV fluids (39–42°C), warmed bladder/gastric/peritoneal lavage, ECMO in extreme cases.
• CARDIAC ARREST WITH HYPOTHERMIA — KEY NLE CONCEPT: 'NOT DEAD UNTIL WARM AND DEAD.' Continue CPR and rewarm the patient before deciding resuscitation has failed. Cold-protected brains and organs have survived after prolonged cardiac arrest. Do NOT stop resuscitation based on initial presentation alone.
• Medications and defibrillation are less effective at low core temperatures — continue warming while performing ACLS.
• Remove wet clothing IMMEDIATELY — wet clothing accelerates heat loss.
• Ventricular fibrillation in hypothermia: attempt defibrillation, but if core temperature is very low (<30°C), VF may not respond until the patient is warmed.
• NANDA diagnoses: Hypothermia, Risk for Decreased Cardiac Tissue Perfusion, Impaired Physical Mobility.

Definitions

Section Title

Hypothermia

Common Mistakes

• Roughly repositioning or jarring a hypothermic patient — can precipitate ventricular fibrillation.
• Stopping resuscitation early in hypothermic cardiac arrest — always rewarm first; many have recovered.
• Applying direct heat sources (hot water bottles, heating pads) directly to skin — can cause burns and rapid peripheral vasodilation (hypotension).
• Forgetting to remove wet clothing FIRST — wet clothing acts as a heat sink.
• Using passive rewarming alone for severe hypothermia — insufficient; active internal rewarming is required.

Exam Tips

• Near-drowning = Hypoxia is the killer → PRIORITY = Airway and Ventilation → Start CPR/rescue breathing immediately.
• 'Even asymptomatic patients need hospital observation' → secondary drowning NLE trap answer.
• Fresh vs. salt water: 'same management, different mechanism' — if NLE asks about differences in treatment, the correct answer is there is no clinical management difference.
• Diving or unknown history near-drowning → add C-spine precautions to all care.
• Remove wet clothes + treat hypothermia = always expected in near-drowning management questions.

Key Points

• NEAR-DROWNING (Submersion Injury): Survival after suffocation by submersion or immersion in a liquid. The term 'near-drowning' is still used clinically despite the WHO preferring 'non-fatal drowning.'
• THE PRIMARY KILLER IN NEAR-DROWNING IS HYPOXIA — not the water in the lungs, not the type of water.
• PRIORITY INTERVENTIONS: Start RESCUE BREATHING and CPR as EARLY as possible, ideally in the water or immediately upon removal. Oxygenation is THE intervention that matters most. Every minute of hypoxia = brain cell death.
• Do NOT wait until on dry land to begin rescue breathing if trained — in-water rescue breathing is acceptable.
• SECONDARY DROWNING / DELAYED PULMONARY EDEMA: Even patients who appear to recover completely can develop pulmonary edema 4–6 hours (up to 24 hours) after the event. This is caused by surfactant damage and inflammatory response in the alveoli. ALL submersion victims — even those initially asymptomatic — require OBSERVATION in hospital for at least several hours.
• FRESH WATER vs. SALT WATER: There is NO clinically significant difference in immediate management. Both cause hypoxia and pulmonary injury. The mechanism differs (hypo-osmotic vs. hyper-osmotic damage), but management is the same — treat the hypoxia.
• Remove wet clothing and treat HYPOTHERMIA — submersion victims are almost always hypothermic.
• Cervical spine injury: suspect if diving accident or unknown mechanism — use C-spine precautions.
• Complications: Acute respiratory distress syndrome (ARDS), aspiration pneumonia, anoxic brain injury, hypothermia.
• NANDA diagnoses: Impaired Gas Exchange, Risk for Aspiration, Hypothermia, Anxiety.

Definitions

Section Title

Near-Drowning (Submersion Injury)

Common Mistakes

• Waiting to begin CPR/rescue breathing until the victim is on dry land — in-water rescue breathing saves lives.
• Discharging an apparently well submersion victim without observation — secondary drowning can develop hours later.
• Thinking fresh water drowning needs different management from salt water drowning — clinical management is the same.
• Forgetting C-spine precautions in diving or unknown-mechanism submersion injuries.
• Focusing on removing water from the lungs rather than on delivering oxygen.