Chapter 69 Emergency, Terrorism, and Disaster Nursing

5 Reasons why the number of ED visits are increasing

1) the inability to see a primary care provider 2) an aging population 3) shorter hospital stays resulting in frequent readmissions 4) acute mental health crises 5) lack of health insurance

Risk factors for heat related emergencies

Age Environmental Conditions Preexisiting illness Prescription drugs Street drugs Alcohol

ABCDE

Airway Breathing Circulation Disability Exposure/Environment Control

AMPLE

Allergies Medications Past Health History Last meal Events/environment surrounding the injury

Most common Biologic agents and treatment

Anthrax/ Antibiotics Smallpox/ No Known cure can give vaccination even after exposure Botulism/ induce vomiting, antitoxin/ can lead to respiratory failure Plague/ Antibiotics Tularemia/ Antibiotics Hemorrhagic fever/ supportive care only

Prescription drugs that are risk factors for heat related emergencies

Anticholinergics Antihistamines Antiparkinsonian Antispasmodics B-Adrenergic blockers Butyrophenones Phenothiazines Tricyclic antidepressants

Why are Antipyretics not useful for heat issues

Antipyretics are for infection not elevated temperature

Breathing Assessment

Assess ventilation look for paradoxic movement of the chest wall during inspiration and expiration note use of accessory muscles or abdominal muscles listen for air being expelled through nose and mouth feel for air being expelled observe and count respiratory rate note color all nail beds, mucous membranes, skin auscultate lungs assess for jugular vein distention and position of trachea

Disability Assessment

Brief Neurologic assessment - level of consciousness using Glascow or AVPU - Assess pupils Identify Deformities - inspect extremities - determine range of motion Brief Pain assessment

Preexisting illness that are risk factors for heat related emergencies

Cardiovascular disease Cystic fibrosis Dehydration Diabetes Mellitus Obesity Previous stroke or CNS lesion Skin disorders

Circulation Assessment

Check carotid or femoral pulse Palpate pulse for quality and rate Assess color, temperature and moisture of skin Check capillary refill Assess for external bleeding Measure blood pressure

Drug of choice to control shivering

Chlorpromazine (Thorazine)

Airway Assessment

Clean and open airway Assess for obstructed airway Assess for respitory distress Check for loose teeth or foreign objects Assess for bleeding, vomitus, or edema

ESI Emergency Severity Index

ESI-1 through ESI-5 ESI-1 being the worst

Submersion Injury

Drowning Immersion syndrome Near-drowning Dry-drowning

FGHI

Full set of vital/Focused Adjuncts/Facilitate Family presence Give comfort measures Head to toe assessment Inspect posterior surfaces

Breathing intervention

Give supplemental oxygen via appropriate deleivery system Ventilate with bag-valve-mask with 100% oxygen if respirations are inadequate or absent Prepare to intubate if respiratory arrest have suction available If absent breath sounds, prepare for needle thoracostomy and chest tube insertion

Colored Tag System

Green - minor injuries Yellow - urgent but not life-threatening Red - life threatening Blue - expected to die Black - dead

Heatstroke S/S

Hot/dry skin altered mental status hypotension tachycardia weakness temp>104

Circulation interventions

If absent pulse, initiate CPR and advanced life-support measures If shock symptoms or hypotensive, insert 2 large-bore (14-16 gauge) IV's and initiate infusion of normal saline or lactated ringer Control bleeding with direct pressure Administer blood products if ordered Consider autotransfusion if isolated chest trauma Consider use of a pneumatic antishock garment or pelvis splint in the presence of a pelvic frature with hypotension Obtain blood samples for type and crossmatch

Treatment of any submersion injuries

Manage ABC's assume cervical spine injury in all victims and stabilize provide 100% O2 Anticipate need for intubation and mechanical ventilation if airway is compromised Establish IV access with two large bore catheters Assess for other injuries remove wet clothing and cover with warm blankets Obtain temp and begin rewarming Obtain cervical spine and chest x-rays insert gastric tube and urinary catheter

Interventions for hyperthermia

Manage and maintain ABC's provide high-flow O2 via non-rebreather mask Establish IV access and begin fluid replacement for significant heat injury Place patient in a cool environment For patient with heatstroke, initiate rapid-cooling measures: remove patients clothing, place wet sheets over patient, and place in front of fan; immerse in a cool water bath; administer cool IV fluids or lavage with cool fluids Obtain ECG Obtain blood for electrolytes and CBC Insert urinary catheter

3 Categories of Hypothermia

Mild 93.2 to 96.8 Moderate 86-93.2 Severe below 86 degrees

Surveys used for trauma patients

Primary and Secondary

The preferred procedure for securing an unprotected airway in the ED

Rapid-sequence intubation

Disability Interventions

Reassess level of consciousness Immobilize deformities reassess pain

Treatment of Superficial frostbite

Remove clothing and jewelry Do not massage Immerse the area in a warm water bath 102 to 108 degrees Debride blisters and apply sterile dressing

Exposure and Environmental Control Interventions

Remove clothing for adequate assessment keep patient warm with blankets, warmed IV fluids, and overhead lights Maintain privacy

What serious syndrome should be monitored for in hypothermia

Rhabdomyolysis

Airway

Saliva, bloody secretions, vomitus, laryngeal trauma, dentures, facial trauma, fractures, and the tongue can obstruct the airway. Patients at risk for airway compromise include those who have seizures, near drowning, anaphylaxis, foreign body obstruction, or cardiopulmonary arrest.

Why do we not want a person to shiver when having heat issues

Shivering increases core temperature (due to the associated heat generated by muscle activity) and complicates cooling efforts

Every critically injured or ill patient has an increased metabolic and oxugen demand therefore

Should have supplemental oxygen. Administer high-flow oxygen (100%) via a non-rebreather mask and monitor the patient's response.

ESI-3

Stable ABC/vital Unlikely but possible life threat or organ threat should see physician with 1 hour Medium.high intensity resource/ multiple diagnostic studies or brief obesrvation/ complex procedure Examples: Abdominal pain or gynecoligical disorder unless in severe distree, hip fracture in elderly patient

ESI-5

Stable ABC/vital no life threat or organ threat physician could be delayed low resource intensity Examination only Examples: Cold symptoms, minor burn, recheck (e.g. wound)

ESI-4

Stable ABC/vital no life threat or organ threat physician could be delayed low resource intensity one simple diagnostic study or simple procedure Examples: Closed extremity trauma, simple laceration, cystitis

ESI-1

Unstable ABC/vitals Obvious life threat or organ threat should be seen by physician immediately HIgh resourse intensity/Staff at bedside continuously/ Often mobilization of team response Examples: Cardiac Arrest, intubated trauma patient, overdose with bradypnea, severe respiratory distress

ESI-2

Threatened ABC/vitals likely but not always obvious life threat or organ threat should be seen by physician within 10 minutes High resource intensity/Multiple, often complex diagnositc studies/ frequent consultation/ continuous monitoring Examples: Chest pain probably resulting from ischemia, multiple trauma unless responsive

Secondary Survey

a brief, systematic process that aims to identify all injuries begins after addressing each step of the primary survey and intitiating any lifesaving interventions FGHI

Rhabdomyolysis

a serious sybdrome caused by the dreakdown of skeletal muscle which leads to myoglobinuria. This places the kidneya at risk for acute failure. Monitor urine for tea color, amount, pH, and myoglobin

Immersion syndrome

cold-water immersion stimulates vagus nerve and potentially fatal dysrhythmias e.g. bradycardia, cardiac arrest

Drowning

death from suffocation after submersion in water or other fluid

Signs and symptoms or airway obstruction

dyspnea, inability to speak, presence of foreign body in the airway, and trauma to the face or neck

Primary Survey

focuses on airway, breathing, circulation, disability, exposure/environment control. It serves to identify life threatening condition so that the appropraite interventions can be initiated At any point during this time if you find life threatening conditions start interventions immediately.

Three most common cause of falls in the elderly

generalized weakness environmental hazards orthostatic hypotension

Treatment of Deep frostbite

immersed in circulating water bath until flushing occurs distally elevation of extremity to reduce edema analgesia amputation may be required

Deep Frostbite

involves muscle, bone, and tendon. The skin is whote, hard, and insensitive to touch. The area has the appearance of deep thermal injury with mottling gradually progressive to gangrene

Superfical frostbite

involves skin and sub-Q tissue ususally the ears, nose, fingers, and tose. Skin appearance will range from waxy pale yellow to blue and mottled, and the skin will feel crunchy and frozen.

Dry drowning

near drowning victim who does not aspirate water may still develop bronchospasm and airway obstruction

Heat Exhaustion S/S

pale/ashen fatigue, weakness profuse sweating extreme thirst altered mental status hypotension tachycardia weak thready pulse Temp from 99.6 to 104

Triage

refers to the process of rapidly determining patient acuity.

Treatment for hymenopteran bites/stings

removal by scraping, mild reactions - elevation, cool compresses, antipruritic lotions, and orla antihistamines More severe reactions - IM or IV antihistamines, Sub-q epinephrine, and corticosteroids

Tick Bites

remove with tweezers

Heat cramps

severe muscle contractions in exerted muscles Thirst Nausea, tachycardia, pallor, weakness, and profuse diaphoresis are often present Treat by elevation, gentle massage, and analgesia to minimize pain avoid strenuous activity for at least 12 hours after the development of heat cramps Teaching should emphasize salt replacement during strenuous activity.

Airway Maintenance

should progress rapidly from the least to most invasive method. Treatment include using the jaw-thrust maneuver, suctioning and/or removal of foreign body, insertion of a nasopharyngeal or oropharyngeal airway( will cause gagging if patient is conscious), and endotracheal intubation. If unable to intubate due obstruction, crichothyroidotomy or tracheotomy is preformed.

Near-drowning

survivial from potential drowning; develops pulmonary edema and acute respiratory distress syndrome if water aspirated

Any patient with face, head, or neck trauma and/or significant upper chest injuries

suspect cervical spine trauma, stabilize the cervical spine, maintain head in a neutral position, use a rigid cervical collar, or a cervical immobilization device aka head blocks DO not use sandbags beacuase the weight of the sandbags could move the head if the patient is logrolled

Frostbite

true tissue freezing that results in the formation of ice crystals in the tissues and cells Can be superficial or deep

Hymenopteran bites/stings S/S

vary from stinging burning, swelling and itching to edema, headache, fever, syncope, malaise, nausea, vomiting, wheezing bronchospasms, laryngeal edema, and hypotension