Adult Critical Care Nursing Manual Flipbook

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CRITICAL CARE & EMERGENCY NURSING Clinical Algorithms • Emergency Protocols • Nursing Reference COMPILED CLINICAL REFERENCE BOOK Compiled from the eight PDF documents provided. Original diagrams, tables, algorithms, and page layouts are retained.

CONTENTS Use the bookmarks in a compatible PDF reader to jump directly to each section. The original pages are kept in their supplied format. Section Pages Acute Compartment Syndrome 3–4 Fat Embolism Syndrome 5–6 Cardiac Critical Care 7–18 Neurological Critical Care 19–28 Oncology Emergencies 29–38 Psychiatric Emergencies 39–41 Respiratory Emergency Protocols 42–48 Emergency Management Protocols 49–65 Clinical-use note: This compilation preserves the supplied documents; it does not independently validate or replace current institutional protocols, clinician judgment, or local guidelines.

SNAKE BITE Snakebite Envenoming: The World Health Organization (WHO) defines snakebite envenoming as a potentially life- threatening disease caused by toxins injected from the bite of a venomous snake or through venom sprayed into the eyes Clinical syndromes of snakebite : Progressive weakness (neuroparalytic/neurotoxic), bleeding (vasculotoxic/haemotoxic), myotoxic and painful progressive Swelling Source: https://ncdc.mohfw.gov.in/uploads/pdf/Standard-Treatment-Guidelines-for-Management-of-Snake-Bite.pdf

Source: https://nirrch.res.in/wp-content/uploads/2023/10/Management-Flowchart.pdf

SNAKE BITE : KEY NOTES Anti Snake Venom Reaction Anaphylaxis can be of rapid onset and life-threatening, monitor closely after giving ASV Urticaria, itching, fever, chills, Nausea, vomiting, diarrhoea, abdominal cramps, Tachycardia, hypotension, bronchospasm and angio-oedema A second dose of 0.5 mg (0.01mg/kg) of adrenalin 1: 1000 iv is given. this can be repeated for a third and final occasion but in the vast majority of reactions, 2 doses of adrenaline will be sufficient If there is hypotension or hemodynamic instability, IV fluids should be given. Once the patient has recovered, the ASV can be restarted slowly for 10-15 minutes, keeping the patient under close observation. Then the normal drip rate should be resumed. At the first sign of any of these ASV to be discontinued give dose of 0.5 mg (0.01mg/kg) of adrenalin 1:1000 In case of Asthmatic symptoms, give Salbutamol bronchodilator.  After Adrenaline, give intravenous antihistamine anti-H1 blocker (e.g. Chlorphenamine maleate, adults 10 mg, children 0.2 mg/kg intravenously) and Hydrocortisone (adults 100 mg, children 2 mg/kg body weight).  Anaphylactic shock unresponsive to adrenaline is treated by laying patient supine, legs elevated, and giving intravenous volume replacement (0.9% saline, adults 1-2 litres rapidly).  Unresponsive Bronchospasm or Angioedema is treated with optimal nebulised/inhaled and/or parental bronchodilator and oxygen.  Late Serum sickness reactions occur after 5 to 7 days can be easily treated with an oral steroid such as prednisolone, adults 5 mg 6 hourly, paediatric dose 0.7 mg/kg/day. oral Antihistaminic provide additional symptomatic relief.

MANAGEMENT OF OP POISIONING: KEY NOTES Immediate Priorities (ABCDE Approach) • Ensure personal safety – wear gloves, mask, gown. • Remove patient from exposure. • Decontaminate skin by removing contaminated clothing and washing with soap and water. • Establish IV access with two large-bore cannulas. • Attach cardiac monitor and pulse oximeter. • Send blood samples as advised (ABG, electrolytes, glucose, cholinesterase if available. • Maintain Airway; suction excessive secretions. • Prepare for early intubation if airway is compromised. Signs of OP Poisoning Remember SLUDGE-M • S – Salivation • L – Lacrimation • U – Urination • D – Defecation/Diarrhea • G – Gastrointestinal cramps • E – Emesis (Vomiting) • M – Miosis (Pinpoint pupils) Other findings: • Bronchorrhea • Sweating • Bradycardia • Muscle fasciculations • Weakness/paralysis • Altered consciousness • Seizures MANAGEMENT Medico-Legal Case (MLC) :Every suspected OP poisoning should be treated as a Medico-Legal Case. Nursing Responsibilities ✓ Inform the treating doctor immediately. ✓ Ensure MLC registration as per hospital protocol. ✓ Inform the police through the hospital as per institutional policy. ✓ Preserve poison container/bottle, vomitus (if required),gastric lavage sample, Contaminated clothing (properly labeled) ✓ Maintain chain of custody for all medico-legal specimens. ✓ Maintain documents & records. Signs of Adequate Atropinization ✔ Chest clear on auscultation ✔ Secretions dry ✔ Oxygen saturation improving (>94%) ✔ Heart rate >80/min ✔ Systolic BP >90 mmHg ✔ No bronchospasm Do NOT use pupil size alone to judge atropinization. Atropine Therapy Initial Dose Adult: 2–3 mg IV bolus Repeat every 3–5 minutes Double the previous dose if no response 2 mg → 4 mg → 8 mg → 16 mg → 32 mg Pralidoxime (2-PAM) Loading Dose 2 g IV over 20–30 minute Maintenance dose 500 mg/hour IV infusion OR 1–2 g IV every 6–8 hours Diazepam Give if: Seizures, Agitation, Severe poisoning Typical adult dose: 5–10 mg IV slowly

MANAGEMENT OF ACUTE ABDOMEN: KEY NOTES Sub Acute Intestinal Obstruction Key Points • Assess and stabilize Airway, Breathing, Circulation (ABC). • Keep the patient Nil Per Oral (NPO). • Insert large-bore IV cannula and begin IV fluid resuscitation. • Correct dehydration and electrolyte imbalance. • Insert Nasogastric (NG/Ryle's) tube for gastric decompression. • Monitor NG tube drainage. • Administer oxygen if required. • Give prescribed analgesics and antiemetics. • Administer broad-spectrum antibiotics if strangulation or perforation is suspected. • Monitor for signs of bowel ischemia (severe pain, fever, tachycardia, guarding). • Prepare for emergency surgery if indicated (complete obstruction, strangulation, perforation, peritonitis). • Obtain informed consent and preoperative investigations. Acute Pancreatitis Key Points • ABC assessment and stabilization. • Keep patient NPO to rest the pancreas. • Aggressive IV fluid resuscitation (especially within first 24 hours). • Administer oxygen therapy if needed. • Provide adequate pain relief (opioids as prescribed). • Administer antiemetics. • Correct electrolyte imbalance. • Monitor blood glucose. • Nutritional support (enteral feeding preferred if prolonged NPO). • Treat underlying cause (e.g., gallstones, alcohol, hypertriglyceridemia). • Antibiotics only if infected pancreatic necrosis is suspected. • Surgical or endoscopic intervention when indicated. Intussception Key Points • ABC stabilization. • Keep patient NPO. • Establish IV access. • Correct dehydration and electrolyte imbalance. • Insert NG tube if persistent vomiting or abdominal distension. • Pain management. • Ultrasound confirmation. • Non-operative reduction with air or contrast enema (if no perforation/peritonitis). • Emergency surgery if: o Perforation o Peritonitis o Failed enema reduction o Hemodynamic instability

FOREIGN BODY INGESTION Foreign body ingestion occurs when a non-food item or problematic object is swallowed, requiring urgent medical attention if it involves button batteries, multiple magnets, or sharp objects. MANAGEMENT OF FOREIGN BODY INGESTION 1. Obtain history: Ensure no concern for button battery or magnet ingestion (refer to those algorithms if there is concern). 2. Obtain STAT X -rays: lateral neck (including nasal cavities and nasopharynx) and AP or PA chest, and AP abdomen/pelvis views. 3. Keep NPO. If symptomatic or esophageal FB, start IV and MIVF. 4. Consult: ENT for above the clavicles; Peds GI for esophagus, below clavicles, or as needed for stomach or intestinal FB. Any concern for perforation or obstruction or history of esophageal or abdominal surgery: Consult Pediatric Surgery ESOPHAGUS STOMACH SMALL BOWEL Symptomatic: Drooling, dysphagia, Asymptomatic Symptomatic Asymptomatic Symptomatic respiratory compromise, severe pain Timely endoscopic removal depending on symptom severity 1. Repeat X -ray to ensure coin is still present 2. Urgent endoscopic removal No endoscopy needed. Consider straining stools, laxatives. Repeat X-ray at 2 weeks to confirm passage, or sooner if symptoms develop. Depending on size of object, consider admission for observation (larger objects could get caught at ileocecal valve). Consider alternative etiologies and alternative foreign bodies. Surgical removal if indicated. Coin Sizes: Quarter: 24mm Nickel: 21mm Penny:19mm Dime: 18mm Endoscopic removal if not passed in 2-4 weeks. Repeat X-ray before removing to ensure coin is still present. COIN & OTHER BLUNT OBJECT OBJEINGESTION

Endoscopic Retrieval Tips • Removal should be performed under general anesthesia • Inspect mucosa for extent, location, and depth of damage Discharge Considerations • Bowel regimen • Reliable/competent caregiver • Regular diet • Encourage activity • Educate on signs of GI bleed (blood-stained vomiting, melena, abdominal pain, change in eating pattern) or features of intestinal obstruction (persistent vomiting, abdominal distention)

MAGNET INGESTION 1. Obtain history: known magnet ingestion? 2. Obtain STAT X -rays: lateral neck (including nasal cavities and nasopharynx) and AP or PA chest, and AP abdomen/pelvis views : Determine single versus multiple magnets. 3. Keep NPO. Start IV and MIVF. 4. Consult: ENT for above the clavicles; Peds GI for esophagus, stomach, intestine, or below clavicles. MULTIPLE MAGNETS Or single magnet + other metal object(s) Any concern for perforation or obstruction or history of esophageal or abdominal surgery: Consult Pediatric Surgery SINGLE MAGNET Assess risk factors for further ingestion All within stomach or esophagus Beyond stomach In stomach or esophagus Beyond stomach Symptomatic: EMERGENT endoscopic removal Successful Removal: Discharge home after feeding tolerance with appropriate follow-up and education Asymptomatic: URGENT endoscopic removal Unsuccessful removal: Notify Pediatric Surgery for removal Symptomatic: 1. Admit for further monitoring. 2. Consult Peds GI and Pediatric surgery for endoscopic, laparoscopic removal 3. Keep NPO, IVF. Asymptomatic AND no concerning radiographic findings: 1. Admit for further monitoring 2. Consult Pediatric GI & Pediatric Surgery 3. Clear liquid diet 4. Serial radiographs q4- 6hrs 5. Can use Golytely, Miralax, or another laxative Non-urgent endoscopic removal if patient at risk for further ingestion Outpatient management with bowel regimen, serial X-rays, parental education if no risk factors. Confirm passage with X- rays at 2-3 days in outpatient. No progression on serial X-rays in 24-48 hours: Attempt removal by colonoscopy or endoscopy Progression of magnets on serial X-rays: Option 1: Option 2: Continue bowel regimen and serial x-rays until magnets have passed Outpatient management with bowel regimen, serial X-rays, parental education See reverse for additional information

Endoscopic Retrieval Tips • Removal should be performed under general anesthesia • Inspect mucosa for extent, location, and depth of damage Discharge Considerations- When Waiting for Single Magnet to Pass • Bowel regimen • Reliable/competent caregiver • Regular diet • Encourage activity • Educate on signs of GI bleed (blood-stained vomiting, melena, abdominal pain, change in eating pattern) or features of intestinal obstruction (persistent vomiting, abdominal distention) • Remove any magnetic objects nearby • Avoid clothes with metallic buttons or belts with buckles • Ensure no other metal objects or magnets are in the child’s environment for accidental ingestion • Discuss notification of Product Safety Commission

SHARP OBJECT INGESTION 1. Obtain STAT X -rays: lateral neck (including nasal cavities and nasopharynx) and AP or PA chest, and AP abdomen/pelvis views. 2. Keep NPO. If esophageal or symptomatic, start IV and MIVF. 3. Consult: ENT for above the clavicles; Peds GI for esophagus, intestine, or below clavicles. RADIO-OPAQUE Any concern for perforation or obstruction or history of esophageal or abdominal surgery: Consult Pediatric Surgery RADIO-LUCENT For example: toothpick, fishbone, glass Endoscopic removal within 2hrs Symptomatic or Length ≥ 3cm Width ≥ 2cm Gastric or Duodenal Asymptomatic and Length < 3cm Width <2cm Small Bowel (distal to ligament of Treitz) Asymptomatic Timely surgical removal Symptomatic, self-reported, or witnessed ingestion Timely endoscopic evaluation & removal Consider CT, ultrasound, MRI, or esophagram for further assessment Timely endoscopic removal Consider observation with bowel regimen, serial X -rays, parental education. Confirm passage with X-ray at 2 -3 days if outpatient. Remove if symptoms develop. Object found: Follow guidelines for found radio- opaque objects No object found: Observe or discharge with return precautions Esophageal Asymptomatic Symptomatic

Endoscopic Retrieval Tips • Removal should be performed under general anesthesia • Inspect mucosa for extent, location, and depth of damage • If sharp end is facing cephalad, consider pushing the object into the stomach and rotate the sharp end caudally before removal • Safety pin: polypectomy snare can be used to close it before withdrawal • Toothpick: polypectomy snare is a good option Discharge Considerations • Reliable/competent caregiver • Regular diet • Encourage activity • Educate on signs of GI bleed (blood-stained vomiting, melena, abdominal pain, change in eating pattern) or features of intestinal obstruction (persistent vomiting, abdominal distention)

ESOPHAGEAL FOOD IMPACTION 1. Obtain STAT X -rays: lateral neck (including nasal cavities and nasopharynx) and AP or PA chest, and AP abdomen/pelvis views. 2. Keep NPO. Start IV and MIVF. 3. Consult Peds GI. SEVERE SYMPTOMS Difficulty breathing, retching, severe pain, not tolerating secretions Any concern for perforation or obstruction or history of previous esophageal surgery: Consult Pediatric Surgery MILD/ MODERATE SYMPTOMS No difficulty breathing, mild pain, tolerating secretions Timely endoscopic removal depending on symptom severity Consider X-ray with water soluble contrast: 1. Obtain AP chest/ abdomen 2. Patient drinks 50mL water soluble contrast 3. AP chest/abdomen immediately afterwards Endoscopic removal at provider discretionEndoscopic Retrieval Tips • Removal should be performed under general anesthesia • Inspect mucosa for extent, location, and depth of damage • Obtain proximal and distal esophageal biopsies • Assess for stricture. Dilation is cautioned against if eosinophilic esophagitis is suspected, or food has been impacted for a long duration Discharge Considerations • Ensure patient has appropriate GI follow-up