What is Acute Biologic Crisis?

Condition that may result to patient mortality if left unattended in a brief period of time and
that warrants immediate attention for the reversal of disease process and prevention of further
morbidity and mortality

Conditions of Acute Biologic Crisis
Cardiac Failure
Inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygenation
and nutrients. CHF is most commonly used when referring to left-sided and right-sided failure.
Formerly called Congestive Heart Failure.

Diagnostic Assessments
- Chest X-ray (may show cardiomegaly or vascular congestion)
- Echocardiogram (shows decreased ventricular function and decreased ejection fraction)
- CVP (elevated in right-sided failure)
*pulmonary artery pressure monitoring may be used as guide treatment in serious case of
pulmonary edema

Pharmacologic Agents
- ACE Inhibitors (promotes vasodilation and diuresis by decreasing afterload and preload
eventually decreasing the workload of the heart.)
- Diuretic Therapy. A diuretic is one of the first medications prescribed to a patient with
CHF. Diuretics promote the excretion of sodium and water through the kidneys
- Digitalis (increases the force of myocardial contraction and slows conduction through
the AV node. It improves contractility thus, increasing left ventricular output.)
- Dobutamine.(Dobutrex) is an intravenous medication given to patients with significant
left ventricular dysfunction. A catecholamine, it stimulates the beta1-adrenergic
receptors. Its major action is to increase cardiac contractility.
- Milrinone (Primacor). A phosphodiesterase inhibitor that prolongs the release and
prevents the uptake of calcium. This in turn, promotes vasodilation, causing a decrease
in preload and afterload and decreasing the workload of the heart.
- Nitroglycerine (a vasodilator reduces preload)
- Morphine to sedate and vasodilate, decreasing the work of the heart
- Anticoagulants may be prescribed. Beta-adrenergic blockers maybe indicated in patients
with mild or moderate failure

Acute Myocardial Infarction
Occurs when the heart muscle is deprived of oxygen and nutrient-rich blood. However, in the
case of MI, this deprivation occurs over a sustained period to the point at which irreversible cell
death and necrosis take place. Infarction results from sustained ischemia and is irreversible
causing cellular death and necrosis.

Diagnostic Assessments
- Electrocardiogram (12-lead) capable of diagnosing MI in 80% of patients, making it an
indispensable, noninvasive, and cost-effective tool. Reading shows ST elevation,
accompanied by T-wave inversion; and later new pathologic Q wave
- Cardiac Enzymes elevated CK with MB isoenzymes >5percent (early diagnosis);
elevated Troponin (early to late diagnosis); or elevated LDH with flipped isoenzymes
(late diagnosis)
- WBC count leukocytosis (10,000/mm3 to 20,000/mm3) appears on thesecond day
after AMI and dis appears after 1 week
- Positron Emission Tomography (PET) is used to evaluate cardiac metabolism and to
assess tissue perfusion
- Magnetic Resonance Imaging helps identify the site and extent of an MI
- Tranesophageal Echocrdiography (TEE) is an imaging technique in which transducer is
placed against the wall of the esophagus; the image of the myocardium is clearer when
the esophageal site is used.

Pharmacologic Agents
- Nitroglycerine (to dilate coronary vessels and increase blood flow)
- Morphine Sulfate (to relieve chest pain)
- Anticoagulant (heparin) and Antiplatelet (aspirin) - to prevent additional clot formation
- Streptokinase (to dissolve clot)
- Beta blockers (to decrease cardiac work)
- Anti-dysrhytmic drugs

Acute Pulmonary failure
Defined as a fall in arterial oxygen tension and a rise in arterial carbon dioxide tension. The
ventilation and/or perfusion mechanisms in the lung are impaired.

Diagnostic Assessments
- ABG analysis indicates respiratory failure when PaO2 is low and PaCO2 is high and the
HCO3 level is normal
- Chest X-ray is used to identify pulmonary diseases such as emphysema, atelectasis,
pneumothorax, infiltrates and effusions
- Electrocardiogram (ECG) can demonstrate arrhythmias, commonly found with cor
pulmonale and myocardial hypoxia
- Pulse oximetry reveals a decreasing SpO2 level
- WBC count aids detection of an underlying infection; abnormally low hemoglobin and
hematocrit levels signal blood loss, indicating decrease oxygen carrying capacity
- PA catheterization is used to distinguish pulmonary causes from cardiovascular causes
of acute respiratory failure
-
Pharmacologic Agents
- Reversal agents such as Naloxone (Narcan) are given if drug overdose is suspected
- Bronchodilators are given to open airways
- Antibiotics are given to combat infection
- Corticosteroids may be given to reduce inflammation
- Continuous IV solutions of positive inotropic agents may be given to increase cardiac
output, and vasopressors may be given to induce vasoconstrictions to improve or
maintain blood pressure
- Diuretics may be given to reduce fluid overload and edema

Acute Renal Failure
A sudden loss of kidney function caused by failure of renal circulation or damage to the tubules
or glomeruli.

Diagnostic Assessments
- Blood studies reveal elevated BUN, serum creatinine, and potassium levels and
decreased blood pH, bicarbonate, HCT, and Hb levels
- Urine studies show cats, cellular debris, decreased specific gravity and, in glomerular
diseases, proteinuria and urine osmolality close to serum osmolality.
- Creatinine clearance testing is used to measure the GFR and estimate the number of
remaining functioning nephrons
- Electrocardiogram (ECG) shows tall, peaked T waves, a widening QRS complex, and
disappearing P waves if increased potassium is present
*other studies used to determine the cause of renal failure:
- kidney ultrasonography
- plain films of the abdomen
- KUB radiography
- excretory urography
- renal scan
- retrograde pyelography
- computed tomography scan and nephrotomography

Pharmacologic Agents
- use volume expanders are prescribed to restore renal perfusion in hypotensive clients
and Dopamine IV to increase renal blood flow
- Loop diuretics to reduce toxic concentration in nephrons and establish urine flow
- ACE inhibitors to control hypertension
- Antacids or H2 receptor antagonists to prevent gastric ulcers
- Kayexelate to reduce serum potassium levels and sodium bicarbonate to treat acidosis
* avoid nephrotoxic drugs

Stroke/Cerebrovascular Accident
It is a condition where neurological deficits occur as a result of decreased blood flow to a
localized area of the brain. Thrombosis of the cerebral arteries supplying the brain or of the
intracranial vessels occluding blood flow. Embolism from a thrombus outside the brain, such as
in the heart, aorta, or common carotid artery. Haemorrhage from an intracranial artery or vein,
such as from hypertension, ruptured aneurysm, AVM, trauma, haemorrhagic disorder, or septic
embolism.

Diagnostic Assessments
- CT scan discloses structural abnormalities, edema, and lesions, such as nonhemorrhagic
infarction and aneurysms
- MRI is used to identify areas of ischemia, infarction and cerebral swelling
- DSA is used to evaluate patency of the cerebral vessels and shows evidence of occlusion
of the cerebral vessels, a lesion or vascular abnormalities
- Cerebral angiography shows details of disruption or displacement of the cerebral
circulation by occlusion or hemorrhage
- Carotid Duplex scan is a high frequency ultrasound that shows blood flow through the
carotid arteries and reveals stenosis due to atherosclerotic plaque and blood clots
- Transcranial Doppler studies are used to evaluate the velocity of blood flow through
major intracranial vessels, which can indicate vessel diameter
- Brain scan shows ischemic areas but may not be conclusive for up to 2 weeks after
stroke
- Single photon emission CT scanning and PET scan show areas of altered metabolism
surrounding lesions that arent revealed by other diagnostic tests
- Lumbar puncture reveals bloody CSF when stroke is hemorrhagic
- EEG is used to identify damaged areas of the brain and to differentiate seizure activity
from stroke
- A blood glucose test shows whether the patients symptoms are related to
hypoglycemia
- Hemoglobin and hematocrit level may be elevated in severe occlusion
- Baseline CBC, platelet count, PTT, PT, fibrinogen level and chemistry panel are obtained
before thrombolytic therapy

Pharmacologic Agents
- Thrombolytics for emergency treatment of ischemic stroke
- Aspirin or Ticlopidine (Ticlid) as an antiplatelet agent to prevent recurrent stroke
- Benzodiazepines to treat patients with seizure activity
- Anticonvulsants to treat seizures or to prevent them after the patients condition has
stabilized
- Stool softeners to avoid straining, which increase ICP
- Antihypertensives and antiarrhythmics to treat patients with risk factors for recurrent
stroke
- Corticosteroids to minimize associated cerebral edema
- Hyperosmolar solutions (Mannitol) or diuretics are given to clients with cerebral edema
- Analgesics to relieve the headaches that may follow a hemorrhagic stroke

Increased Intracranial Pressure
Prolonged pressure greater than 15mmHg or 180mmH2O measured in the lateral ventricles.

Diagnostic Assessments
- skull radiography
- CT scan
- MRI
* Lumbar puncture is not performed because of brain herniation caused by sudden release of pressure
*Laboratory tests are performed to augment and monitor treatment approaches; serum
osmolarity monitors hydration status and ABGs measure pH, oxygen and carbon dioxide

Pharmacologic Agents
- Osmotic diuretics such as Mannitol and loop diuretics such as Furosemide ( Lasix) are
mainstays used to decrease ICP
- Corticosteroids are effective in decreasing ICP especially with tumors

Diabetic Ketoacidosis
Life threatening metabolic acidosis resulting from persistent hyperglycemia and breakdown of
fats into glucose, leading to presence of ketones in blood; can be triggered by emotional stress,
uncompensated exercises, infection, trauma, or insufficient or delayed insulin administration.

Diagnostic Assessments
- Serum glucose is elevated (200 to 800 mg/dl)
- Serum Ketone Level is increased
- Urine acetone test is positive
- Arterial Blood Gas analysis reveals metabolic acidosis
- ECG findings shows tall tented T waves and widened QRS complex changes related to
hyperkalemia; later with hypokalemia, shows flattened T wave and the presence of U
wave
- Serum osmolality is elevated

Pharmacologic Agents
- Administer IV Insulin and fluid and electrolyte replacements based on laboratory test
results

Hyperosmolar Hyperglycemic Nonketotic Coma
Life threatening disorder of hyperglycemia usually recurring with DM type 2 medications,
infections, acute illness, invasive procedure, or a chronic illness.

Diagnostic Assessments
- Serum glucose is elevated, sometimes 800 to 2,000 mg/dl
- Ketones are absent, urine and serum ketones are absent
- Urine glucose levels are positive
- Serum osmolality is increased
- Serum Sodium levels are elevated and the serum potassium level is usually normal
- ABG results are usually normal, without evidence of acidosis

Pharmacologic Agents
- IV infusion of NS to replace fluids and sodium, regular insulin IV to manage the
hyperglycemia, and potassium to replace losses and shifts

Massive bleeding
Uncontrolled bleeding; commonly defined as loss of entire blood volume within 24 hours, or
loss of 50% of blood volume within three hours

Diagnostic Assessments
- evidence of bleeding from thorocostomy that indicates bleeding from chest area
- abdominal or pelvic CT scan, abdominal ultrasound or peritoneal lavage indicate intra-
abdominal bleeding
- Endoscopy indicates upper or lower GI bleeding
- Angiography procedures diagnose severe vascular damage
- Extremity radiographs show long bone fractures
- Hemoglobin and hematocrit from the CBC are decreased due to blood loss
- Elevated serum lactate if bleeding continues and client becomes acidotic
- ABGs show metabolic acidosis as blood loss continues
- Baseline coagulation studies should be reviewed; initial PT/PTT and platelet counts will
be within normal limits but as coagulation factors become depleted, clotting times will
increase and platelet counts will decrease
- Serum electrolytes to assess renal function

Pharmacologic Agents
- Crystalloids and blood products to maintain adequate circulating volume status
- Sodium Bicarbonate to correct acidosis state
- Vasopressor such as Dopamine

Burns
An alteration in skin integrity resulting in tissue loss or injury caused by heat, chemicals, electricity or
radiation.
Diagnostic Assessments
Rule of Nines chart determines the percentage of body surface area (BSA) covered by the burn
- ABG levels may be normal in the early stages but may reveal
- hypoxemia and metabolic acidosis
- Carboxyhemoglobin level may reveal the extent of smoke inhalation due to the
presence of carbon monoxide
- Complete blood count may reveal a decrease hemoglobin due to hemolysis, increased
hematocrit and leukocytosis
- Electrolyte levels show hyponatremia and hyperkalemia, other laboratory tests reveals
elevated BUN, decreased total protein and albumin
- Creatinine kinase (CK) and myoglobin levels may be elevated
- Presence of myoglobin in urine may lead to acute tubular necrosis

Pharmacologic Agents
- Antibiotic prophylaxis will eradicate bacterial component
- Pain therapy
- Tetanus prophylaxis
- Topical antimicrobial
- Enzymatic debriding agents such as collagenase, fibrinolysin-desoxyribonuclease, papin
or sutilins are used with a moisture barrier to protect surrounding tissue
- Recommended dressings include polyurethane films (Op-site, Tegaderm), absorbent
hydrocolloid dressings (Duoderm).

Poisoning
Substances that are harmful to humans that are inhaled, ingested (food, drug overdose) or
acquired by contact

Diagnostic Assessments
The diagnosis of many poisonings is based on a thorough client history and clinical
manifestations
- Laboratory toxicology screens (serum, vomitus, stool and urine) determine the extent of
the absorption
- Baseline blood work such as CBC, electrolytes, renal and hepatic studies enable future
determination of organ and tissue damage
- Chest X-ray may show aspiration pneumonia in inhalation poisoning
- Abdominal X-rays may reveal iron pills or other radiopaque substances
- ABG analysis used to evaluate oxygenation

Pharmacologic Agents
Antidotes will vary with medication ingested
- Ipecac syrup 30ml PO followed by 240ml water is used for adults
- Activated charcoal powder slurry 30 to 100g PO or per NG tube
- Magnesium Citrate will be used for GI evacuation
- Naloxone (Narcan) for respiratory depression caused by narcotic overdose
- Flumazanil (Romazicon) for benzodiazepine ingestions

Multiple Injuries
Is a physical injury or wound thats inflicted by an external or violent act; it may be intentional
or unintentional; involve injuries to more than one body area or organ

Diagnostic Assessment
- Chest X-ray detect rib and sterna fractures, pneumothorax, flail chest, pulmonary
contusion and lacerated or ruptured aorta
- Angiography studies performed with suspected aortic laceration or rupture
- Ct scan, cervical spine X-rays, skull X-rays, Angiogram test for a patient with head
trauma
- ABG analysis to evaluate respiratory status and determine acidotic and alkalotic states
- CBC to indicate the amount of blood loss
- Coagulation studies to evaluate clotting ability
- Serum electrolyte levels to indicate the presence of electrolyte imbalances

Pharmacologic Agents
- Tetanus immunization
- Antibiotics for infection control
- Analgesics for pain
Conditions of Multi organ Failure
Circulatory shock
Systemic Inflammatory Response Syndrome
Injury (Accidents / Surgery)
General Management of Multi organ Failure
NCP of Acute Biologic Crisis

Massive Bleeding
Description
Uncontrolled bleeding; commonly defined as loss of entire blood volume within 24 hours, or loss of
50% of blood volume within three hours
Etiology
Result of blunt or penetrating trauma
Hemoptysis
Gastrointestinal/Genitourinary bleeding
Pathophysiology
Due to the lack of adequate circulating blood volume causing decreased tissue perfusion and
metabolism resulting in hypoxia., vasoconstriction and shunting of the available circulating
blood volume to the vital organs (hear and brain); Sympathetic nervous system stimulation,
hormonal release of antidiuretic hormone and the angiotensin-renin mechanisms and neural
responses attempt to compensate for the loss of circulating volume but eventually metabolic
acidosis, multi organ system failure occurs.
Clinical Manifestations
Cool, clammy, pale skin (especially distal extremities)
Decreased blood pressure (systolic pressure <90mmHg)
Cardiac Dysrhythmias (abnormalities of cardiac rhythm)
Delayed capillary refill (>3 seconds)
Rapid shallow respirations (>28/min)
Decreased urinary output
Weak, rapid pulses
Restless, anxious, decreased LOC
Diagnostics
Evidence of bleeding from thoracotomy that indicates bleeding from chest area
Abdominal or pelvic CT scan, abdominal ultrasound or peritoneal lavage indicate intra-
abdominal bleeding
Endoscopy indicates upper or lower GI bleeding
Angiography procedures diagnose severe vascular damage
Extremity radiographs show long bone fractures
Hemoglobin and hematocrit from the CBC are decreased due to blood loss
Elevated serum lactate if bleeding continues and client becomes acidotic
ABGs show metabolic acidosis as blood loss continues
Baseline coagulation studies should be reviewed; initial PT/PTT and platelet counts will
be within normal limits but as coagulation factors become depleted, clotting times will
increase and platelet counts will decrease
Serum electrolytes to assess renal function
Nursing Diagnoses
Impaired Tissue Perfusion
Deficient Fluid volume
Decreased cardiac Output
Nursing Management
Establish an adequate airway, breathing pattern, and applying supplemental oxygen
Give priority interventions to control bleeding such as direct pressure to wound site, or
assisting with surgical interventions
Establish IV access and begin with fluid replacement
Draw blood specimens as ordered to assist in evaluation of hemoglobin, hematocrit,
electrolyte, oxygenation and hydration status
Insert an indwelling catheter and NG tube to assist in accurate recording of fluid balance
status
Perform and document continuous serial assessments of hemodynamic parameters
such as VS, capillary refill, CVP, cardiac rhythm, LOC, urinary output and laboratory
findings
Pharmacotherapy
Crystalloids and blood products to maintain adequate circulating volume status
Sodium Bicarbonate to correct acidosis state
Vasopressor such as Dopamine
Client Education
Explain procedure to the client
Support the family by explaining emergency measures and interventions

Severe external bleeding

Even a small injury can result in severe external bleeding, depending on where it is on the body.
This can lead to shock. In medical terms, shock means the injured person no longer has enough
blood circulating around their body. Shock is a life-threatening medical emergency.

First aid management for severe external bleeding includes:
Check for danger before approaching the injured person. Put on a pair of gloves, nitrile
ones, if available.
If possible, send someone else to call triple zero (000) for an ambulance.
Lie the person down. If a limb is injured, raise the injured area above the level of the
persons heart (if possible).
Get the person to apply direct pressure to the wound with their hand or hands to stem
the blood flow. If the person cant do it, apply direct pressure yourself.
You may need to pull the edges of the wound together before applying a dressing or pad.
Secure it firmly with a bandage.
If an object is embedded in the wound, do not remove it. Apply pressure around the
object.
Do not apply a tourniquet.
If blood saturates the initial dressing, do not remove it. Add fresh padding over the top
and secure with a bandage.
Internal bleeding visible

The most common type of visible internal bleed is a bruise, when blood from damaged blood
vessels leaks into the surrounding skin. Some types of internal injury can cause visible bleeding
from an orifice (body opening). For example:
bowel injury bleeding from the anus
head injury bleeding from the ears or nose
lung injury coughing up frothy, bloodied sputum (spit)
Urinary tract injury blood in the urine.
Internal bleeding not visible

It is important to remember that an injured person may be bleeding internally even if you cant
see any blood. An internal injury can sometimes cause bleeding that remains contained within
the body; for example, within the skull or abdominal cavity.

Listen carefully to what the person tells you about their injury where they felt the impact, for
example. They may display the signs and symptoms of shock. In the case of a head injury, they
may display the signs and symptoms of concussion. Therefore, it is important to ask the right
questions to collect the relevant information.
Symptoms of concealed internal bleeding

The signs and symptoms that suggest concealed internal bleeding depend on where the
bleeding is inside the body, but may include:
pain at the injured site
swollen, tight abdomen
nausea and vomiting
pale, clammy, sweaty skin
breathlessness
extreme thirst
Unconsciousness.
Some signs and symptoms specific to concussion (caused by trauma to the head) include:
headache or dizziness
loss of memory, particularly of the event
confusion
altered state of consciousness
wounds on the head (face and scalp)
Nausea and vomiting.
Internal bleeding is a medical emergency

First aid cannot manage or treat any kind of internal bleeding. Prompt medical help is vital.
Suggestions include:
Check for danger before approaching the person.
If possible, send someone else to call triple zero (000) for an ambulance.
Check that the person is conscious.
Lie the person down.
Cover them with a blanket or something to keep them warm.
If possible, raise the persons legs above the level of their heart.
Dont give the person anything to eat or drink.
Offer reassurance. Manage any other injuries, if possible.
If the person becomes unconscious, place them on their side. Check breathing
frequently. Begin cardiopulmonary resuscitation (CPR) if necessary.
Spread of disease through bleeding

Some diseases can be spread through open wounds. Remember:
If possible, wash your hands with soap and water before and especially after
administering first aid. Dry your hands thoroughly before putting on gloves.
First aid kits contain gloves. Always put on gloves beforehand if available. If not,
improvise.
Do not cough or sneeze over the wound.