MS3 Exam 1
Triage
"to sort" - determine the priority of their health care needs and the proper site for treatment -Decisions are based on the likelihood of survival and consumption of available resources
What is the nursing management of burns in the acute phase?
(1) Wound care - Goals prevent infection & promote wound re-epithelialization (2) Excision & grafting (3) Pain management (4) Physical & occupational therapy Passive & active ROM performed on all joints (5) Nutritional therapy - Goals : provide adequate calories & protein to promote healing
What are the possible causes of violence?
(temporal lobe epilepsy), psychosis (schizophrenia), or criminal behavior (assault, murder)
Animal Bite tx
* Always update tetanus* Tx: - Copious irrigation - Tetanus prophylaxis - Analgesics as needed - Prophylactic antibiotics if at risk for infection...such as wounds over joints, those greater than 6-12 hrs old, puncture wounds, and bites of hand or foot - Leave puncture wounds open - Lacerations loosely sutured - Consider rabies post-exposure prophylaxis spread by bites, scratches, and contact w/ infection secretions - Dogs, raccoons, & bats carry rabies Prophylaxis must be started BEFORE symptoms appear DRUG ALERT: Rabies Post-exposure Prophylaxis give calculated dose of RIG via infiltration around the wound edges - Give any remaining volume of RIG IM at a site distant from the vaccine site (e.g. gluteal site for bite wounds on the arm) - Give the HDCV IM in the deltoid
Smoke inhalation injury
* Metabolic Asphyxiation* - primarily carbon monoxide (CO) or hydrogen cyanide - hypoxia and carboxyhemoglobin occurs - oxygen reverses effects *Upper Airway Injury* - inhalation injury to mouth, oropharynx, &/or larynx - *redness, blistering, & edema, Substernal & intercostal retractions, Total airway obstruction, stridor, copious secretions* - Swelling can be massive w/ rapid onset *Lower Airway Injury* - Inhalation injury to trachea, bronchioles, & alveoli - * facial burns, singed nasal hairs, hoarseness, painful swallowing, darkened oral & nasal membranes, carbonaceous sputum, hx of being burned in an enclosed space, & clothing burns around neck & chest, Carbonaceous sputum, altered mental status, dyspnea* - *Pulmonary edema may not appear until 12-48 hrs after the burn & then it may manifest as ARDS*
Hypothermia tx
* manage & maintain ABCs, rewarm the patient, correct dehydration & acidosis, and treat cardiac dysrhythmias* - Passive or spontaneous rewarming - move pt to warm environment - remove damp clothing - use radiant lights - place warm blankets - Active external or surface rewarming - fluid- or air-filled warming blankets, warm water immersion - Active internal or core rewarming - heated humified O2 - warmed IV fluids - peritoneal lavage w/ warmed fluids, & extracorporeal circulation w/ cardiopulmonary bypass - rapid fluid infuser - hemodialysis - Gentle handling of pt is required to prevent stimulation of cold myocardium Rewarming shock - further drop in core body temperature due to cold peripheral blood returning to central circulation * WATCH FOR HYPOTENSION AND DYSRHYTHMIAS*
What are complications during the emergent phase of burns?
*CV* - Dysrhythmias, hypovolemic shock - Circulation impaired (by deep circumferential burns & edema formation) - Blood thickens (sludging) - Increased risk for VTE *Respiratory system* - NO correlation between percentage TBSA burned and the severity of inhalation injury *Other cardiopulmonary problems* - pre-existing heart or lung disease --> increased risk for complications - If fluid replacement is too vigorous, watch for early signs of heart failure or pulmonary edema - Watch for respiratory infection (e.g. pneumonia) especially if pre-existing lung disease *Urinary system* - Most common is acute tubular necrosis (ATN) likely secondary to hypovolemia (poor renal perfusion) or myoglobinuria secondary to muscle cell breakdown
What are the Prehospital & Emergency Care (general) for chemical and inhalation burns?
*Chemical burns* - Best treated by quickly removing any chemical particles or powder from the skin - Remove all clothing containing chemical - Flush affected area w/ copious amounts of water to irrigate the skin anywhere from 20 minutes to 2 hours post exposure - Tap water is acceptable for flushing eyes exposed to chemicals * Inhalation injuries* -Watching closely for signs of respiratory distress *If CO poisoning is suspected treated w/ 100% humidified O2* *BURN PT MAY HAVE ANOTHER INJURY THAT TAKES PRIORITY OVER THE BURN*
Strategies to Reduce Burn Injury
*Flame or Contact* - Never smoke in bed - "child-resistant" lighters - regular home fire drills - Never leave hot oil unattended while cooking - Never use gasoline/ flammable liquids to start a fire - Never leave candles unattended or near open windows or curtains - Consider a flame-retardant smoking apron for older or "at risk" people - Exercise caution when microwaving food & beverages *Scald* - Use "anti-scald" devices w/ showerhead or faucet fixtures - Lower hot water temperature to the "lowest point" or 120ºF - After running bath water, check temperature w/ back of hand or bath thermometer - Supervise bathing w/ small children, older adults, or anyone w/ impaired physical movement, physical sensation, or judgment *Inhalation* - Install smoke & carbon monoxide detectors & change batteries annualy (if appropriate) *Chemical* - Store chemicals safely in approved containers & label clearly - Ensure safety of workers handling chemicals (education, protective eyewear, gloves, masks, clothing) *Electrical* - Avoid or repair frayed wiring - Avoid outdoor activities during electrical (i.e. - lightning) storms - Ensure electrical power source is shut off before beginning repairs - Wear protective eyewear & gloves when making electrical repairs
When is Cricothyroidectomy used?
*HAILL CO* - intubation doesn't work - airway obstruction from extensive maxillofacial trauma - cervical spine injuries - laryngospasm - laryngeal edema (after an allergic reaction or extubation) - hemorrhage into neck tissue - obstruction of the larynx
What are the 3 components of injury prevention?
*LEA* - Education - Legislation - Automatic protection (airbags & automotive design)
How do you establish an airway?
*RUN, HOME. SOON, AMY - Reposition - Head, tilt, chin, left (modified jaw thrust w/ cervical) - Suction - Airway adjuncts (Naso/orophygeal airways) Provider would: - Intubate - Cryc
What is the pre-hospital and emergency care for small/large burns?
*Small Burns (<10% TBSA)* - Cover w/ clean, cool, tap water-dampened towel for patient comfort & protection until medical care is available Cooling w/in 1 minute of injury helps minimize depth of injury *Large Burns(>10%) or electrical or inhalation burn* - Focus on CAB: circulation (C), airway (A), breathing (B)
What are treatments of burns in the emergent phase?
*Tetanus Immunization* - Routinely given to all burn patients d/t likelihood of anaerobic burn wound contamination - If patient has not received an active immunization w/in 10 years before the burn injury, give tetanus immunoglobulin *Antimicrobial Agents*: - Topica/systemic abx used later on - Venous Thromboembolism (VTE) Prophylaxis: If there are no contraindications, it is recommended that low-molecular weight heparin (enoxaparin) or low-dose unfractionated heparin be started as oon as it is considered safe
Moderate hypothermia
- (32-34ºC) - rigidity, bradycardia, slowed RR, BP obtained only by Doppler, metabolic & respiratory acidosis, & hypovolemia; shivering diminishes
Mild Hypothermia
- (34-36ºC) - shivering, lethargy, confusion, rational to irrational behavior, & minor HR changes
Severe hypothermia
- (<32ºC) - appears dead; HR & RR so slow that may be difficult to detect, reflexes are absent, pupils fixed & dilated
Types of Biological Warfare Agents
- *Anthrax* - *Smallpox* - *Botulism* - Plaque - Tularemia - Hemorrhagic fever - *Ebola Virus Disease* *BASE*
What is the Nursing & Interprofessional Management during the Emergency Phase for burns?
- *Care focuses on airway management, fluid therapy, & wound care* *Airway management* - Early intubation to reduce need for emergency tracheostomy (extubation when edema resolves in approx 3-6 days) - Escharotomy is circumferential burns to neck &/or chest - If no intubation, 100% humidified O2 & place in high fowler's - Encourage TCDB *Fluid therapy* - Parkland (Baxter) formula - If electrical burn then require both fluids & mannitol (osmotic diuretic) - Assess for adequacy of fluid resuscitation using clinical parameters: *Urine output 0.5-1.0mL/kg/hr; 75-100mL/hr for electric burns* Cardiac parameters MAP >65, SBP >90, HR <120
What is the protocol for volume replacement when a patient is hemorrhaging?
- 2 Large Iv Catheters (16/18) - Blood samples for type and cross - Isotonic fluids (LR, NS, blood components) - PRBCs (massive), platelets/clotting factors
What are the 2 full thickness skin destructions?
- 3rd degree - 4th degree
What is a secondary survey? Log roll
- A head to toe assessment - Person at head controls - Roll patient at the end of the secondary survey
Nuclear radiation exposure : Decontamination interventions
- Access restriction - Triage outside the hospital - Floors are covered to - Strict isolation precautions - All air ducts and vents sealed - Waste is double-bagging with plastic-lined containers outside of the facility - All radiation-contaminated waste disposed in color-coded yellow and magenta canisters - PPE: water-resistant gowns, two pairs of gloves, masks, caps, goggles, and booties - Dosimetry devices should be worn by all staff members participating in patient care
Acids & Alkalis overdose (Acids?/ Alkalines?/other?, sx?)
- Acids: toilet bowel cleaners, antitrust compounds - Alkalis: drain cleaners, dishwashing detergents, ammonia - Aspirin & aspirin containing drugs sx: - (Excessive salivation, dysphagia, epigastric pain, pneumonitis, burns of mouth, esophagus, & stomach, Tachypnea, tachycardia, hyperthermia, seizures, pulmonary edema, occult bleeding or hemorrhage, metabolic acidosis) tx: - Immediate dilution (water, milk), corticosteroids (for alkali), induced vomiting is contraindicated - Activated charcoal, gastric lavage, urine alklinization, hemodialysis for severe acute ingestion, intubation & mechanical ventilation, supportive care * IF THE PT INGESTS ACID, DO NOT FORCE VOMITING*
What are the options for decreasing absorption of poisons?
- Activated charcoal - Dermal cleansing - Eye irrigation - Gastric lavage
Acetaminophen (Tylenol) overdose tx
- Activated charcoal - N-acetylcysteine (MUCOMYST) (oral form may cause vomiting, IV form can be used)
Burn prevention education
- Advise that matches & lighters be kept out of the reach of children - never leave children unattended around fire or in bathroom/bathtub - Educate about the installation & maintenance of smoke & carbon monoxide detectors on every level of the home & changing batteries annually on birthday - Recommend the development & practice of a home exit fire drill with all members of the household - Advocate setting the water heater temperature no higher than 48.9ºC (120ºF) E- ducate about the perils of smoking in bed, smoking while using home oxygen, or falling asleep while smoking - Caution against using flammable liquids to start fires &/or throwing flammable liquids onto an already burning fire - Warn of the danger of removing the radiator cap from a hot care engine - Recommend avoidance of overhead electrical wires & underground wires when working outside - Advise that hot irons & curling irons be kept out of the reach of children - Discourage running electric cords under carpets or rugs - Recommend storage of flammable liquids well away from fire source, such as pilot light - Educate about the importance of being aware of loose clothing when cooking over a stovetop or flame - Recommend having a working fire extinguisher in the home & knowing how to use it
The deadly 6 trauma
- Airway - Cardiac tamponade - Tension pneumoathorax - Hemothorax - Sucking chest wound - Flail chest *HFACTS*
What is the priority assessment in burn patients and what should you monitor?
- Airway - Ongoing air
How do you control external hemorrhage?
- Apply pressure - TOURNIQUET is applied as a last resort - Elevate - immediate surgery is not feasible
Acute phase of Burns
- Begins w/ the mobilization of extracellular fluid & subsequent diuresis and concludes when partial-thickness burns are healing or full-thickness burns are covered by skin grafts * Clinical Manifestations* - Partial-thickness wounds form eschar; once eschar is removed, re-epithelialization begins at wound margins & appears as red or pink scar tissue - Healing is spontaneous & usually occurs w/in 10-21 days - Margins of full-thickness eschar take longer to separate; as a result, full-thickness burns require surgical debridement & skin grafting to heal *Complications Infection!*
Rehabilitation phase of burns
- Begins when the patient's wounds have healed & he/she is engaging in some level of self - occurs as 2 weeks - 7/8 months after a major burn injury *Goals* (1) work toward resuming a functional role in society (2) rehabilitate from any functional and cosmetic post-burn reconstructive surgery *Complications* - Joint contractures - a happens if adequate ROM is not started & new tissue shortens - Succeptible ares: anterior & lateral neck, axillae, AC fossae, fingers, groin areas, popliteal fossa, knees, & ankles
When do you want to refer a patient to the burn unit?
- Burns that involve the face, hands, feet, genitalia, perineum, or major joints - Partial-thickness burns >10% of total body surface area (TBSA) - Third-degree burns in any age group Electrical burns including lightning injury, Chemical burns, Inhalation injury - Burn injury in patients w/ pre-existing medical disorders that could complicate care (kidney disease, diabetes) - Any patients w/ burns & concomitant trauma (e.g. fractures) - Burn injury in children in hospitals w/o qualified personnel or equipment needs to care for them. - Burn injury in patients who will require special social, emotional, or long-term rehabilitation intervention.
Anthrax
- Caused by Bacillus anthracis - Contracted through digestive system, abrasions in the skin, or inhalation through lungs - Transmitted by direct contact w/ bacteria and spores - Blood test is available to detect anthrax - *Treated w/ ciprofloxacin, doxycycline, or penicillin* - Vaccine has limited availability
Thermal Burns
- Caused by flame, flash, scald, or contact w/ hot objects - Most common type of burn injury
Ebola
- Caused by infection w/ a virus of the family Filoviridae, genus Ebolavirus - Natural reservoir unknown - Spread through contact w/ objects that have been contaminated w/ the virus (clothes, bedding, needles, syringes/sharps, or medical equipment - Assessment: Ask the client if he/she traveled to an area w/ EVD such as Guinea, Liberia, or Sierra Leone w/in the last 21 days of if has had contat with someone w/ EVD - Interventions: Isolated in private room w/ private bathroom, wear proper PPE, limited number of healthcare workers caring for patient, only necessary tests/procedures should be performed
What effects can circumferential burns cause?
- Circumferential burns to extremities can cause circulation problems distal to the burn, w/ possible nerve damage to the affected extremity - Patients may also develop compartment syndrome from direct heat damage to the muscles, swelling, &/or pre-burn vascular problems
What are wound care interventions during the emergent phase?
- Cleansing /gentle debridement (using scissors & forceps) during a regular shower or w/ patient in bed - Once daily shower & dressing change w/ an evening dressing change in the patient's room are often routine in burn centers - Extensive, surgical debridement done in OR - Source of infection is likely the patient's own normal flora, mostly from skin, respiratory, & GI systems Always wear PPE and use sterile gloves when applying ointments & sterile dressings - Permanent skin coverage is the primary goal * autograft (patient's own skin) or allograft (cadaver skin)* is generally used; newer biosynthetic options are now available
Heat exhausion *Mildy Severe* (causes, sx, tx)
- Clinical syndrome - strenuous activity in hot, humid weather, sometimes sedentary - Subjective: fatigue, N/V, extreme thirst, & feelings of anxiety, dehydration - Objective: hypotension, tachycardia, elevated body temp, dilated pupils, mild confusion, ashen color, & profuse diaphoresis - tx: - Place in cool area & remove constrictive clothing - Place moist sheet over patient to decrease core temperature - Monitor ABCs (possible dysrhythmias secondary to electrolyte disturbances) - Start oral fluids & electrolyte replacement (IV fluid if can't tolerate oral, IV fluid bolus for hypotension) - Consider admission if older adult, chronically ill, or if do not improve w/in 3 to 4 hrs
Chest tube set-up
- Collect fluid, air, and/or blood from the thoracic cavity *1st compartment (collection chamber)* - Receives fluid and from the pleural or mediastinal space - Drained fluid stays in this compartment while expelled air vents to the 2nd compartment *2nd compartment (water-seal chamber)* - Contains 2cm of water acts as a 1 way valve - Incoming air enters the collection chamber & bubbles up through the water - Water prevents backflow of air into the pt - *Brisk bubbling often occurs w/ a pneumothorax is initially evacuated* - *Intermittent bubbling during exhalation, coughing, or sneezing may be observed as long as there is air in the pleural space* - *When air leak resolves and lung becomes more fully expanded, bubbling ceases* - *Normal fluctuation of water w/in the water-seal chamber is called tidaling; this up and down movement in concert w/ respiration reflects intrapleural pressure changes during inspiration and expiration * - *Investigate any cessation of tidaling, since this may signify an occluded chest tube* *3rd compartment (suction control chamber)* - Applies suction to chest drainage system
Hypothermia
- Core temperature <35ºC - Occurs when heat produced by body cannot compensate for heat lost to environment - Most body heat is lost as radiant energy, w/ greatest loss from head, thorax, & lungs - Wet clothing increases evaporation heat loss to 5x greater than normal
What is the protocol for internal hemorrhage?
- Diffuse blood products rapidly - Prepare for surgery
Describe hypertonic salt water
- Draws fluid from the vascular space==>alveoli, impairing alveolar ventilation ==> hypoxia - Body compensates for hypoxia by shunting blood to the lungs; this results in increased pulmonary pressures and deteriorating respiratory status - More and more blood is shunted through the alveoli, however, the blood is not adequately oxygenated, and hypoxemia worsens - Can result in cerebral injury, edema, and brain death
Full Thickness Skin Destruction (3rd & 4th degree burns)
- Dry, waxy white, leathery, or hard skin - Visible thrombosed vessels - Insensitivity to pain because of nerve destruction - Possible involvement of muscles, tendons, & bones *Involved All skin & local nerve endings * - Coagulation necrosis present - Surgical intervention required for healing.
What are nutrition requirements during the emergent phase of burns?
- Early & aggressive nutritional support w/in several hours - Basal metabolic rate is 40-100x higher than normal w/ burn injury - Maintain NPO status until bowel sounds are heard, & then advance to clear liquids as prescribed - high protein, carbohydrates, fats, & vitamins, w/ major burns requiring more than 5000 calories/day - Monitor calorie intake & daily weights
Gastric Lavage
- Elevate HOB or place patient on side to prevent aspiration - If altered LOC or diminished gag reflex, intubate before performing lavage - If ingested caustic agents, co-ingest sharp objects, or ingest non-toxic substances then DO NOT lavage - Perform w/in 1 hr of ingestion of poison - Risky * concern for esophageal perforation and aspiration*
Emergency Management Thermal Burns INTERVENTIONs
- Elevated burned limbs above heart to decrease edema - Insert indwelling urinary catheter if burn >15% TBSA - Establish IV access w/ 2 large bore catheters if burn >15% TBSA - Ancticipate intubation
Emergent phase of burn managemnent
- Emergent (resuscitative) phase is time required to resolve the immediate, life-threatening problems resulting from burn injury - Lasts up to 72 hrs from the time the burn occurred - Primary concerns= onset of hypovolemic shock & edema formation -massive shift of fluids out of the blood vessels as a result of increased capillary permeability ( 20 min post-burn) - Na/protein plasma proteins (albumin) move into interstitial spaces & tissue, hemolysis, hyperkalemia, hyponatremia--> edema - result is intravascular volume depletion: there is enough fluid its just not where its suppose to be *great risk for infection*
What are the phases of burn management?
- Emergent/Resuscitative Phase - Acute Phase - Rehabilitation Phase
What is the nursing management for the rehabiliation phase?
- Encourage both patient and caregiver to participate in care - If needed, arrange home care nursing to assist w/ care - Give advice on scar management, moisturizing, & sun protection - *Suggest using water-based creams that penetrate into the dermis (Vaseline Intensive Rescue) for moisture and reduce itching - encourage pt to maintain; recovery can be slow REHABILITATION MAY HAVE TO BE THE PRIMARY GOAL FOR AT LEAST THE NEXT 6-12 MONTHS
Partial superficial thickness (1st degree)
- Erythema - blanching on pressure - pain & mild swelling - no vesicles or blisters (although after 24 hr skin may blister & peel). *Epidermis involved*
EMTALA
- Every person that comes into the ED has to be seen by a provider - 2 providers must ok procedures if patient cannot give consent - protects patient privacy
Partial thickness Deep (2nd degree)
- Fluid-filled vesicles that are red, shiny, wet (if vesicles have ruptured). - Severe pain caused by nerve injury - Mild to moderate edema. *epidermis and dermis involved*
What is a primary survey? What takes priority over this? What does disability refer to ?
- Focuses on ABCDEFs (rapid ax of anything that could kill the pt 1st) - Hemorrhage - Neuro status
What are the cold related emergencies and the contributing factors?
- Frostbite (localized) - Hypothermia (systemic) - Contributing factors - age - duration of exposure - environmental temperature - homelessness - pre-existing conditions - drugs that suppress shivering (opioids, anti-emetics) - alcohol intoxication
What are the 3 heat- related emergencies?
- Heat stroke - Heat cramps - Heat Exhaustion
What are the different type of insect bites?
- Hymenopteran Stings - Tick bites - Animal & human bites
What are the clinical manifestation of emergent phase of burns?
- Hypovolemic shock - Patients w/ larger burn may develop a paralytic ileus, w/ absent or decreased bowel sounds - Shivering may occur as a result of chilling that is caused by heat loss, anxiety, or pain
Chest tubes
- If enough fluid or air accumulates in the pleural space, the negative pressure becomes positive and the lungs collapse - Chest tubes are inserted to reestablish negative pressure and allow for proper lung expansion - May also be inserted in the mediastinal space to drain air and fluid postoperatively
Traige colors during mass casualty incident
- Immediate is priory and is red - Delayed is priority 2 and yellow - Minimal is Priority 3 and green - Expectant is priority 4 and black
Deep Frostbite (where does it occur on body, sx, tx?)
- Involves muscle, bone, & tendon - white, hard, insensitive skin tx: - After re-warming elevate extremity to reduce edema significant edema may begin w/in 3 hrs w/ blistering in 6 hrs to days - IV analgesia - Amputation may be required if injured area is untreated or treatment is unsuccessful **May take as long as 90 days for final demarcation of necrotic area; pt may be admitted for observation w/ bedrest, elevated of injured body parts, and prophylactic antibiotics if wound at risk for infection
ESI level 5
- Low resource - Examination only - Delayed Cold symptoms, minor burn, recheck (e.g. wound), prescription refill
Tick Bites
- Lyme disease, Rocky Mountain spotted fever, & tick paralysis - Ticks release neurotoxic venom as long as the tick head attaches to the body==> safe removal of tick is essential for effective treatment
Lyme disease
- Lyme disease==> Most common tick-borne disease in the US - Symptoms appear w/in days of bite from a Ixodid (hard) tick that has been attached for at least 48 hrs
Inserting an Oropharyngeal Airway
- Measure the airway alongside the head (should reach from lip to ear) - Extend head place one hand under the bony chin (only if the cervical spine is uninjured). - With the other hand, tilt the head back by applying pressure to the forehead while lifting the chin forward. - Open the patient's mouth. - Insert the oropharyngeal airway with the tip facing up toward the roof of the mouth until it passes the uvula. - Rotate the tip 180 degrees so that the tip is pointed down toward the pharynx. This displaces the tongue anteriorly, and the patient then breathes through and around the airway. An alternate method is to use a tongue blade to hold the tongue and insert the oropharyngeal airway directly without rotation. - The distal end of the oropharyngeal airway is in the hypopharynx, and the flange is approximately at the patient's lips. Make sure that the tongue has not been pushed into the airway.
Activated Charcoal
- Most common & effective intervention - Administer orally or via gastric tube w/in 1 hr of poison ingestion - Many toxins adhere to charcoal & pass through GI tract rather than being absorbed into the circulation - Adults receive 50-100g of charcoal - Contraindications: - Diminished bowel sounds, paralytic ileus, & ingestion of substance poorly absorbed by charcoal
Animal & Human Bites
- Most significant problems are infection and mechanical destruction of skin, muscle, tendons, blood vessels, & bone -Assess q15-30 if bitten by snake, spider -Give opioids for nsake bite Dog bites: - May involve significant tissue damage w/ deaths reported (usually small children) Plastic surgery consult for wounds to face Cat bites: - Cause deep puncture wounds that can involve tendons & joint capsules - Cause more infection than dog bites Pasteurella species most common causative organism Human bites: - Carry high risk of infection from oral bacterial flora, most commonly Staph, Strep, and hepatitis virus - Frequently result of violence or sexual activity Boxer's fracture ( fracture of 4th or 5th metacarpal (punch)) - often have concurrent open wounds on knuckles from striking teeth - Infection rates as high as 50% when victims do not seek medical care w/in 24 hrs of injury
The nurse's role in disaster triage
- Nurses may be asked to perform duties outside their areas of expertise and may take on responsibilities normally held by physicians or advanced practice nurses - A nurse may serve as the triage officer - New settings and atypical roles for nurses arise during a disaster (For example, may provide shelter care in a temporary housing area or bereavement support and assistance with identification of deceased loved ones)
Tick Paralysis
- Occurs 5-7 days after exposure to neurotoxin introduced by a wood tick or dog tick - Classic manifestations include flaccid ascending paralysis, - Without tick removal patient diets as respiratory muscles become paralyzed - Tick removal leads to return of muscle movement, usually within 48-72 hrs
Frostbite
- Peripheral vasoconstriction = decrease blood flow & vascular stasis - Depth of frostbite depends on ambient temperature, length of exposure, type and condition (wet or dry) of clothing, & contact w/ metal surfaces
Rocky Mountain Spotted Fever
- Pink macular rash appears on palms, wrists, soles, feet, & ankles w/in 10 days of exposure -Also c/o fever, chills, malaise, myalgias, and HA - Doxycycline is treatment of choice
What are forensic protocols with criminal trauma incidents?
- Place each piece of clothing in its on paper bag - don't cut through/tear any parts of clothing - do not place evidence in plastic bag - evidence is not left unattended - do not give clothing to family - place bags over deceased pts hands
Personal & Professional Preparedness
- Plan a meeting place for family members - Identify where to go if an evacuation is necessary - Determine when & how to turn off water, gas, & electricity at main switches - Locate the safe spot in the home for each type of disaster - Replace stored water supply every 3 months & stored food supply every 6 months
What are patient risk factors r/t burns?
- Pre-existing heart, lung, or kidney disease = poorer prognosis for recovery - Diabetes or PVD = poor healing, especially w/ foot or leg burns - General physical weakness from chronic disease challenging for pt to fully recover - Also, a burn patient who also sustained injuries such as fractures, head injuries, or other trauma will also have a more difficult recovery
If a patient has CO poisoning, what vital sign can you not rely on?
- Pulse ox - *OBTAIN ABGS*
Describe hypotonic fresh water
- Rapidly absorbed into circulatory system through the alveoli - Often contaminated w/ chlorine, mud, or algae - causes breakdown of lung surfactant, fluid seepage, and pulmonary edema
Lightning injury
- Result from a direct strike, a high-voltage DC injury, or a side flash wherein the current discharges from an object nearby through the air to an adjacent object or person - Respiratory & cardiac arrest common
Chemical Burns
- Result of contact w/ acids, alkalis, and organic compounds - Acids (hydrochloric acid, oxalic, and hydrofluoric acid) - Alkali burns more difficult, adheres to tissue, causing protein hydrolysis and liquefaction - Alkalis found in cement, oven and drain cleaners, and heavy industrial cleaners - Organic compounds - phenols (chemical disinfectants) and petroleum products (creosote & gasoline), produce contact burns and systemic toxicity
Heat Stroke *most severe* (Causes, sx, effects on body, how does it cause death?, tx)
- Results from failure of hypothalamic thermo-regulatory processes - Increased sweating, vasodilation, and increased respiratory rate deplete fluids & electrolytes (specifically sodium) - sweat glands stop functioning & core temperature increases rapidly within 10-15 minutes - Objective: core temperature >105.3, altered mental status, absence of perspiration, & circulatory collapse - Neurologic symptoms due to brain sensitivity to thermal injuries, hallucinations, loss of muscle coordination, combativeness - Death directly relates to amount of time the patient's body temperature remains elevated - patients are at risk for rhabdomylsis tx: - Goal stabilize ABCs and rapidly reduce core temperature - Supplemental O2 to compensate for hypermetabolic state - Correct fluid & electrolyte imbalances & monitor for dysrhythmias - Cooling methods: (1) remove clothing, cover w/ wet sheets, place in front of large fan, (2) immersing in cool bath water, (3) applying ice packs to the groins & axillae, or (4) peritoneal lavage w/ iced fluids - Control shivering (shivering increases body temp) w/ IV chlorpromazine (Thorazine) - Monitor for rhabdomyolysis caused from breakdown of skeletal muscle
Botulism
- Serious paralytic illness cause by nerve toxin produced by the bacterium Clostridium bolulinum - Spores found in soil and can be spread through the air or food (improperly canned food) or via contaminated wound - Botulism cannot be spread from person to person - Neurologic symptoms begin 12-36 hrs after ingestion of food borne botulism and 24-72 hrs after inhalation & can progress to paralysis of the arms, legs, trunk, or respiratory muscles - If diagnosed early food-borne and wound botulism can be treated w/ an antitoxin - Other treatments include induction of vomiting, enemas, and PCN - No vaccine is available
ESI Level 4
- Stable - no threat - Low resource - One diagnostic study - Delayed Closed extremity trauma, simple laceration, cystitis Ex. Knee pain
ESI level 3
- Stable - unlikely but possible threat - Complex procedures - Multiple resources (labs, pt, ot etc.) - Seen up to 1 hr Chest pain probably resulting from ischemia, multiple trauma unless responsive Ex. abdominal pain or GYN issues
What is suction generated by? Does an increase in wall suction increase suction of the chamber>
- Suction is only generated by amount of water - No
What are the 2 partial thickness skin destructions?
- Superficial 1st degree - Deep 2nd degree
Types of Burn Injury
- Thermal burns - Chemical burns - Smoke & Inhalation Injury - Electrical Burns - Cold Thermal Injury
What are pre-hospital and emergency (general) interventions for burns?
- To prevent hypothermia, cool large burns for no more than 10 min - Do not immerse burned body part in cool water because it may cause extensive heat loss - Never cover a burn w/ ice may cause hypothermia & vasoconstriction of blood vessels, thus further reducing blood flow to injury - Gently remove as much burned clothing as possible to prevent further tissue damage - Leave adherent clothing in place until patient is transferred to hospital - Wrap pt in dry, clean sheet or blanket to prevent further contamination of the wound and to provide warmth *DO NOT RUB BURN CREAM ON BURN*
Smallpox
- Transmitted in air droplets and by handling contaminated materials - Highly contagious - Symptoms begin 7-17 days after exposure & include fever, back pain, & vomiting, malaise, and headache - Papules develop 2 days after symptoms develop and progress to pustular vesicles that are abundant on the face & extremities initially - Vaccine is available to those at risk for exposure to smallpox
ESI level 1
- Unstable - Obvious organ threat Cardiac arrest, intubated trauma patient, overdose w/ bradypnea, severe respiratory distress
Superficial frostbite (where does it occur on body, sx, tx?)
- Usually ears, nose, fingers, & toes - tingling, numbness, or a burning sensation tx: - Immerse in water37-40ºC - Avoid heavy blankets & clothing because friction & weight can lead to sloughing of damaged tissue -Rewarming is painful! (residual pain may last weeks to years) - Give analgesia & tetanus prophylaxis as appropriate
Biological warfare agents
- a biologic or chemical substance that can cause mass destruction or fatality - Can be used for sabotage, such as food or water contamination with a small target area, or may be used by global terrorists with intentions to enable global objectives
Hymenopteran Stings (what insects are includd, what does it causes, sx?, t, pt)
- bees, yellow jackets, hornets, wasps, & fire ants - cause mild discomfort or life-threatening anaphylaxis - Symptoms can be immediate or delayed up to 48 hrs sx: - stinging - burning - swelling - itching - edema - HA - fever - syncope - malaise - N/V - wheezing - bronchospasm - laryngeal edema - hypotension Tx: Depends on severity of reaction Mild reactions - elevation - cool compresses - antipruritic lotions, & oral antihistamines Severe reactions - IM or IV antihistamines (diphenhydramine) - SC epinephrine, or corticosteroids (dexamethasone) Basic Safety if Stung: - Remove stinger using scraping motion w/ fingernail, knife, or needle - Avoid using tweezers because may squeeze the stinger & release more venom - Remove rings, watches, or any restrictive clothing around the sting site
Heat cramps (Causes, sx, who does this effect?, tx, pt teaching?) *not severe*
- caused by heavy work (cramps occur fast/intense during rest) - Nausea, tachycardia, pallor, weakness, & profuse diaphoresis - athletes w/ inadequate fluid intake - Replace sodium and water - avoid strenuous activity for at least 12 hrs - emphasize salt replacement
What are the Pathophysiologic Skin Changes of Wound Healing?
- darker pigment = longer color recovery (skin does not regain its original color) - Scarring has 2 characteristics discoloration & contour (Discoloration fades over time) - Altered contours (no longer flat or slightly raised) - gentle pressure is maintained on wound w/ custom fitted garments & masks. - pressure garments worn up to 24 hrs a day for as long as 12-18 months - Itching water-based moisturizers & short term use of antihistamines - newly healed areas can be hypersensitive or hyposensitive until peripheral nerve regeneration occurs - Protect healed burn areas from direct sunlight for about 3 months to prevent hyperpigmentation & sunburn injury - always wear sunscreen
What is the role of the nurse during sexual assault admissions? What role does the nurse play in suspected violence?
- evidence collection and advocation Violence: - Making referrals - Notifying appropriate agencies (required by law) - Providing emotional support - Informing victims about their options (e.g. safe house, legal rights)
What are signs of internal hemorrhage?
- tachycardia, falling blood pressure, thirst, apprehension, cool and moist skin, or delayed capillary refill *FCCATT*
What are the goals of hemorrhage in emergency management? Where can blood from an internal hemorrhage build up?
- to control the bleeding - maintain adequate circulating blood volume for tissue oxygenation - prevent shock - (retroperitoneum, pelvis, chest, and thighs) *CPRT*
Skin & Ocular Decontamination
- water or saline - Wear PPE for decontamination to prevent secondary exposure - Decontamination usually done before the patient arrives at the hospital and again at the hospital - Decontamination takes priority over all interventions except those needed for basic life support
ESI level 2
-Threatened -Not always obvious - Multiple, complex diagnostic studies - Frequent consultation - Continuous monitoring - Seen Within 10 mins Chest pain probably resulting from ischemia, multiple trauma unless responsive
Parkland's formula
4mL/kg *TBSA burn ½ of total in 1st 8 hrs ¼ of total in 2nd 8 hrs ¼ of total in 3rd 8 hrs
Define Blast injury
A blast may result from terrorism but can also occur anywhere at any time if the right (or wrong) circumstances come together (e.g., welding inside of a tank that formerly contained tar but was not properly cleaned can result in an explosion as well as severe tar burns to the worker)
What mechanism occurs in the body as core temperature drops?
As core temperature drops==> metabolic rate decreases ==>cold myocardium is extremely irritable making it vulnerable to dysrhythmias (atrial and ventricular fibrillation)
What are 3 types of smoke and inhalation injuries?
Asphyxiation Upper airway injury Lower airway injury airway compromise & pulmonary edema can develop over the 1st 12-24 hrs *Always assess airway, lung damage can lag*
If the patient can breathe and cough spontaneously what should you have them do?
Cough forecefully
What are submersion injury tx?
Goal : correct hypoxia and fluid imbalances, support basic physiologic functions, and rewarm if hypothermia is present tx: - Mechanical ventilation w/ PEEP or CPAP to improve gas exchange across the alveolar-capillary membrane when significant pulmonary edema is present - Mannitol or furosemide to treat cerebral edema or decrease free water
Fasciotomy aka Escharotomy
High pressure from burn, cut skin to relieve pressure *Not Painful* *Goal is return of distal pulses*
What is the triad of death?
Hypothermia, acidosis and coagulability
How can you tell if the patient has an air leak?
If you want to know if the patient has an air leak and the suction is causing bubbling, turn off wall suction to see if bubbling persists, if so air leak
Expectant triage priority 4 black
Injuries are extensive, and chances of survival are unlikely even with definitive care. Persons in this group should be separated from other casualties, but not abandoned. Comfort measures should be provided when possible. - Unresponsive patients with penetrating head wounds - high spinal cord injuries - wounds involving multiple anatomic sites and organs - 2nd/3rd degree burns in excess of 60% of body surface area - seizures or vomiting within 24 hours after radiation exposure - profound shock with multiple injuries - agonal respirations - no pulse, no blood pressure, pupils fixed and dilated
Immediate triage (Priority 1, red)
Injuries are life threatening but survivable with minimal intervention. Individuals in this group can progress rapidly to expectant if treatment is delayed. - Sucking chest wound - airway obstruction secondary to mechanical cause - shock - hemothorax - tension pneumothorax - asphyxia - unstable chest and abdominal wounds - incomplete amputations - open fractures of long bones - 2nd/3rd degree burns of 15%-40% total body surface area
Minimal triage priority 3 (Green)
Injuries are minor, and treatment can be delayed hours to days. Individuals in this group should be moved away from the main triage area - Upper extremity fractures - minor burns - sprains - small lacerations without significant bleeding - behavioral disorders or psychological disturbances
Delayed triage priority 2 (yellow)
Injuries are significant and require medical care but can wait hours without threat to life or limb. Individuals in this group receive treatment only after immediate casualties are treated. - Stable abdominal wounds without evidence of significant hemorrhage - soft tissue injuries - maxillofacial wounds without airway compromise - vascular injuries with adequate collateral circulation - genitourinary tract disruption - fractures requiring open reduction - débridement - external fixation; most eye and central nervous system injuries
What is often a priority before a medical diagnosis is made?
Interventions to reverse or prevent a crisis
What are health care facilities required to do for preparation for emergency?
JCO requires health care facilities have a plan of emergency in place to practice at least twice a year
Fema Level of Disasters
Level I: Massive, significant damage & results in a presidential declaration, w/ major federal involvement & full engagement of federal, regional, & national resources Level II: Moderate disaster, presidential declaration of an emergency, moderate federal assistance Level III: Minor disaster, a minimal level of damage, but could result in a presidential declaration of an emergency
What is the most common cause of airway obstruction?
Meat
what ages are involved more commonly in submersion injuries? what are risk factors for? How does this end?
Most victims are children <5 or males between ages 15-25 *** inability to swim, use of alcohol or drugs, trauma, seizures, hypothermia, stroke, and child neglect Acute resp. distress syndrome
What are the common chemical agents? (Actions, S/sx, tx)
Nerve Agents - Sarin - Soman Action: Inhibition of cholinesterase S/sx: Increased secretions, gastrointestinal motility, diarrhea, bronchospasm Decontamination and treatment: Soap and water Supportive care Benzodiazepines Pralidoxime *Atropine*
What is the order of survey of trauma patients vs non trauma patients?
Primary then secondary (trauma) Primary then focused (non- trauma)
Phases of blast injury
Primary: Results from pressure wave - Pulmonary barotraumas, including pulmonary contusions - Head injuries, including concussion, other severe brain injuries - Tympanic membrane rupture, middle ear injury - Abdominal hollow organ perforation, hemorrhage Secondary: Results from debris from the scene or shrapnel from the bomb - Penetrating trunk, skin, and soft tissue injuries - Fractures, traumatic amputations Tertiary: Results from pressure wave that causes the victim to be thrown - Head injuries - Fractures, including skull
NCLEX Prep: Summary of Burn Management
Priority Nursing actions: 1. Assess for airway patency 2/ Administer oxygen as prescribed. 3. Obtain vital signs 4. Initiate IV line & begin fluid replacement as prescribed 5. Elevate extremities if no fractures are obvious 6. Keep client warm & place the client on NPO status 7. Tetanus toxoid may be prescribed for prophylaxis *Primary goal for a burn injury is to maintain a patent airway, administer IV fluids to prevent hypovolemic shock, & preserve vital organ functioning*
What is one of the most important goals of the Emergency nursing?
Recognition of the life-threatening injury
Electrical Burns
SEVERITY OF ELECTRICAL INJURY CAN BE DIFFICULT TO DETERMINE, SINCE MOST OF THE DAMAGE IS BELOW THE SKIN *Do Primary and secondary survey* - Delayed dysrhythmias or arrest can also occur w/o warning during 1st 24 hrs after injur - Patient at risk for dysrhythmias or cardiac arrest, metabolic acidosis, & myoglobinuria
What is the #1 priority when dealing with violent/difficult patients in the ED?
Safety
What is the top priority when their is gunfire?
Self protection
SANE
Sexual assault nurse examiner
Tick bite stages
Stages: - 1st stage: flu-like symptoms (HA, stiff neck, fatigue), maybe bull's eye rash tx: doxycycline - Later stages: monoarticular arthritis, meningitis, & neuropathies occur days or weeks after initial manifestations tx: ceftriaxone (Rocephin) Chronic arthritis,k peripheral radiculoneuropathy, & heart disease occur
What kind of precautions must be used by all providers in the ED?
Standard
What are the 2 steps of decontamination?
Step #1: Removal of the patient's clothing and jewelry and then rinsing the patient with water Step #2: Consists of a thorough soap-and-water wash and rinse
What are the 2 submersion injuries?
Submersion Injury Drowning
What is an emergency system index?
Triage tool used to standardize triage across the country (5 levels )
What is the incident command system?
a federally mandated command structure that coordinates personnel, facilities, equipment, and communication in any emergency situation "the center" Decides which patients go to which hospitals in disaster
What are mass casualty incidents?
any incident that causes a large numbers of casualties to the extent that necessary resources become too scarce casualties >resource capabilities "the greatest good for the greatest number of patients"
Endotracheal Intubation used for? *
bypass an upper airway obstruction and secretion removal
Rule of nines
circumferential burns
Hemodialysis
for patients w/ severe acidosis from ingestion of toxic substances (e.g. Aspirin)
If patient demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis what do you do?
manage as if there were complete airway obstruction
Tricyclic antidepressants (eg. Amitriptyline)
sx: - In low doses: anti-cholingeric effects, agitation, hypertension, tachycardia In high doses: CNS depression, dysrhythmias, hypotension, respiratory depression tx: - Multi-dose activated charcoal, gastric lavage, serum alkalinization w/ sodium bicarbonate, intubation & MV, supportive care; never induce vomiting *TRICYCLIC AND ANTIDEPRESSANT OVERDOSES UNDERGO CONSTANT EKG MONITORING*
Bleaches (SX, TX?)
sx: - Irritation of lips, mouth, & eyes, superficial injury to esophagus, chemical pneumonia & pulmonary edema tx: - Washing of exposed skin & eyes, dilution w/ water & milk, gastric lavage, prevention of vomiting & aspiration
Carbon monoxide (sx?, tx?)
sx: Dyspnea, HA, tachypnea, confusion, impaired judgment, cyanosis, respiratory depression tx: Removal from source, administration of 100% O2 via NRB, BMV, or intubation and MV, consider hyperbaric O2 therapy
