NLE Emergency & Critical Care Nursing — Trauma, Poisoning & Environmental EmergenciesSummary

The ABCDE framework is the gold standard for rapid trauma assessment and must be performed in order, with reassessment every 5–15 minutes as the patient's condition may change unpredictably. **Airway (with C-spine control):** Assume cervical spine injury in any significant blunt trauma and maintain immobilization while opening the airway using a jaw-thrust maneuver (not head-tilt, chin-lift, which may worsen spine injury). **Breathing:** Identify and treat immediately life-threatening chest injuries (tension pneumothorax, open pneumothorax, massive hemothorax, flail chest) because respiratory failure is the fastest path to death in the first minutes. **Circulation with hemorrhage control:** Hemorrhage is the leading preventable cause of trauma death; apply direct pressure to bleeding wounds, apply a tourniquet above the knee or elbow for uncontrolled limb bleeding, establish two large-bore IVs, and begin balanced resuscitation with blood products (plasma and red cells in 1:1:1 ratio) for major hemorrhage. Watch for occult (hidden) bleeding into the chest, abdomen, pelvis, and thighs. **Disability:** Assess level of consciousness using the Glasgow Coma Scale (GCS) and check pupil reactivity; a declining GCS may signal rising intracranial pressure. **Exposure and environment:** Fully undress the patient to find hidden wounds, then aggressively prevent hypothermia — this is not an afterthought but a genuine resuscitation priority because the trauma lethal triad (hypothermia + acidosis + coagulopathy) is self-reinforcing and deadly.

Hemorrhage is responsible for more than one-third of trauma deaths and is the leading preventable cause of death in the first 24 hours. Modern trauma resuscitation emphasizes stopping bleeding immediately. **Direct pressure** is the first intervention for all bleeding; it controls bleeding in approximately 90% of compressible wounds if applied with adequate force for sufficient time (at least 3 minutes without releasing to check). For bleeding that does not stop with direct pressure — particularly from the extremities — **a tourniquet is applied above the knee or above the elbow, as high as possible on the limb to occlude both artery and vein.** The tourniquet should be tight enough that distal pulses are absent and should be marked with the time of application. Contrary to older teaching, a tourniquet does not cause tissue damage in the first 2 hours and can be left in place during transport. For ongoing internal hemorrhage, **establish two large-bore IV lines (16-gauge or larger) and initiate balanced resuscitation** using a 1:1:1 ratio of packed red blood cells (pRBCs), fresh frozen plasma (FFP), and platelets — this contrasts with older practice of large volumes of crystalloid, which increases the risk of dilutional coagulopathy and hypothermia. Massive transfusion protocols (often defined as ≥10 units of pRBCs in 24 hours) should be initiated early in the severely bleeding patient.

The trauma lethal triad — **hypothermia, acidosis, and coagulopathy** — represents a cascading, self-reinforcing pattern that worsens outcomes in severely injured patients. Hypothermia (core temperature <35°C) develops insidiously in trauma because of exposure, infusion of cold IV fluids, and evaporative losses. Hypothermia causes **metabolic acidosis** (lactic acidosis from inadequate perfusion, plus respiratory acidosis if ventilation is impaired) and **coagulopathy** (hypothermia impairs coagulation enzyme function, platelet aggregation, and fibrinolysis). Acidosis worsens coagulopathy, and coagulopathy causes continued bleeding, which worsens shock and acidosis. Once all three elements are present, outcomes are grim. **Prevention is the only effective strategy:** warm all IV fluids to body temperature, remove wet clothing, apply warm blankets, and maintain a warm environment in the resuscitation area. Use warmed humidified oxygen if available. For severe hypothermia with cardiac arrest, **passive external rewarming is not sufficient** — active core rewarming (e.g., extracorporeal membrane oxygenation [ECMO] or cardiopulmonary bypass if available) may be necessary.

Burns threaten life primarily through **airway compromise** and **massive fluid loss.** **Airway management comes first:** suspect inhalation injury if there are facial burns, singed nasal hairs, soot in the mouth, hoarseness, or stridor. Airway edema develops rapidly (often within 1–2 hours), so **early intubation before the airway closes is far safer than attempting delayed emergency intubation through a swollen airway.** After airway is secured, **stop the burning process** by removing clothing and jewelry, but do **not** peel away adherent material (leave it in place to avoid further tissue damage). **Assess burn extent using the Rule of Nines:** In adults, the head is 9%, each arm is 9%, each leg is 18%, the anterior trunk is 18%, the posterior trunk is 18%, and the perineum is 1%. (In children, the head is proportionally larger — up to 18% — and the legs are proportionally smaller.) Partial-thickness burns cause significant fluid loss; full-thickness burns do not hurt (nerve endings are destroyed) and appear white or charred. **Fluid resuscitation for burns ≥15% TBSA in adults (≥10% TBSA in children) is guided by the Parkland formula: 4 mL × body weight (kg) × %TBSA of lactated Ringer's, given over 24 hours, with half of the total administered in the first 8 hours (timed from the moment of injury, not from arrival at the hospital).** Titrate the infusion rate to maintain a **urine output of 0.5 mL/kg/hr in adults** (0.5–1 mL/kg/hr in children, and up to 1 mL/kg/hr in electrical burns). Use a Foley catheter to monitor urine output accurately. Under-resuscitation causes hypovolemic shock and organ failure; over-resuscitation causes compartment syndrome, pulmonary edema, and abdominal compartment syndrome (ACS). **Suspect carbon monoxide (CO) poisoning in enclosed-space fires;** treat with high-flow 100% oxygen. **Pulse oximetry is falsely normal in CO poisoning** because the pulse oximeter cannot distinguish carboxyhemoglobin from oxyhemoglobin, both of which absorb red light similarly — so a normal SpO₂ does not rule out CO poisoning. **Cover burn wounds with clean dry dressings,** provide analgesia, and maintain warmth.

The universal approach to poisoning is: **(1) support the ABCs first,** (2) identify the toxin, (3) decontaminate when appropriate, (4) give a specific antidote if one exists, and (5) enhance elimination. **Most poisoned patients are managed with supportive care alone; antidotes are the exception, not the rule.** **Activated charcoal** adsorbs many ingested toxins and is most effective when given within 1 hour of ingestion (later doses have diminishing returns). Activated charcoal is **contraindicated when the airway is unprotected** (patient has decreased consciousness without a secured airway) because of aspiration risk, and it does not bind all toxins — notably it is ineffective for alcohols (ethanol, methanol, ethylene glycol, isopropanol), iron, lithium, and caustic substances. **Routine gastric lavage and induced emesis (ipecac) are no longer recommended.** **Never induce vomiting after ingestion of a caustic/corrosive substance or a hydrocarbon,** as re-exposure to the esophagus and aspiration into the lungs cause more harm than the initial ingestion. For specific toxins, **key antidote pairings** are: **opioids → naloxone** (reverses respiratory depression and sedation; titrate to restore adequate breathing; may need repeating because naloxone's duration is shorter than many opioids), **acetaminophen/paracetamol → N-acetylcysteine (NAC)** (most effective within 8 hours of ingestion; replenishes glutathione to prevent hepatic necrosis), **organophosphate/anticholinesterase poisoning → atropine** (dries excessive secretions and reverses muscarinic effects) **plus pralidoxime** (reactivates cholinesterase; suspect organophosphate poisoning with the muscarinic toxidrome: excessive salivation, lacrimation, urination, defecation, GI distress, and vomiting), **digoxin → digoxin-specific antibody fragments (Fab)** (for life-threatening toxicity with dangerous dysrhythmias or severe hyperkalemia), **benzodiazepines → flumazenil** (use with caution because it can precipitate seizures in chronic benzodiazepine users or in mixed overdoses, so it is not given routinely). Additional important antidote pairings: **beta-blockers → glucagon, heparin → protamine sulfate, warfarin → vitamin K, iron → deferoxamine, methanol/ethylene glycol → fomepizole, and cyanide → hydroxocobalamin.**

Heat exhaustion and heat stroke are both forms of heat illness but differ critically in **mental status and treatment urgency.** **Heat exhaustion** presents with heavy sweating, weakness, headache, nausea, dizziness, and a body temperature that is normal or only mildly elevated (typically <40°C); **crucially, mental status is intact** — the patient is alert and oriented. Treatment is conservative: remove the patient from the heat, have the patient rest in a cool place, remove excess clothing, and provide oral or IV fluids. Heat exhaustion is not an emergency, though it can progress to heat stroke if not treated. **Heat stroke is a medical emergency** defined by a core temperature above approximately 40°C **combined with altered mental status** (confusion, disorientation, seizures, loss of consciousness, coma). The skin appearance depends on the type: in **classic heat stroke** (non-exertional, often in elderly or chronically ill people), the skin is hot and dry; in **exertional heat stroke** (in young, healthy people exercising in heat), sweating may persist. **The priority in heat stroke is immediate, aggressive cooling;** delays in cooling increase morbidity and mortality. Cooling methods include: removing all clothing, **evaporative cooling** (misting the skin and fanning), **cold-water immersion** if available, and applying **ice packs to areas of major blood vessels** (groin, axillae, and neck). Give cooled IV fluids. **Do not delay cooling for transport to a hospital or for diagnostic workup;** every minute of elevated core temperature increases the risk of organ damage. **Antipyretics (acetaminophen, NSAIDs) do not work for heat stroke** because the problem is an external heat load overwhelming the body's cooling mechanisms, not a raised hypothalamic set point. Monitor for complications: rhabdomyolysis, disseminated intravascular coagulation (DIC), acute kidney injury, hepatic damage, and cerebral edema.

Hypothermia is defined as a **core temperature below 35°C.** As core temperature falls, shivering initially increases (producing heat) but eventually ceases below approximately 30°C, and consciousness progressively declines. Paradoxical undressing may occur (the patient removes clothing despite being cold, likely due to vasodilation and a false sensation of warmth). In severe hypothermia with cardiac arrest, **the maxim is 'not dead until warm and dead'** — meaning that **resuscitation efforts should be continued during active rewarming, and a decision to terminate resuscitation is made only after the patient is rewarmed to normal temperature without return of spontaneous circulation.** This principle is based on documented cases of survival after prolonged hypothermic cardiac arrest (one famous case of a 7-year-old girl submerged in ice-cold water for 66 minutes who was successfully resuscitated). **Management is matched to severity:** For **mild hypothermia** (core temperature 32–35°C), **passive external rewarming** (warm blankets, warm beverages if the patient is alert) is sufficient because the body's own shivering produces heat. For **moderate to severe hypothermia** (core temperature <32°C), **active external rewarming** (warm IV fluids, warmed humidified oxygen, external heat sources) and **active core rewarming** (warm IV fluids, warmed gastric or bladder lavage, or — for profound hypothermia with cardiac arrest — extracorporeal rewarming via ECMO or cardiopulmonary bypass if available) are necessary. **Handle the severely hypothermic patient gently;** rough movement can trigger **ventricular fibrillation in the cold, irritable heart,** a phenomenon known as 'rescue collapse' or 'afterdrop.' In hypothermic cardiac arrest, some sources recommend delaying medications and prolonging the interval between defibrillation attempts because the cold heart may be unresponsive to drugs and defibrillation, and there are reports of successful resuscitation with minimal medication after prolonged hypothermia.

**Near-drowning (submersion injury) is primarily a hypoxia problem;** the sequence is immersion in water → breath-holding → aspiration of water → loss of consciousness → cardiac arrest. **Airway and ventilation take absolute priority.** Begin **rescue breathing and CPR early;** oxygenation is the intervention that matters most and determines survival. The classic distinction between **fresh water** (hypotonic, causes hyponatremia and pulmonary edema more readily) **and salt water** (hypertonic, causes hypernatremia and pulmonary edema from osmotic fluid shifts) is clinically less important than previously thought, because **hypoxia is the killer in both cases,** and acute management is identical. **Remove the patient from the water,** remove wet clothing to prevent ongoing heat loss (treat accompanying hypothermia), and begin rescue breathing. **Transport the patient to a hospital for observation and monitoring,** because **delayed pulmonary complications (secondary drowning or pulmonary edema) can develop hours after submersion,** even in patients who appear to have recovered.** Secondary drowning results from aspiration of water (or freshwater-induced surfactant washout or salt-water-induced pulmonary edema) and can manifest 1–72 hours after the event as progressive respiratory distress, hypoxemia, and respiratory failure. Any submersion victim, even one who is alert and breathing at the scene, needs hospital observation, usually for 24 hours, with serial arterial blood gas measurements and chest imaging.

**Snakebite management** centers on preventing venom spread and providing antivenom. **Immobilize the bitten limb at or below heart level** (not elevated, which accelerates venom absorption). **Keep the patient calm and still;** movement accelerates venom spread. **Mark the advancing edge of swelling with a pen and record the time,** so the rate of progression can be monitored. **Transport urgently to a facility with antivenom.** Administer **antivenom for signs of envenomation** (local swelling, systemic symptoms, coagulopathy). **Do not apply ice** (increases tissue damage), **do not cut and suck the wound** (causes more tissue damage and infection), and **do not apply an arterial tourniquet** (which causes limb ischemia). A limb-immobilization bandage (pressure immobilization) can slow venom spread but should not completely occlude blood flow. **Insect stings (bee, wasp, hornet):** **remove a retained stinger by scraping it off with the edge of a card** (do not squeeze, which injects more venom). Apply cold. **Watch for systemic reactions (anaphylaxis);** treat with **intramuscular epinephrine 0.3–0.5 mg (1:1000 solution) immediately,** as anaphylaxis can be life-threatening. **Animal and human bites:** **irrigate the wound copiously** to remove bacteria and debris, assess for tendon and nerve injury, **update tetanus prophylaxis,** consider **post-exposure rabies prophylaxis for mammal bites** (in the Philippines, this includes dogs, bats, and other carnivores), and administer **antibiotics for high-risk wounds** (bites on the hand or face, deep puncture wounds, immunocompromised patients, or human bites).

In emergency and critical care nursing, **NANDA nursing diagnoses provide a standardized language for identifying patient problems** and guide intervention planning. For trauma, poisoning, and environmental emergencies, the highest-priority diagnoses typically fall into **Maslow's hierarchy of needs,** starting with **physiological needs** (breathing, circulation, temperature) and progressing to safety, love/belonging, esteem, and self-actualization only after immediate survival is assured. **High-priority diagnoses in trauma and poisoning include:** **Ineffective airway clearance** (related to injury, edema, or decreased consciousness), **Ineffective breathing pattern** (related to chest wall injury, tension pneumothorax), **Decreased cardiac output** (related to hemorrhage, cardiac contusion), **Deficient fluid volume** (related to hemorrhage or burn fluid loss), **Hyperthermia** (in heat stroke) or **Hypothermia** (in cold exposure or trauma), **Acute pain** (related to injuries or procedures), and **Risk for infection** (related to open wounds, aspiration, or surgical interventions). **Lower-priority but important diagnoses** (addressed after ABCs are stabilized) include **Anxiety** (related to trauma, fear of death), **Deficient knowledge** (about poison control, heat illness prevention), and **Compromised family coping** (related to sudden critical illness). Under **RA 9173 (Philippine Nursing Practice Act),** nurses at Level 4 (Critical Care Nursing) are expected to formulate nursing diagnoses, plan care, implement interventions, and evaluate outcomes in these settings. The principle of **Maslow-based prioritization** ensures that life-threatening problems (airway, breathing, circulation) are addressed before psychological or safety concerns.

The ABCDE survey is the systematic framework that guides assessment of all trauma patients. Every step must be performed in order and repeated frequently because trauma patients can decompensate suddenly. Skipping steps or reordering them leads to missed lethal injuries.

Hemorrhage is the leading preventable cause of trauma death. Direct pressure controls bleeding in most cases; for uncontrolled limb bleeding, a tourniquet is the correct next step. Balanced resuscitation with blood products (pRBCs, FFP, platelets in 1:1:1 ratio) replaces massive crystalloid infusion, reducing dilutional coagulopathy and hypothermia.

Hypothermia causes acidosis and coagulopathy, which worsens bleeding and shock, which worsens acidosis — a self-reinforcing, deadly spiral. Preventing hypothermia (using warm fluids, warm oxygen, warm environment) interrupts this cascade and is as important as blood transfusion.

The Parkland formula provides an initial infusion rate for burn resuscitation, but the true endpoint is urine output (0.5 mL/kg/hr in adults). Under-resuscitation causes hypovolemic shock and organ failure; over-resuscitation causes pulmonary edema, compartment syndrome, and abdominal compartment syndrome. Titration to urine output, not fixed rates, is essential.

Burns in enclosed spaces risk inhalation injury (hot gas, soot, CO). Early signs include singed nasal hairs, soot in mouth, hoarseness, and stridor. Airway edema develops within hours. Simultaneously, pulse oximetry is falsely normal in CO poisoning because carboxyhemoglobin mimics oxyhemoglobin on the sensor. Both require high-flow oxygen and early intubation before the airway closes.

Activated charcoal is most effective within 1 hour of ingestion and is contraindicated with an unprotected airway. Once the airway is secured and the patient is stable, charcoal may be given. Specific antidotes (naloxone, NAC, atropine, etc.) are then given as indicated by the toxin identified.

Heat exhaustion has intact mental status and is managed conservatively (rest, fluids, cooling). Heat stroke has altered mental status (confusion, seizures) and core temperature >40°C; it is a medical emergency requiring immediate aggressive cooling (evaporative, cold immersion, ice packs). This distinction is critical because treatment approach differs completely.

Mild hypothermia (32–35°C) requires only passive rewarming; moderate to severe (<32°C) requires active rewarming. In severe hypothermia with cardiac arrest, resuscitation should continue during active rewarming because documented cases of survival exist after prolonged arrest. The decision to terminate resuscitation is made only after full rewarming.

The immediate threat in submersion is hypoxia; airway and ventilation are prioritized. However, pulmonary edema can develop hours after apparent recovery (secondary drowning), so all submersion victims require 24-hour hospital observation with serial blood gas and chest imaging monitoring.

Correct snakebite management includes immobilization, keeping the patient calm, marking swelling, and rapid transport with antivenom. Incorrect practices (ice, cutting and sucking, arterial tourniquet) cause more harm. These distinctions are critical for effective outcomes.

NANDA diagnoses are organized by Maslow's hierarchy in emergency settings. Physiological diagnoses (ineffective airway clearance, decreased cardiac output, deficient fluid volume) take absolute priority over safety, psychological, or educational diagnoses. This hierarchy ensures that life-threatening problems are addressed first.

Nurses at Level 4 (Critical Care/Emergency Nursing) are expected to perform rapid assessment, formulate nursing diagnoses, plan and implement interventions, and evaluate outcomes in emergency presentations. RA 9173 defines the legal scope of nursing practice in these settings and requires proper documentation and interprofessional communication.