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T.L Male, 4/13/24 years ago - Coggle Diagram
T.L Male, 4/13/24 years ago
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Orders
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Atropine. 1 mg, IVP.
Repeat every 3 to 5 minutes as needed for low heart rate <60 bpm, max dose of 3 mg.
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Insert peripheral IV: Frequency: Once, draw labs with IV start
Insert straight catheter: PRN, do STAT and as needed.
Lactated Ringer's: 1000 mL stat, Rate of 1000 mL, Route: IV
If BP is still low, may repeat x1, monitor for fluid overload during infusion.
Methylprednisolone
30 mg/kg stat. Rate: 200 mL/hour, route: IV
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Morphine Sulfate. 4 mg every 2 hours, Route IVP
To be given over 1 to 2 minutes, monitor for respiratory depression, do not give if RR <12.
Norepinephrine in D5W, Route: IV
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Oxygen, use best tolerated means to keep sats >94%, if unable to maintain use ambu bag until intubated. Frequency: stat.
Urinalysis (UA) Frequency: once, do with foley insertion
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X-ray Cervical spine, frequency:stat
Labs
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No protein in the urine and no bilirubin, no glucose, no ketones, no blood, no bacteria.
X-ray: several fractures noted at C4 and above. Severe spinal cord compression with swelling and edema extending from lower C2 down to mid C6 representing cord contusion.
Chief complaint: no feeling below the neck, spinal cord injury.
Client was diving into a pool, aspiration?
What's happening? Neurogenic shock, several decreased BP I would imagine. Help fix this problem by stabilizing the spine along with fluid resuscitation to correct the BP imbalance. Monitor for sensation as well as pain, along with respirations. Keep an eye also on heart rate along with neuros