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Emergency Medical Cases: Comprehensive Nursing Study Notes

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HOW TO USE THESE NOTES

• F - First Aid / Pre-hospital
• M - Medical Management
• S - Surgical Management (where applicable)
• N - Nursing Management

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PART 1: CARDIAC EMERGENCIES

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1. CARDIAC ARREST

Pathophysiology

• Asystole - 50% (worst prognosis)
• Ventricular Fibrillation (VF) / Pulseless VT - 20-25%
• Pulseless Electrical Activity (PEA) - 20-25%
• Mechanical causes: cardiac tamponade, ventricular rupture, acute flow obstruction

First Aid (Bystander / Pre-hospital)

1. Call for help - activate EMS (call 999/112/911)
2. Check responsiveness - tap shoulders, shout "Are you okay?"
3. Look, listen, feel - no breathing or only gasping = cardiac arrest
4. Begin CPR immediately:
   • 30 compressions : 2 breaths (if trained)
   • Compression-only CPR if untrained
   • Rate: 100-120/minute
   • Depth: at least 5 cm (2 inches) adults
   • Allow full chest recoil
5. Use AED as soon as available - follow voice prompts

Medical Management

• Hypoxia, Hypovolaemia, Hypothermia, Hypo/Hyperkalemia
• Tension pneumothorax, Tamponade, Thrombosis (PE/MI), Toxins

• Targeted Temperature Management (TTM): 32-36°C for 24 hours
• 12-lead ECG - look for STEMI (requires emergent PCI)
• IV fluids, vasopressors to maintain MAP >65 mmHg
• ICU admission, mechanical ventilation

Surgical Management

• Emergency PCI if post-arrest ECG shows STEMI
• Pericardiocentesis for tamponade
• Thoracotomy - for traumatic arrest (internal cardiac massage)

Nursing Management

• Maintain CPR quality - rotate compressors every 2 minutes
• Establish IV/IO access - large bore (antecubital or IO if IV fails)
• Prepare and administer medications per protocol
• Attach cardiac monitor and defibrillator pads
• Secure airway - assist with intubation, BVM ventilation
• Document arrest time, interventions, drug administration times
• Post-ROSC: monitor vitals every 15 min, neurological status (GCS)
• Family support - assign dedicated nurse for family communication
• Use GO-FAR score to guide shared decision-making in terminal patients

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2. ACUTE MYOCARDIAL INFARCTION (AMI / Heart Attack)

Types

• STEMI - ST-Elevation MI (complete occlusion - immediate reperfusion)
• NSTEMI - Non-ST Elevation MI (partial occlusion)
• Unstable Angina - no enzyme rise, no ST changes

Classic Presentation

• Crushing/pressure chest pain, radiating to left arm, jaw, or back
• Diaphoresis, nausea/vomiting, dyspnea
• Feeling of "impending doom"
• Atypical (elderly, women, diabetics): epigastric pain, fatigue only, no chest pain

First Aid

1. Sit patient down or semi-recumbent - do NOT lie flat if breathing difficulty
2. Call EMS immediately
3. Aspirin 300mg chewed (if not allergic, no contraindications)
4. Loosen tight clothing
5. Be ready to perform CPR if patient collapses
6. Do not leave patient alone

Medical Management

• P2Y12 inhibitor: Ticagrelor 180mg loading dose (preferred) or Clopidogrel 600mg
• Thrombolysis if PCI not available within 120 min: Alteplase (tPA) or Streptokinase

Surgical Management

• Primary PCI (Percutaneous Coronary Intervention) - gold standard for STEMI; door-to-balloon time < 90 minutes
• Coronary Artery Bypass Grafting (CABG) - for multi-vessel disease, left main disease, or failed PCI
• IABP (Intra-Aortic Balloon Pump) - cardiogenic shock

Nursing Management

• 12-lead ECG within 10 minutes of arrival - PRIORITY
• Continuous cardiac monitoring
• IV access x2 large bore
• Blood samples: Troponin I/T (x2, 3-6 hours apart), CK-MB, FBC, U&E, coagulation, lipids
• Administer medications as prescribed; document times
• Nil by mouth if going to PCI/surgery
• Monitor for complications: arrhythmias, heart failure (crackles, JVD, S3), cardiogenic shock
• Semi-recumbent positioning (30-45°)
• Reassure and reduce anxiety - pain scoring every 30 minutes
• Post-PCI: monitor puncture site (femoral or radial), neurovascular observations
• Educate patient: medications, lifestyle modification, cardiac rehab

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3. CARDIOGENIC SHOCK

Definition

Signs

• SBP <90 mmHg for >30 min
• Cold, clammy extremities; oliguria (<30 mL/hr); altered consciousness
• Pulmonary edema, elevated JVP

Medical Management

• Treat underlying cause (AMI -> urgent PCI)
• Vasopressors: Noradrenaline (first choice) 0.1-2 mcg/kg/min IV
• Inotropes: Dobutamine 2-20 mcg/kg/min IV
• Diuretics: Furosemide IV only if fluid overloaded
• Avoid fluid boluses unless clearly hypovolaemic

Surgical Management

• IABP, ECMO, or ventricular assist device (VAD) in refractory cases
• Emergency PCI/CABG

Nursing Management

• Hourly urine output monitoring (catheterise patient)
• Arterial line for continuous BP monitoring
• Central venous access
• Strict fluid balance chart
• Monitor vasopressor infusion rates and titrate to MAP >65 mmHg
• Cardiac output monitoring if PA catheter or non-invasive CO monitor placed

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PART 2: SHOCK (ALL TYPES)

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4. HAEMORRHAGIC / HYPOVOLAEMIC SHOCK

Classification (American College of Surgeons)

First Aid

1. Control external bleeding - direct pressure, elevation
2. Apply tourniquet proximal to wound for limb haemorrhage
3. Lay patient flat, raise legs (unless spinal injury or breathing difficulty)
4. Keep warm - prevent hypothermia (lethal triad: hypothermia + acidosis + coagulopathy)
5. Call for emergency transport

Medical Management

• 2 large-bore IV cannulas (16G or larger)
• Damage control resuscitation: Blood products over crystalloids
  • 1:1:1 ratio - Packed Red Blood Cells : Fresh Frozen Plasma : Platelets
  • Tranexamic Acid (TXA) 1g IV over 10 min within 3 hours of injury (CRASH-2 evidence)
• Target SBP 80-90 mmHg (permissive hypotension) until haemorrhage controlled
• Warm all IV fluids
• Massive Transfusion Protocol (MTP) activation for haemorrhage >150 mL/min

Surgical Management

• Damage Control Surgery (DCS): rapid haemostasis, bowel stapled but not anastomosed, abdomen packed and left open
• Surgical haemostasis: vessel ligation, splenectomy, hepatic packing
• Interventional radiology: embolisation for solid organ/pelvic haemorrhage
• Definitive repair in Stage 2 once physiology corrected

Nursing Management

• Elevate legs 15-20° (modified Trendelenburg) - unless contraindicated
• Insert urinary catheter - target urine output 0.5 mL/kg/hr
• IV access x2, take bloods (FBC, U&E, coagulation screen, crossmatch, ABG, lactate)
• Warm blankets, warm IV fluids
• Fluid balance chart, strict monitoring every 15 minutes
• Administer blood products per MTP protocol
• Pain management with IV opioids
• Alert surgical team early

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5. SEPTIC SHOCK

Definition (Sepsis-3)

• Sepsis: life-threatening organ dysfunction caused by dysregulated host response to infection
• Septic shock: sepsis + vasopressor requirement to maintain MAP ≥65 mmHg + serum lactate >2 mmol/L despite fluid resuscitation

First Aid / Recognition

• SEPSIS-6 (within 1 hour):
  1. Give oxygen
  2. Take blood cultures
  3. Give IV antibiotics
  4. Give IV fluids
  5. Check serial lactate
  6. Monitor urine output

Medical Management (Surviving Sepsis Bundle - 1 hour)

Surgical Management

• Source control: Drainage of abscesses, debridement of necrotising fasciitis
• Laparotomy if bowel perforation/peritonitis
• Device removal (infected prostheses, lines)

Nursing Management

• Implement NEWS2/qSOFA early warning tool
• Hourly urine output (catheterise)
• Serial lactate monitoring (target <2 mmol/L, clearance ≥10% per 2 hours)
• Blood glucose monitoring every 1-2 hours (target 6-10 mmol/L)
• Temperature management (cooling blanket for hyperpyrexia)
• Pressure area care (vasopressors increase skin ischaemia risk)
• Family communication - explain ICU trajectory
• Strict hand hygiene and infection control

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6. ANAPHYLACTIC SHOCK

Triggers

Signs & Symptoms (Usually within minutes of exposure)

• Skin: urticaria (hives), angioedema, flushing, pruritus
• Airway: stridor, hoarseness, bronchospasm, wheeze
• Cardiovascular: hypotension, tachycardia, cardiac arrest
• GI: nausea, vomiting, abdominal cramping
• Neurological: dizziness, altered consciousness

First Aid

1. Remove or stop the trigger (stop IV drug, remove bee sting)
2. Call for emergency help
3. Lay patient flat with legs elevated (if no respiratory distress)
4. Adrenaline (Epinephrine) auto-injector (EpiPen 0.3mg IM) - anterolateral thigh - first-line treatment
5. If collapse: CPR

Medical Management

Surgical Management

• Emergency surgical airway (cricothyroidotomy) if complete upper airway obstruction despite adrenaline

Nursing Management

• Position: flat + legs elevated (unless respiratory compromise - then semi-upright)
• Continuous monitoring: HR, BP, SpO2, respiratory rate
• IV access x2; administer medications as prescribed
• Prepare intubation trolley (airway at risk)
• Document allergen - alert bracelet, allergy documentation in notes
• Educate patient before discharge: avoid triggers, carry 2 EpiPens, wear MedicAlert, refer to allergy clinic
• Observe for biphasic reaction

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PART 3: RESPIRATORY EMERGENCIES

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7. ACUTE SEVERE ASTHMA

Red Flag Features (Life-Threatening)

• Silent chest (no wheeze - air movement ceased)
• SpO2 <92%, PaO2 <8 kPa
• PaCO2 normal or raised (respiratory exhaustion)
• Bradycardia, hypotension
• Confusion, cyanosis

First Aid

1. Sit patient upright (tripod position)
2. Give high-flow oxygen
3. Use own salbutamol inhaler with spacer (10 puffs)
4. Call EMS

Medical Management

Surgical Management

• No routine surgical management
• Needle decompression if tension pneumothorax suspected (complication of ventilation)

Nursing Management

• Position: HIGH Fowler's / tripod (lean forward on arms - opens accessory muscles)
• Monitor peak flow before and after treatment (target >75% predicted)
• Count respiratory rate every 15-30 minutes
• Monitor SpO2 continuously
• ABG monitoring in severe/life-threatening attacks
• Ensure patient can use inhaler/spacer correctly
• Reassure (anxiety worsens bronchospasm)
• Prepare IV magnesium, have intubation equipment ready
• Discharge education: step-up/step-down action plan, avoidance of triggers

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8. PULMONARY EMBOLISM (PE)

Risk Factors (Virchow's Triad)

• Stasis: immobility, long flights, bed rest
• Hypercoagulability: pregnancy, OCP, cancer, thrombophilia
• Vascular damage: surgery, trauma

Presentation

• Sudden dyspnea, pleuritic chest pain, haemoptysis
• Tachycardia, tachypnoea, hypoxia
• Massive PE: haemodynamic collapse, cardiac arrest

First Aid

1. Sit patient upright, high-flow oxygen
2. Do not leave patient
3. Call for urgent medical review/EMS

Medical Management

Surgical Management

• Surgical pulmonary embolectomy - for massive PE with absolute contraindication to thrombolysis
• Catheter-directed thrombolysis/thrombectomy - interventional radiology option
• IVC filter - for recurrent PE or contraindication to anticoagulation

Nursing Management

• High-flow oxygen, monitor SpO2 and ABG
• IV access, bloods: D-dimer, FBC, coagulation, troponin, BNP, ABG
• ECG monitoring (S1Q3T3 pattern, sinus tachycardia, right heart strain)
• Administer anticoagulants; monitor for bleeding
• Monitor haemodynamic status - signs of right heart failure
• Strict bed rest until anticoagulated (prevent further emboli)
• DVT prevention in contralateral limb: compression stockings
• Discharge education: duration of anticoagulation, bleeding precautions, INR monitoring if on warfarin

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9. PNEUMOTHORAX (Tension)

Signs of Tension Pneumothorax (EMERGENCY - MUST NOT WAIT FOR X-RAY)

• Severe respiratory distress
• Deviated trachea AWAY from affected side (late sign)
• Absent breath sounds on affected side
• Distended neck veins
• Hypotension, tachycardia, cyanosis

First Aid

• Sit patient upright
• Call for immediate medical help
• Do NOT put needle in unless trained

Medical Management

• Immediate needle decompression (before X-ray if haemodynamically compromised):
  • 14-16G cannula, 2nd intercostal space, midclavicular line
  • Hiss of air confirms diagnosis
• Followed by chest drain (intercostal tube thoracostomy): 5th ICS, anterior axillary line

Surgical Management

• Video-Assisted Thoracoscopic Surgery (VATS) for recurrent pneumothorax
• Pleurodesis (chemical or surgical) for prevention of recurrence

Nursing Management

• Monitor SpO2 and respiratory rate continuously
• Prepare for needle decompression - 14G cannula, cleaning swabs
• Assist with chest drain insertion: consent, positioning (supine with arm raised), Betadine, drapes, underwater seal drain
• Chest drain care: ensure no kinks, observe for bubbling/swinging, volume of drainage
• Pain management
• Chest X-ray after intervention to confirm lung re-expansion
• Monitor for re-accumulation

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PART 4: NEUROLOGICAL EMERGENCIES

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10. STROKE / CEREBROVASCULAR ACCIDENT (CVA)

Types

• Ischaemic (87%): thrombotic or embolic occlusion
• Haemorrhagic (13%): intracerebral or subarachnoid haemorrhage

FAST Recognition

• F - Face drooping (ask to smile - asymmetry)
• A - Arm weakness (raise both arms - does one drift?)
• S - Speech difficulty (slurred, unable to speak)
• T - Time to call 999/911

First Aid

1. Note exact time of symptom onset
2. Do NOT give aspirin (may be haemorrhagic)
3. Lie patient down if unconscious, recovery position if vomiting
4. Call EMS - alert stroke team ("CODE STROKE")
5. Keep NBM until swallow assessed

Medical Management

• Reverse anticoagulation urgently (Vitamin K, PCC for warfarin; specific reversal agents for DOACs)
• BP target SBP <140 mmHg (within 1 hour for ICH)
• Neurosurgical referral

Surgical Management

• Mechanical thrombectomy (neuro-interventional): stent retriever or aspiration catheter
• Craniotomy with haematoma evacuation: large cerebellar haemorrhage or accessible lobar ICH causing herniation
• External ventricular drain (EVD): hydrocephalus post-subarachnoid haemorrhage
• Decompressive hemicraniectomy: malignant MCA infarction

Nursing Management

• Stroke pathway initiation within 4.5 hours - time is brain
• Continuous monitoring: Glasgow Coma Scale (GCS) hourly, NIHSS scoring
• Blood glucose finger-stick immediately
• CT scan preparation - urgent
• NBM - formal swallow assessment within 4 hours (SALT referral)
• IV access, bloods: FBC, U&E, glucose, coagulation, group & save
• Aspiration precautions: 30-degree HOB elevation
• Pressure area care (paralysed limb)
• Compression stockings + LMWH for DVT prevention (after CT excludes haemorrhage)
• Urinary catheter if incontinent
• Emotional support and family communication
• Rehabilitation referral (physiotherapy, OT, speech therapy) from day 1

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11. STATUS EPILEPTICUS

Definition

First Aid

1. Protect from injury: clear area, cushion head, do NOT restrain
2. Do NOT put anything in mouth
3. Loosen clothing
4. Time the seizure
5. Recovery position after seizure ends
6. Call EMS if >5 minutes, or first seizure, or no recovery

Medical Management (Tiered Protocol)

Nursing Management

• Time the seizure from onset
• Maintain airway (jaw thrust, suction, NPA)
• Oxygen 15L/min via non-rebreathe mask
• IV access x2; bloods: glucose, U&E, Ca2+, Mg2+, AED levels, toxicology
• Pad bed rails, lower bed
• Do not restrain patient
• ECG (phenytoin causes arrhythmias)
• Monitor for post-ictal period: GCS, vital signs
• Document seizure type, duration, movements, incontinence

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PART 5: TRAUMA EMERGENCIES

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12. MAJOR TRAUMA (Primary Survey - ATLS)

First Aid

• D - Danger: scene safety
• R - Response: assess consciousness
• A - Airway (with C-spine control)
• B - Breathing (expose chest, look/listen/feel)
• C - Circulation (haemorrhage control, feel for pulse)
• D - Disability (AVPU: Alert/Voice/Pain/Unresponsive)
• E - Exposure (undress but prevent hypothermia)

Medical Management

• Airway: jaw thrust if C-spine suspected; intubation if GCS ≤8
• Breathing: tension pneumothorax needle decompression; chest seal for sucking wounds
• Circulation: 2 large-bore IVs, blood product resuscitation (1:1:1); TXA within 3 hours
• Disability: GCS, pupils (asymmetry = herniation)
• Exposure: full body inspection, warm environment, warming blankets
• Secondary Survey: head-to-toe examination once stabilised

Surgical Management

• Damage Control Surgery (DCS): haemostasis first, physiology correction second, definitive repair third
• FAST scan (Focused Assessment with Sonography in Trauma) to detect haemopericardium, haemoperitoneum
• Emergency thoracotomy: penetrating thoracic trauma with witnessed arrest
• Laparotomy: abdominal haemorrhage, hollow viscus injury
• Fracture fixation: pelvic binder for pelvic fracture (reduces volume by up to 50%)

Nursing Management

• Activate Major Trauma Protocol / Trauma Team
• Prepare resuscitation bay: airway trolley, IV fluids, blood products, warming blankets
• Cut clothing off - do NOT remove impaled objects
• C-spine immobilisation (collar + blocks)
• 2x large-bore IVs, bloods: FBC, coagulation, crossmatch, metabolic panel, ABG, toxicology
• Urinary catheter (unless urethral injury suspected - blood at meatus, perineal bruising)
• NGT (unless base of skull fracture - use orogastric)
• Continuous monitoring: vitals, GCS, urine output
• Documentation: MIST handover (Mechanism, Injuries, Signs, Treatment)
• Post-operative care and wound management

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13. HEAD INJURY (Traumatic Brain Injury - TBI)

Classification

• Mild TBI: GCS 14-15, brief LOC, post-traumatic amnesia <1 hour
• Moderate TBI: GCS 9-13
• Severe TBI: GCS ≤8 (requires intubation)

First Aid

1. Assume C-spine injury - maintain neutral alignment
2. If unconscious, recovery position maintaining neutral spine
3. Do not remove helmet if motorcyclist (without training)
4. Call EMS; prevent further injury

Medical Management

• Maintain airway: intubate if GCS ≤8 (RSI - Rapid Sequence Intubation)
• Target SpO2 >94%, avoid hypoxia AND hyperoxia
• ICP management: Head of bed 30°, normocapnia (PaCO2 35-40 mmHg)
• Osmotherapy: Mannitol 1g/kg IV OR Hypertonic saline 3% for herniation
• Anticonvulsants: Levetiracetam prophylaxis x7 days
• Avoid hypoglycaemia and hyperthermia
• CT Head scan: NICE criteria guide indication

Surgical Management

• Emergency burr hole / craniotomy: for expanding extradural or subdural haematoma
• ICP monitoring: intracranial pressure bolt/catheter insertion
• Decompressive craniectomy: refractory raised ICP

Nursing Management

• Hourly GCS and pupil assessment (dilated fixed pupil = transtentorial herniation)
• Cushing's Triad: hypertension + bradycardia + irregular breathing = imminent herniation - alert doctor immediately
• Head of bed 30° neutral alignment
• Avoid hypoxia, maintain normothermia
• Seizure precautions
• Strict fluid balance - monitor for diabetes insipidus (high urine output + low urine osmolality) post TBI
• Pain management (avoid opioids that raise ICP unless intubated)
• Communication with family (prognosis discussions)

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PART 6: METABOLIC / ENDOCRINE EMERGENCIES

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14. HYPOGLYCAEMIA (Blood Glucose <3.9 mmol/L)

Symptoms

• Mild: sweating, tremor, palpitations, hunger
• Moderate: confusion, aggression, slurred speech
• Severe: seizures, unconsciousness

First Aid (Conscious Patient)

1. Rule of 15: 15g fast-acting carbohydrate every 15 minutes
   • 150mL fruit juice, 3-4 glucose tablets, 6 Glucotabs
2. Recheck glucose after 15 min; repeat if still <4.0
3. Follow with long-acting carbohydrate (biscuits, sandwich)

Medical Management

• Conscious: Oral glucose gel (Glucogel) - 2 tubes buccally
• Unconscious/Unable to swallow:
  • IV Glucose: 75-80 mL of 20% glucose (or 150mL of 10%) IV
  • Glucagon 1mg IM (if no IV access; less effective in liver failure/starvation)
• Find and treat cause: insulin overdose, missed meal, alcohol

Nursing Management

• Point-of-care blood glucose testing immediately
• Administer glucose or glucagon; recheck glucose 15 minutes after
• Monitor GCS - document neurological recovery
• Once stable, ensure patient eats a meal
• If on insulin: review insulin dose, timing, carbohydrate ratio
• Educate patient on recognition and self-management

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15. DIABETIC KETOACIDOSIS (DKA)

Diagnostic Criteria

• Blood glucose >11 mmol/L (or known diabetes)
• Ketonaemia ≥3 mmol/L or heavy ketonuria (3+ on dipstick)
• Bicarbonate <15 mmol/L OR pH <7.3

First Aid

1. Check blood glucose and urine/blood ketones
2. Drink water if conscious
3. Call medical help urgently - do not self-treat with insulin alone

Medical Management (JBDS Protocol)

1. IV Fluids (most important): 0.9% NaCl 1L over 1 hour, then 1L over 2 hours, then 1L over 4 hours
2. Fixed Rate Insulin Infusion (FRIII): 0.1 units/kg/hour (do NOT give stat bolus)
3. Potassium replacement: Add KCl to fluid bags based on serum K+ levels (insulin drives K+ into cells - risk of hypokalaemia)
4. Glucose: Add 10% dextrose when blood glucose <14 mmol/L (to prevent hypoglycaemia while continuing insulin)
5. Treat precipitant: antibiotics for infection, manage MI
6. Resolution criteria: pH >7.3, ketones <0.6 mmol/L, HCO3 >18

Nursing Management

• Hourly blood glucose and ketone monitoring
• Hourly urine output (catheterise if anuric or unconscious)
• 2-hourly U&E for potassium monitoring
• Careful IV fluid and insulin infusion management
• VTE prophylaxis (DKA = prothrombotic)
• NBM if vomiting (risk of aspiration), NGT if GCS low
• Look for signs of cerebral oedema (headache, GCS decline) - especially in children
• Patient education: sick day rules, ketone testing at home

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PART 7: ENVIRONMENTAL EMERGENCIES

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16. BURNS

Classification

Rule of Nines (Adult)

First Aid

1. STOP the burning process: cool with running water 15-20°C for minimum 20 minutes
2. Remove jewellery and clothing (unless stuck)
3. Do NOT use ice, butter, or toothpaste
4. Cover loosely with clean cling film (not face)
5. Keep patient warm (hypothermia risk)
6. Call EMS for burns >10% BSA, face, hands, genitalia, circumferential, chemical, electrical

Medical Management

• Fluid resuscitation (Parkland Formula): 4 mL x weight (kg) x %TBSA; give half in first 8 hours, half in next 16 hours (Hartmann's solution)
• Analgesia: IV morphine titrated to pain
• Wound care: Silver sulfadiazine or mafenide acetate; Mepitel/biobrane dressings
• Tetanus prophylaxis
• Prophylactic antibiotics: NOT routine; use only for confirmed infection
• Nutritional support: early enteral feeding (burns are hypermetabolic)

Surgical Management

• Escharotomy: for circumferential full-thickness burns (limb/chest compression)
• Excision and split-thickness skin grafting: standard for full-thickness burns
• Fasciotomy: for electrical burns with deep tissue damage
• Reconstructive surgery: for facial, hand, contracture burns

Nursing Management

• Fluid resuscitation monitoring: target urine output 0.5-1 mL/kg/hr (higher for electrical burns - 1-1.5 mL/kg/hr)
• Daily weight, strict fluid balance
• Wound dressing changes (aseptic technique, adequate analgesia before procedure)
• Monitor for inhalation injury: hoarse voice, carbonaceous sputum, singed nasal hairs, face burns - prepare for early intubation
• Nutritional assessment - liaise with dietitian (high-calorie, high-protein diet)
• Pressure garments for scar management
• Psychological support - burns cause severe body image disturbance

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17. DROWNING / NEAR-DROWNING

First Aid

1. Remove from water safely (do not enter without training)
2. Call EMS
3. Begin CPR immediately if not breathing - start with 5 rescue breaths
4. Use AED when available
5. Keep warm - all drowning victims are hypothermic

Medical Management

• Airway management: oxygen, early intubation if severe
• PEEP ventilation for pulmonary oedema / ARDS
• Treat hypothermia: active external rewarming (>30°C), cardiopulmonary bypass for severe hypothermia (<28°C)
• Chest X-ray, ABG, ECG
• "No one is dead until warm and dead" - continue CPR in hypothermic arrests until rewarming

Nursing Management

• Core temperature monitoring (rectal)
• Active rewarming: warm IV fluids, warm blankets, Bair Hugger
• Monitor for ARDS (worsening hypoxia 6-24 hours after event)
• Urine output monitoring
• Neurological monitoring (GCS)

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PART 8: OBSTETRIC EMERGENCIES

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18. ECLAMPSIA

Definition

First Aid

1. Call for help immediately
2. Left lateral position (prevents aortocaval compression)
3. Do not restrain
4. Time seizure
5. Protect airway

Medical Management

• Magnesium Sulphate: 4g IV loading dose over 5-10 min, then 1g/hour IV infusion
  • If seizure recurs: 2g IV bolus
  • Antidote for toxicity: Calcium Gluconate 10 mL of 10% IV
• Monitor for Mg toxicity: loss of patellar reflexes (first sign), respiratory depression
• Antihypertensives: Labetalol 20mg IV boluses or Hydralazine 5mg IV for BP >160/110
• Urinary catheter; fluid balance (restrict IV fluids - risk of pulmonary oedema)
• Deliver baby - definitive treatment

Surgical Management

• Caesarean section: if vaginal delivery not imminent after stabilisation

Nursing Management

• Left lateral position, padded cot sides
• Hourly urine output, aim >25 mL/hr
• Monitor reflexes and respiratory rate hourly (Mg toxicity signs)
• CTG (continuous fetal monitoring)
• Seizure precautions: suction, oxygen at bedside
• Fluid balance chart
• Post-partum: continue Mg for 24 hours after last seizure

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PART 9: ABDOMINAL / GI EMERGENCIES

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19. ACUTE ABDOMEN (General - includes Appendicitis, Perforation, Obstruction)

First Aid

1. Do NOT give food or water (NBM - likely needs surgery)
2. Lay patient in comfortable position (flexed knees reduces peritoneal pain)
3. Call EMS
4. Do NOT give strong analgesia before diagnosis (historical - now safe with opioids early)

Medical Management

• IV access, bloods: FBC, U&E, LFTs, amylase, CRP, lactate, group & save
• IV fluids: 0.9% NaCl or Hartmann's
• Analgesia: morphine IV (early adequate analgesia is humane and does not obscure diagnosis)
• Antibiotics: broad-spectrum if peritonitis/perforation (e.g., Piperacillin/Tazobactam)
• Antiemetics: Ondansetron 4mg IV
• NBM, nasogastric tube if vomiting or obstruction

Surgical Management

• Appendicitis: Laparoscopic appendicectomy (or conservative antibiotics in uncomplicated cases)
• Bowel perforation: Emergency laparotomy (Hartmann's procedure for perforated sigmoid)
• Bowel obstruction: NGT decompression; laparotomy if strangulation
• Ruptured AAA (Abdominal Aortic Aneurysm): Emergency EVAR or open repair - mortality >50% even with surgery

Nursing Management

• NBM, IV fluids, IV access
• Analgesia assessment (pain score 0-10 every hour)
• Monitor for peritonitis signs: rigidity, rebound tenderness (report to doctor)
• Urine output monitoring
• NGT insertion if obstruction/vomiting (attach to free drainage)
• Pre-operative preparation if surgery planned
• Post-operative: wound care, drain management, bowel function monitoring

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20. UPPER GI BLEEDING (UGIB)

Causes

• Peptic ulcer disease (most common), oesophageal varices (cirrhosis), Mallory-Weiss tear, oesophagitis

Presentation

• Haematemesis (fresh red blood = active bleeding; coffee-ground = slower bleeding)
• Melaena (black, tarry stools)
• Haemodynamic instability in massive bleeds

Risk Scoring: Blatchford Score (pre-endoscopy), Rockall Score (post-endoscopy)

First Aid

1. Lay patient flat or in recovery position if vomiting blood
2. Call EMS
3. Keep warm

Medical Management

Nursing Management

• Lay flat or Trendelenburg; high-flow O2
• 2x large-bore IV cannulas; urgent bloods
• Activate massive haemorrhage protocol if needed
• Blood transfusion: verify patient identity, two-check procedure, monitor for transfusion reactions
• Monitor urine output (catheterise)
• Strict fluid balance
• Endoscopy preparation: informed consent, IV access, resuscitate before procedure
• Post-endoscopy: vital signs every 15 min, report any re-bleeding

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QUICK REFERENCE SUMMARY TABLE

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NURSING MNEMONICS FOR EMERGENCIES

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