NURSING PRACTICE & SKILL

Size: px

Start display at page:

Download "NURSING PRACTICE & SKILL"

Franklin Webster
6 years ago
Views:

NURSING PRACTICE & SKILL ICD-9 93.5, 93.

1 NURSING PRACTICE & SKILL ICD , Authors Carita Caple, RN, BSN, MSHS Eliza Schub, RN, BSN Reviewers Jennifer Kornusky, RN, MS Nursing Practice Council Glendale Adventist Medical Center, Glendale, CA Editor Diane Pravikoff, RN, PhD, FAAN Pneumatic Anti-Shock Garment: Deflating and Removing Link to Skill Competency Checklist Link to Interactive Skill Competency Checklist What Is a Pneumatic Anti-Shock Garment? A pneumatic anti-shock garment (PASG; also known as a military anti-shock garment [MAST] or shock pants) is a device developed to initially stabilize patients with significant trauma of the pelvis or lower extremities by decreasing blood flow to the extremities. PASGs are intended to be used as a temporizing measure (i.e., short-termintervention) until definitive treatment is available. The PASG is distinguished from the nonpneumatic anti-shock garment, which does not use a pump for inflation (for more information, see Nursing Practice and Skill Postpartum Hemorrhage: Applying a Non-Pneumatic Anti-Shock Garment ; and Nursing Practice and Skill Postpartum Hemorrhage: Removing Non-Pneumatic Anti-Shock Garment). The information contained in this Nursing Practice & Skill is intended to present a brief overview of the PASG and is not intended to replace facility protocols, clinician orders, or the coursework and clinical experience necessary to become proficient in applying, removing, or monitoring a patient with a PASG What: A PASG is an inflatable garment with three compartments: abdominal, left leg, and right leg. A pump with a pressure gauge is used to inflate each compartment to the desired pressure in a manner similar to inflating a blood pressure cuff. Once the patient is stabilized or if a complication develops, the PASG is deflated as ordered. The patient is monitored continuously during deflation; rapid reinflation may be necessary, especially if the patient experiences sudden, severe hypotension. For information regarding application of a PASG, see Nursing Practice & Skill Anti-Shock Garment: Applying and Inflating; CINAHL Topic ID Number: T705457) How: PASGs should be applied per institutional or facility protocol. PASGs are never the sole treatment for a patient experiencing hemorrhage other measures (e.g., I.V. fluid resuscitation, medications) are also initiated to help achieve hemodynamic stability. To remove the garment once the patient is stabilized and the treating clinician has issued an order, the nurse slowly deflates it while closely monitoring vital signs. If vital signs remain stable and the treating clinician has ordered garment removal, the PASG is removed; if hypotension develops, it might be necessary to administer I.V. fluids and medications, as prescribed, and to rapidly reinflate the garment to stabilize the patient Where: PASGs are typically used in the prehospital (e.g., at the scene of an accident) or emergency department setting Who: In the prehospital setting, PASGs are applied by paramedics and emergency medical technicians (EMTs) according to institutional protocols. In the hospital setting, emergency department nurses apply PASGs per clinician orders and facility protocols. Depending on the situation and the patient s preference, it may be appropriate to have family members present during placement and use of the PASG March 3, 2017 Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright 2017, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

2 What Is the Desired Outcome of Removing a Pneumatic Anti-Shock Garment? The desired outcome of deflation and/or removal of the PASG is for the patient to remain physiologically stable and experience no adverse consequences or complications If the patient survives the initial stabilization period, he/she will receive definitive treatment for the condition that necessitated use of the PASG Why Is Successful Removal of a Pneumatic Anti-Shock Garment Important? Successful removal of a PASG is an indication of physiologic stability and readiness of the patient to receive definitive treatment; the garment must be rapidly reinflated and applied if blood pressure drops or other vital sign abnormalities occur Facts and Figures There are very few randomized controlled clinical trials of PASG use During the Vietnam War, the use of a PASG improved the survival of United States soldiers who had severe lower extremity trauma from 0% to 50%. The transport time from the field to the trauma center for these soldiers was approximately 45 minutes via helicopter (Cutler et al., 1971) Use of a PASG in a patient with a chest injury increases the risk for mortality (Cayten et al., 1993; Honigman, 1991) Most adverse effects of PASG use are caused by decreased distal perfusion (Hauswald, 2003) What You Need to Know Before Deflating and Removing a Pneumatic Anti-Shock Garment Use of PASGs is controversial, and protocols outlining the appropriate circumstances for PASG use vary greatly by geographic area, facility, and institution PASGs have been found particularly useful as a means to stabilize patients in war zones The use of PASGs in the civilian setting (i.e., non-war zone environment) has been controversial, with many experts stating that their utility is limited Generally a PASG is ordered when a patient is in decompensated shock I.V. fluids and oxygen should always be administered in conjunction with PASG use to maximize hemodynamic stability hemodynamic status must be monitored throughout the use of PASG and before removing the PASG has a pelvic fracture and hypotension has significant trauma and expected transport time is minutes The nurse s primary responsibilities in removing and deflating a PASG are to complete a thorough patient assessment assess and accurately record the patient s vital signs and physiologic status, and monitor for any complications (for details, see Red Flags, below)adjust the pressure in the PASG compartments according to clinician orders assist in the removal of the PASG Nurses should be familiar with the contraindications to and risks associated with PASG use (for details, see Red Flags, below) Familiarity with all applicable equipment (e.g., PASG, tubing, airflow control valves) is essential Preliminary steps that should be performed before deflating and removing a PASG include the following: Review the facility/unit-specific protocol for PASG deflation and removal, if one is available Review the treating clinician s order for the removal of the PASG Review the patient s medical record for any allergies (e.g., to latex or other substances); use alternative materials, as appropriate Identify a colleague to assist; removal of a PASG may require more than one person, especially if rapid reinflation becomes necessary Gather supplies and equipment necessary to deflate and remove the PASG, as follows: Personal protective equipment (PPE; e.g., nonsterile gloves); use additional PPE (e.g., gown, mask, eye protection) if exposure to body fluids is anticipated Vital signs monitoring equipment, including stethoscope, sphygmomanometer, and a blood pressure cuff of appropriate size for the patient Long spine board or scoop stretcher

3 Board straps Airflow control valves (e.g., stopcocks) Deflation valves Pressure gauge Emergency resuscitation equipment and supplies (e.g., crash cart, bag-valve-maskresuscitator, oxygen source and delivery system) How to Remove and Deflate a Pneumatic Anti-Shock Garment Perform hand hygiene and don PPE as appropriate Identify the patient according to facility protocol Establish privacy by closing the door to the patient s room and/or drawing the curtain surrounding the patient s bed Introduce yourself to the patient and family member(s), if present; explain your clinical role in the deflation and removal of a PASG; assess the anxiety level of the patient/family and for knowledge deficits and anxiety regarding removal of the PASG Determine whether the patient/family requires special considerations regarding communication (e.g., due to illiteracy, language barriers, or deafness); make arrangements to meet these needs, if present Use professional certified medical interpreters, either in person or via telephone, when language barriers exist Explain the procedure and its purpose; answer any questions and provide emotional support as needed Maintain in-line spinal immobilization at all times, if indicated Deflate the PASG as ordered when the patient has stabilized or if a complication develops. Perform the following steps to deflate the PASG: Assess and document the patient s vital signs, hemodynamic status, and level of consciousness before initiating deflation Gradually deflate the abdominal compartment while monitoring and documenting the patient s vital signs If the SBP drops more than 5 mm Hg or the heart rate increases by 10 beats/min or more, deflation should be halted and I.V. fluids should be administered, as ordered. If the patient s SBP is not restored, the abdominal compartment should be reinflated Pause for 5 minutes or per facility/unit-specific protocol Gradually deflate one of the leg compartments while monitoring and documenting the patient s vital signs If one of the legs is injured, the compartment containing the uninjured leg should be deflated first If the SBP drops more than 5 mm Hg or the heart rate increases by 10 beats/min or more, deflation should be stopped and I.V. fluids should be administered, as ordered. If the SBP is not restored, the leg compartment should be reinflated Pause for 5 minutes or per facility/unit-specific protocol Gradually deflate the other leg compartment while monitoring and documenting the patient s vital signs If the SBP drops more than 5 mm Hg or the heart rate increases by 10beats/min or more, deflation should be stopped and I.V. fluids should be administered, as ordered. If the SBP is not restored, the leg compartment should be reinflated Monitor the patient s vital signs closely. Sudden and severe hypotension can occur Do not remove the PASG until ordered. Rapid reinflation may be necessary if the patient becomes unstable To remove the PASG, release the Velcro closures; do not use scissors Leave the garment beneath the patient in case reinflation is necessary Discard used procedure materials appropriately; perform hand hygiene Update the patient s plan of care, as appropriate, and document the following information in the patient s medical record: Date and time of PASG deflation and removal Description of the procedure, including amount of supplemental oxygen administered, type and amount of I.V. fluids and blood products infused, and any medications administered Patient assessment information (and the time each element was assessed)regarding vital signs level of pain/anxiety/consciousness pulse oximetry readings Patient s response to use of the PASG Any unexpected outcomes and the interventions performed All patient/family teaching

4 Other Tests, Treatments, or Procedures That Might Be Necessary with Use of a Pneumatic Anti-Shock Garment Imaging studies may be performed to assess the extent of the patient s injuries Use of a PASG can mask a pelvic fracture. The abdominal compartment should be deflated prior to obtaining pelvic X-rays in order to assess for pelvic fractures An electrolyte panel may be ordered before, after, and while the patient is wearing a PASG to identify any electrolyte shifts caused by the PASG that require treatment Vasopressors (e.g., DOPamine), I.V. fluids, oxygen administration, and other measures are often necessary to stabilize the patient Patients often require surgical intervention to definitively treat the underlying condition (e.g., uncontrolled bleeding, pelvic fracture) What to Expect After Deflating and/or Removing a Pneumatic Anti-Shock Garment Following deflation and/or removal of the PASG, the patient will remain physiologically stable and will experience no adverse consequences or complications (see Red Flags, below) If the patient survives the initial stabilization period, he/she will receive definitive treatment for the condition that necessitated use of the PASG Red Flags PASG pressure changes can occur with changes in altitude (e.g., during air transport or ground transport over mountain passes). PASG pressure should be monitored carefully during transport that involves changes in altitude PASG use is absolutely contraindicated in patients with pulmonary edema congestive heart failure penetrating thoracic wounds PASG use is relatively contraindicated in patients impaled by a foreign body with abdominal evisceration who are pregnant. If a PASG is used to treat a pregnant woman, it is suggested that only the leg compartments be inflated. In the event of complications following emptying of the uterus (e.g., abortion complications, ectopic pregnancies, hypocoagulation states, hydatidiform mole bleeding), the entire garment can be utilized to tamponade hemorrhage who have isolated lower-extremity fractures; splinting is preferred for isolated lower-extremity fractures PASGs should be used cautiously in patients with expected transport times > 40 minutes Potential complications of PASG use include skin breakdown compartment syndrome (i.e., compression of muscle, blood vessels, and nerves within a compartment of the body, which leads to tissue necrosis) in the lower extremities metabolic acidosis with prolonged PASG use because lactic acid is released from peripheral tissues decreases in renal perfusion, urine output, and glomerular filtration rate as a result of decreased renal blood flow impaired respiration if the PASG abdominal compartment is incorrectly positioned over the rib cage aggravation of lumbar instability if the abdominal compartment is inflated on a patient who has lumbar instability masking of pelvic fractures increased bleeding as blood pressure increases What Do I Need to Tell the Patient/Patient s Family? Educate about the function of the PASG, that it is a temporary intervention, and that definitive treatment will be performed as soon as possible On discharge from acute care, instruct the patient to seek immediate medical attention for new or worsening signs and symptoms (e.g., pain, swelling, bleeding)

5 Note Recent review of the literature has found no updated research evidence on this topic since previous publication on August 7, 2015 References 1. Ali, J., & Duke, K. (1991). Timing and interpretation of the hemodynamic effects of the pneumatic antishock garment. Annals of Emergency Medicine, 20(11), doi: /s (05) (R) 2. Baskerville, J. R. (2009). A blast from the present meets the MAST from the past: Should the pneumatic anti-shock garment ever be used? Emergency Medicine Journal, 26(10), 689. doi: /emj (X) 3. Cayten, C. G., Berendt, B. M., Byrne, D. W., Murphy, J. G., & Moy, F. H. (1993). A study of pneumatic antishock garments in severely hypotensive trauma patients. Journal of Trauma: Injury, Infection, and Critical Care, 34(5), (R) 4. Chang, F. C., Harrison, P. B., Beech, R. R., & Helmer, S. D. (1995). PASG: Does it help in the management of traumatic shock? Journal of Trauma: Injury, Infection, and Critical Care, 39(3), (RCT) 5. Connolly, B., Gerlinger, T., & Pitcher, J. D. (1999). Complete masking of a severe open-book pelvic fracture by a pneumatic antishock garment. Journal of Trauma, 46(2), (C) 6. Cutler, B. S., & Daggett, W. (1971). Application of the "G-suit" to the control of hemorrhage in massive trauma. Annals of Surgery, 173(4), (C) 7. Hauswald, M., & Greene, E. R. (2003). Regional blood flow after pneumatic anti-shock garment inflation. Prehospital Emergency Care, 7(2), doi: /s y (R) 8. Holleran, R. S. (2009). Pneumatic antishock garment. In J. A. Proehl (Ed.), Emergency nursing procedures (4th ed., pp ). St. Louis: Saunders Elsevier. (GI) 9. Honigman, B., Lowenstein, S. R., Moore, E. E., Roweder, K., & Pons, P. (1991). The role of the pneumatic antishock garment in penetrating cardiac wounds. Journal of the American Medical Association, 266(17), doi: /jama (R) 10. Vahedi, M. H., Ayuyao, A. A., Parsa, M. H., & Freeman, H. P. (1995). Pneumatic antishock garment-associated compartment syndrome in uninjured lower extremities. Journal of Trauma: Injury, Infection, and Critical Care, 38(4), (C)

Chapter 20. Learning Objectives. Learning Objectives 9/18/2012. Bleeding and Shock

Chapter 20. Learning Objectives. Learning Objectives 9/18/2012. Bleeding and Shock Chapter 20 Bleeding and Shock Learning Objectives Describe structure & function of circulatory system Differentiate among arterial, venous, & capillary bleeding Describe methods of emergency medical care