Emergency and Disaster Nursing
OB Patients •EMERGENT OB- •URGENT OB- ... •NON-URGENT- .... • •Most OB patients can be transferred to labor and delivery via wheelchair, usually patients 20 weeks gestation and greater are evaluated in labor and delivery or by the obstetrician. • •It is important to know, per hospital policy,...
"Presenting part" must be delivered in the ED. •prepare for delivery if the patient is multi-gravida, completely dilated, or complains of rectal pressure. Patients in active labor •Contractions two minutes apart lasting 60 to 90 seconds, presence of bloody show. Patients not in active labor, per hospital policy who can transport patients to L&D
Emergency Severity Index 5 Level Triage •Level 1 - Resuscitation ... •Level 2 - Emergency ... •Level 3 - Urgent ... •Level 4- Semi-... •Level 5 - Non- ...
0 minutes 10 minutes 30 minutes Urgent 60 minutes Urgent >60 min.
Hypothermia •Core temperature <95º F (<35º C) •Risk factors •... •... •.... •...) •...1 •Core temperature... F (30º C) is potentially life-threatening.
Advanced age Certain drugs Alcohol intoxication Cold water immersion(near-drowning Shock, Trauma <86º
ETOH •ETOH - OD •Fluids •Alcohol Withdrawal Syndrome/Delirium tremens •Management •... (Librium) •... (Ativan) •... (Catapres) •... (Haldol) •... (Zofran) •IVFs - banana bag -..... •
Chlordiazepoxide Lorazepam Clonidine Haloperidol Ondansetron vits and min, thiamine, folic acid, mag sulfate
What Do I Do In Triage?
Introduce yourself Confirm the patient's identity Obtain a chief complaint / reason for the visit Gather subjective and objective data Perform a rapid, concise, focused assessment, with quick primary and secondary survey - for trauma patients. For nontrauma the primary survey is followed by a focused assessment.
Emergency Severity Index ESI Level 5
Healthy 10 y/o c "poison ivy" Healthy 52 y/o ran out of BP meds yesterday 22 y/o, MVC 2 days ago, wants to be "checked out" 46 y/o c a "cold"
Chemical Agents of Terrorism •Categorized by target organ or effect •...: yellow to brown in color with garlic-like odor •Irritates... •Remove clothing and wash skin with ... •Decontaminate with..
Mustard gas eyes and causes skin burns/blisters soap and water soap and water unless it is lyme
NOP •N:... •O: ... •P:
Nasogastric tube to decompress and empty the stomach, reduce the risk of aspiration, and test the contents for blood. Place an orogastric tube in a patient with significant head or facial trauma, since a nasogastric tube could enter the brain. Oxygenation and ventilation assessment. Continuously monitor O2 saturation and end-tidal carbon dioxide if intubated Pain assessment and management
•Life threat or organ threat ESI-1: ESI-2: ESI-3: ESI-4: ESI-5:
Obvious Likely but not always obvious Unlikely but possible No No
Mechanism of action -Give comfort measures. Pain management strategies— combination of ... -History and head-to-toe assessment Obtain history of ... Perform...assessment to obtain information about all other body systems.
Pharmacologic measures Nonpharmacologic measures event, illness, injury from patient, family, and emergency personnel. head-to-toe
EMTALA: Emergency Medical Treatment and Active Labor Act
Requires a hospital to provide an appropriate medical screening exam to any person who comes to the emergency department and request treatment or an examination for medical condition. If the examination reveals an emergency medical condition, the hospital must also provide either necessary stabilizing treatment or appropriate transfer to another medical facility. EMTALA - EMTALA imposes financial penalties on physicians and hospitals who do not comply
Main Areas to Assess •.... •.... •.... •Are they ambulatory (Can you move all extremities) •Yes=.... •No= ....
Respiration Pulse Mental status Green Yellow
Decision- ESI Level 3 •How many resources will this patient require? ...
•Based on the standard of care •Independent of type of hospital, location, physician on duty, acuity of the department
Hypothermia •Severe (...F [30º C]) makes the person appear dead. • ... •... •... •... •... •Rewarming methods ... to ...
<86º Bradycardia Decreased resp Severe hypotension Ventricular fibrillation Asystole internal to external.
Emergency Severity Index ESI Level 4
A healthy 19 year old with a sore throat and fever. A healthy 29-year-old with a UTI, denies vaginal discharge. A healthy 43-year-old with a stubbed toe who states "I think I broke it!". A healthy 12-year-old with a minor thumb laceration.
Primary Survey •D-Disability: measured by patient's level of consciousness •AVPU *A = .. *V = ... *P = ... *U = .... •Not accurate with ... what other assessment measures?
Alert Responsive to voice Responsive to pain Unresponsive intubated or aphasic patients •Glasgow coma scale •Pupils •Assess size, shape, equality, and reactivity
Pandemic Global and Domestic Preparedness: Pandemic Contagions - ... is the nation's leader in public health preparedness and response to disease pandemics. ... fights contagions at home and abroad, continuing to enhance our ability to rapidly detect new viruses and improve federal, state, and local pandemic readiness.
CDC CDC
Secondary Survey Brief, systematic process to identify all injuries Full set of vital /Facilitate family presence. FAST ultrasound ...
Complete set of vital signs Blood pressure (bilateral) Heart rate Respiratory rate Oxygen saturation Temperature collect blood for lab studies insert orogastric and nasogastric tube insert indwelling catheter ECG monitoring identify all injuries brief and systemic
Emergency and Mass Casualty Incident Preparedness •Response to MCIs often requires the aid of a federal agency such as the ... •Section within the U.S. Department of Homeland Security that is responsible for... •Ongoing education and mandated drills •.... - management and communication •....: organizes and trains volunteer disaster medical assistance teams (DMATs) •DMATs: ....
National Incident Management System (NIMS). coordination of the federal medical response to MCIs Incident Command System National Disaster Medical System categorized according to ability to respond to an MCI
Snakebites - Call ...
POISON CONTROL
Heatstroke vs. Heat Exhaustion Heat Exhaustion Symptoms & Warning Signs ... Heat Stroke Symptoms & Warning Signs ...
Pale, cool, clammy skin Profuse sweating Core body temperature usually is elevated to more than 100 F (37.7 C), but not above 104 F (40 C) Dizziness or lightheadedness Flushed, hot, dry skin The person may no longer sweat due to dehydration. Core body temperature is >104 F (40 C) or more. Fainting, confusion, coma Blood pressure changes (may be high or low) Hyperventilation (rapid breathing)
Sample
Symptoms Allergies Medication history - Pharmacy Past health history - may come from family and friends Last meal/oral intake Events or environmental factors leading to illness or injury
•Stability of vital functions Definition Stability of vital functions (ABCs) ESI-1: ESI-2: ESI-3: ESI-4 ESI-5
Unstable Threatened Stable Stable Stable
Heat stroke •Failure of the hypothalamic thermoregulatory processes •... deplete fluids and electrolytes, specifically sodium. •... stop functioning, and core temperature increases (...). S/S
Vasodilation, increased sweating, and respiratory rate Sweat glands >104º F [40º C] •Confusion, bizarre behavior, seizures or coma •Hypotension, Tachycardia and Tachypnea •Skin is hot and dry - ashen •Hallucinations, combativeness, loss of coordination •Cerebral edema and hemorrhage
Primary Survey •A-Airway with cervical spine ... and/or ... •Signs/symptoms in patient with compromised airway ...
stabilization and/or immobilization •Dyspnea •Inability to vocalize •Gasping breaths •Presence of foreign body in airway •Trauma to face or neck
Family and Intimate Partner Violence •Pattern of coercive behavior in a relationship; involves fear, humiliation, intimidation, neglect, and/or intentional physical, emotional, financial, or sexual injury •Found in all professions, cultures, socioeconomic groups, ages, and genders •Most victims are ... •Screening for domestic violence is required in ... •Appropriate interventions - - -
women, children, elderly ED. •Make referrals. •Provide emotional support. •Inform victims about options.
Rewarming Risks ...
•Afterdrop, a further drop in core temperature •Hypotension •Dysrhythmias •Rewarming should be discontinued once the core temperature reaches 90 to 95º F (32 to 35º C). •They are never dead until they are warm and dead
Care of Emergency Patient Primary Survey •ABCDEFG ...
•Alertness and airway with cervical spine stabilization and/or immobilization •Breathing •Circulation •Disability •Exposure and environmental control •Facilitate adjuncts and family •Get resuscitation adjuncts
Psychiatric Patients tell me about it
•All patients exhibiting aggressive behavior are considered dangerous unless proven otherwise. •Do not turn your back on these patients. •If they are aggressive - they are violent until proven otherwise •Speak in simple, direct, clear and concise terms •Do not overlook physical injuries or illnesses in psychiatric patients
Pediatric Patient Are Special
•Chief complaint •Immunizations •Allergies •Medications •PMH & Parents impression of the child •Events surrounding illness/injury •Diet bottles, ounces •Diapers •Symptoms
Terrorism •Involves overt actions for the expressed purpose of causing harm ....
•Disease pathogens (e.g., bioterrorism) •Chemical agents •Radiologic/nuclear, explosive devices •Decontaminate immediately Anthrax Evacuate Smallpox can be prevented or ameliorated by vaccination even when first given after exposure. Botulism Treat with antitoxin Plague
Heat Exhaustion Prolonged exposure to heat over hours or days •Clinical syndrome characterized by ...
•Fatigue •Nausea/vomiting •Extreme thirst •Feelings of anxiety •Hypotension, Tachycardia •Temp (<104º F) •> 104 - heat stroke •Dilated pupils •Mild confusion •Ashen color •Profuse diaphoresis
Decision: Level 2 PAIN •Examples of level 2 severe pain ...
•Kidney stone •Burn victim •Oncology patients •Possible dislocated shoulder, with deficits •Possible compartment syndrome
Heatstroke Complications ...
•MODS •Renal impairment •Monitor for signs of rhabdomyolysis, myoglobinuria = AKI •Severe electrolyte and acid-base imbalances •Coagulopathy •Disseminated intravascular coagulation
Altitude-Related Illness tx
•Move to a lower altitude •Supplemental Oxygen •Keep patient warm at all times
Violence •Acting out of emotions (e.g., fear or anger) to cause harm to someone or something ....
•Organic disease •Psychosis •Antisocial behavior
Cardiac Arrest and Therapeutic Hypothermia Goal core temperature .... A variety of methods are used ...
89.6º to 93.2º F (32º to 34º C) - 72 hours only Cold saline infusions Cooling devices Intubation and mechanical ventilation, invasive monitoring, and continuous assessment are required
Hypothermia •Warm patient to at least ... (32.2º C) before pronouncing dead. •Cause of death—... •Treatment of hypothermia •Manage and maintain ... •... patient. •Correct ... and ... •Treat ...s. •Treatment of choice for severe case is internal rewarming methods such as ...
90º F refractory ventricular fibrillation ABCs. Rewarm dehydration and acidosis cardiac dysrhythmias cardiopulmonary bypass and hemodialysis, warm IV fluids, NG irrigation, foley irrigation
Frostbite Treatment •Rapid rewarming in a water bath at temperature range of ... (37 to 40 C) •If no warming tub, then ... •Rewarming causes severe ..., give ... •... •Handle injured area gently and elevate ... •May require surgery to debride ...
98.6 to 104 degrees F hot towels pain analgesics, esp IV opiates and IV rehydration NSAIDS and tetanus above heart level to decrease tissue edema necrotic tissue
Corrective action •... improves survival of submersion victims. •Treatment of submersion injuries ...
Aggressive resuscitation efforts and the mammalian diving reflex •O2, intubation, CPR, and defibrillation •NG or orogastric tube for decompression •Correct acid-base and fluid imbalances. •Support basic physiologic functions. •Rewarm if hypothermia is present.
Examples ESI-1 ... ESI-2 ... ESI-3 ... ESI-4 ... ESI-5 ...
Cardiac arrest, intubated trauma patient, overdose with bradypnea, severe respiratory distress Chest pain from ischemia, multiple trauma unless responsive Abdominal pain or gynecologic disorders unless in severe distress, hip fracture in older patient Closed extremity trauma, simple laceration, cystitis Cold symptoms, minor burn, recheck (e.g., wound), prescription refill
Emergency and Mass Casualty Incident Preparedness -When an emergency or MCI occurs, first responders (e.g., police, emergency medical personnel) are dispatched. -Must have communication Triage of casualties differs from usual ... -Keep in mind: ... -Triage:...
ED triage and is conducted in <15 seconds. Greatest good for greatest amount of people survey the scene, treat victim's, stabilize, decontaminate
Go to 2ndary or interventions? •... and has become synonymous with beside ultrasound in trauma. •The FAST exam, per ATLS protocol, is performed immediately after the ... • Ultrasound is the ideal initial imaging modality because .... •The concept behind the FAST exam is that many life-threatening injuries cause...
FAST" is an acronym for Focused Assessment with Sonography in Trauma primary survey of the ATLS protocol. it can be performed simultaneously with other resuscitative cares, nearly perfect for recognizing intraperitoneal bleeding in hypotensive patients who need an emergent laparotomy and for diagnosing cardiac injuries from penetrating trauma, hemothorax or pneumothorax without the time delay caused by radiographs or computed tomography (CT). bleeding.0
Poisonings: Management •ABC's *Decrease absorption. •__________,_______________,_________________________ •... before lavage if altered... •Perform lavage within ... of ingestion of most poisons. •Contraindicated .... *Enhance elimination. •Administration... *Implement toxin-specific interventions per poison control center. *Hemodialysis for ...
Gastric lavage, hemodialysis, activated charcoal. Intubate level of consciousness or diminished gag reflex 2 hours •Caustic agents •Co-ingested sharp objects •Ingested nontoxic substances hemodialysis, urine alkalization, chelating agents, and antidotes promote the elimination of poisons. extreme acidosis
Goals for Disaster Training -The focus of disaster management training is generally on improving the technical skills of the participants, but also on personnel and team management. ... -It also aims to improve coordination of disaster response and the quality and availability of disaster management tools -Types of Disaster ...l (e.g. Earthquakes, Landslides, Tsunamis and Volcanic Activity) -... (e.g. Avalanches and Floods) -...(e.g. Extreme Temperatures, Drought and Wildfires) -... (e.g. Cyclones and Storms/Wave Surges) -... (e.g. Disease Epidemics and Insect/Animal Plagues)
Geophysical Hydrological Climatological Climatological Biological
•Expected resource intensity ESI-1: ESI-2: ESI-3: ESI-4: ESI-5:
High resource intensity Staff at bedside continuously Often mobilization of team response High resource intensity Multiple, often complex diagnostic studies Frequent consultation Continuous monitoring Medium to high resource intensity Multiple diagnostic studies (e.g., multiple laboratory studies, x-rays) or brief observation Complex procedure (e.g., IV fluids, drugs Low resource intensity One simple diagnostic study (e.g., x-ray) or simple procedure (e.g., sutures Low resource intensity Examination only
Black Widow Spider Bite: Hospital Care •... on bite immediately - NEVER... •Monitor vital signs •... pain medication •... for spasms •... prophylaxis •... agents •Treatment of ...
Ice heat Opioid Muscle relaxants Tetanus Antihypertensive pulmonary edema, uncontrollable hypertension, shock
•How soon should the HCP see the patient? ESI-1: ESI-2: ESI-3: ESI-4: ESI-5:
Immediately Within 10 min Up to 1 hr Could be delayed Could be delayed
Don't know what patient will enter the emergency department (ED) so must be prepared for many situations Including life threatening Unsafe for staff 141 million patients/year visit the ED, leading to overcrowding and long wait times 11.2 million admitted to the hospital Numbers increasing due to: ...
Inability to see a HCP An aging population Shorter hospital stays resulting in frequent readmissions Acute mental health crises ED and hospital closures Lack of or inadequate health insurance or a HCP
LM •L: ... •M: ...
Laboratory studies (e.g., type and crossmatch, complete blood count and metabolic panel, blood alcohol, toxicology screening, arterial blood gases [ABGs], coagulation profile, cardiac biomarkers, pregnancy [urine]). Monitor ECG for heart rate and rhythm.
Sexual Assault •Each year, more than 5 million women and 3 million men are treated in EDs for battery (assault) inflicted by spouses, caregivers, or individuals known to them. •As many as 20% of battered females are pregnant at the time of the assault. •Sexual Assault •Assessment and Diagnostic Findings •Management •.... - evidence •Don't underestimate ... •Specimen Collection - label carefully, .... bags only no plastic •Criminal Case •Specialized kit and training (....) •Treating Potential Complications of Rape •Follow-up Care •Prophylaxis against .....may be offered •...s in the form of an emergency contraceptive pill to prevent pregnancy may be prescribed after a pregnancy test is done
Physical Examination neuro status paper SANE nurses STDs Antipregnancy measures
TOXIN EXPOSURE •S= .... •L= ... •U= ... •D= ... •G= ... •E= ... •M= ... •+ ....
Salivation Lacrimation (Tearing) Urination Defecation/Diarrhea Gastrointestinal Distress Emesis Muscle Twitching Resp. Distress & Agitation
Decision: ESI Level 2 Determination is made on a brief interview, gross observations, "sixth sense".
Samples: Rule out PE Adolescent found confused Newborn c Fever Patients in SEVERE pain Rule out Ectopic Pregnancy Sexual Assault Patient Suicidal / Homicidal New onset confusion elderly Chest Pain / Known Cardiac Hx
Death •... - Spouse is dead •Important in preparing the bereaved to grieve (e.g., collecting belongings, viewing the body) •Determine if patient could be candidate for non-heart beating donation. •Tissues and organs (e.g., corneas, heart valves, skin, bone, kidneys) can be harvested from patient after death. organ donation nurses do this autopsy must be done if death was 24 hours after ed visit or suspected trauma or violence.
Simple and concrete communication
Chemical Agents of Terrorism •Categorized by target organ or effect •Phosgene: ... •If inhaled at high concentrations for long enough period, causes severe... •Decontaminate with ... unless it is lyme
colorless gas normally used in chemical manufacturing respiratory distress, pulmonary edema, and death soap and water
Heat Exhaustion •Place patient in ... area and ... clothing. •Place ... sheet over patient to decrease core temperature. •Provide ... fluid. •Draw blood for serum ... •Initiate .... solution if oral solutions are not tolerated.
cool remove constrictive moist oral electrolytes. 0.9% saline IV
Explosive Devices as Agents of Terrorism -Result in one or more of following types of injuries: ... $Blast injuries from supersonic overpressurization shock wave that results from explosion *Damage to the....
blast, crush, or penetrating (shrapnel) lungs, middle ear, gastrointestinal tract
Arthropod Bites and Stings •Brown recluse spider bites cause... •... •In 1-3 days, site becomes..., eschar forms •Rarely systemic effects- ...
cell damage Bleb or vesicle surrounded by redness and edema and resolve OR dark and necrotic rash, fever, chills, N&V, joint pain
•C-Circulation •Check__________________pulse (peripheral pulses may be absent because of injury or vasoconstriction) •Insert two large-bore IV catheters. •Consider ... •Initiate aggressive fluid resuscitation using ... •Active bleed - ... •If life-threatening hemorrhage, may give blood not cross-matched (... is the universal donor)
central CVL or intraosseous normal saline or lactated Ringer's solution pressure (hemorrhaging reorder your ABCDs) O negative
Roll and look for insidious issues 1/2 •Assess ... •Frequent evaluation for subtle changes in the abdomen is essential. •Motor vehicle crashes and assaults can cause blunt trauma. •Penetrating trauma tends to injure specific, solid organs (e.g., spleen) based on their trajectory. •.... any impaled objects. They need to be removed in a controlled environment such as an operating room. •Inspect the abdomen for ....
abdomen and flank areas. Stabilize bruising, petechiae, and ecchymosis.
Poisonings •Activated charcoal •Charcoal can ... give ASAP if not treated with antidote •Dose depends on ingested amount of poison typically... •Most effective intervention: ... •Contraindications •Diminished .. •Paralytic ... •Ingestion of ... •Do not mix with... •Watch for....
absorb and neutralize 1mg/kg administer orally or via gastric tube within 30 - 60 minutes of poison ingestion bowel sounds ileus substance poorly absorbed by charcoal milk. aspiration and vomiting.
Rewarming: •Moderate to severe hypothermia: ... •... •... •...
active core rewarming Use of heated, humidified oxygen Warmed IV fluids Peritoneal, gastric, or colonic lavage with warmed fluids
Emergency Drugs for Poisoning Naloxone (Narcan) Reverses the effects of ... May need to be repeated several times - why? Monitor patient for ...
all opiate drugs by competitively binding to opiate receptor sites short half life combative or violent behavior.
Poisonings •Treat the client first, then the poison •Identify poison- ... •Poison Control Center will advise to ... •...is no longer recommended for treatment at home; any ... in home should be ...
amount ingested, time of ingestion begin treatment at home or bring child in to ED Syrup of Ipecac Ipecac disposed of safely
Scorpions -Most species' venom effects typically self-limiting; best treated by ... -Bark scorpion sting inflicts ... -Assess vital signs -Continuous monitoring for symptom progression -Use ...on site to control pain -...agents -Treat fever with ... and ...blanket -... prophylaxis -Basic wound care Contact ...
analgesics, supportive management, basic wound care severe, potentially fatal systemic response ice pack Analgesic and sedative acetaminophen and cooling Tetanus Poison Control Center
Emergency and Mass Casualty Incident Preparedness -Emergency: -Disaster plan - priority to identify hazards Mass casualty incident (MCI) Manmade or natural event or disaster that overwhelms community's ability to respond with existing resources Need to know what resources are available - number of beds, staff, ambulances, helicopters. Etc.. Each person must also be aware of role ie. Outside sources, FEMA, Red Cross
any extraordinary event that requires a rapid and skilled response and can be managed by a community's existing resources Med-surg nurse, vs admin, vs ED nurse.
Care of Emergency Patient •Triage system (see Table 68-2 in the textbook) •Emergency severity index (ESI) •ESI-1: ... •Is the patient in imminent danger of dying? •ESI-2: .... •ESI-3, ESI-4, or ESI-5: ... Triage and Table 68-2 in the textbook.
assess for threats to life high-risk patient who should not wait to be seen number of anticipated resources needed
Emergency Drugs for Poisoning Flumazenil (Romazicon) Reversal agent for the respiratory depressant and sedative effects of ... First dose—Give ... Second dose—.... Third and subsequent doses—.... Monitor ... Apply ... precautions.
benzodiazepines 0.2 mg IV over 15 seconds. 0.3 IV over 30 seconds 0.5 mg IV q1 min until desired clinical response is achieved or total dose of 3 mg respirations, BP, mental status. seizure
Animal and Human Bites •Initial treatment: clean with ... •... for bites at risk for infection •Wounds over joints - ... •Wounds older than 6 to 12 hours old •Puncture wounds -... •Lacerations - ... •Bites on hand or foot •Rabies postexposure prophylaxis essential in management of animal bites •Initial injection: ... •Series of ...
copious irrigation, debridement, tetanus prophylaxis, and analgesics Prophylactic antibiotics splint leave open suture loosely rabies immune globulin (one dose) four injections of human diploid cell rabies vaccine: days 0, 3, 7, and 14
•B-Breathing •Is the patient's airway obstructed or partially obstructed? •How is the patient's breathing? •Are they apneic? Intubated prehospital? Severe respiratory distress? Oxygen saturation less than 90%? •Assess for .... •Every critically injured or ill patient has an increased metabolic and oxygen demand and should have ... •Administer .... •... with ... for life-threatening conditions •Monitor patient response.
dyspnea, cyanosis paradoxic/asymmetric chest wall movement, decreased/absent breath sounds, tachycardia, hypotension supplemental O2. high-flow O2 via a non-rebreather mask. Bag-valve-mask (BVM) ventilation 100% O2 and intubation
Primary Survey •E-Exposure •E stands for .... •Remove all ... for a complete physical assessment •Do not cut through .... •Do not remove ... •Prevent hypothermia •Remove ... •Warm..., warm ..., ... warmers •Maintain privacy •Obtain ...
exposure and environmental control clothing forensic evidence impaled objects wet sheets or clothing blankets IV fluids overhead VS and pulse ox; BP in both arms
Submersion Injury •Submersion injury- results when person becomes ... as the result of submersion in substance, usually water •S/S •Drowning: ... •Drowning process is considered a continuum with outcomes that range from survival to death
hypoxic Crackles, bradycardia (diving reflex), cyanosis, hypotensive, cool skin respiratory impairment after submersion
Frostbite •Frostbite is true tissue freezing that results in the formation of ... •...n is the initial response to cold stress and results in a .... •As cellular temperature decreases and ice crystals form in intracellular spaces, the ... •This results in ...
ice crystals in the tissues and cells. Peripheral vasoconstriction decrease in blood flow and vascular stasis. organelles are damaged and the cell membrane destroyed. edema.
Human Bites •Result in puncture wounds or lacerations •High risk of ... •Oral bacterial flora ... •... most common - sexual activity or violence.
infection Staph and strep, and hepatitis Hands, fingers, ears, nose, vagina, and penis
Mechanism of Injury •Details of the incident are extremely important because the mechanism of ... and ... can predict specific injuries. For example, a restrained front-seat passenger may have a head injury or knee, femur, or hip fracture from hitting the dashboard, and an abdominal injury caused by the seat belt. The history should include the following questions: ...
injury and injury patterns 1. What is the chief complaint? What caused the patient to seek attention? 2. What are the patient's subjective complaints? 3. What is the patient's description of pain (e.g., location, duration, quality, character)? 4. What are witnesses' (if any) descriptions of the patient's behavior since the onset?
Geriatrics •People >65 years old account for 43% of ED visits •Aggressive interventions are warranted for all injuries regardless of age unless patient has a •Preexisting terminal illness •Extremely low chance of survival •Advance directive • •The proportion of the population over age 65 is growing, with most leading active lives. Make sure you get ....
living will DNR AND in order from the get go!
Radiologic/Nuclear Agents of Terrorism Radiologic dispersal devices (RRDs) ("dirty bombs"):... When detonated, ... Ionizing radiation (e.g., nuclear bomb, damage to a nuclear reactor): ... Exposure may or may not include skin contamination with radioactive material. Give ... - immediately
mix of explosives and radioactive material blast scatters radioactive dust, smoke, and other material into environment, resulting in radioactive contamination. Main danger from RRDs: explosion serious threat to safety of casualties and environment Potassium Iodine
Altitude-Related Illness -Also known as high altitude disease -Risks: ... -... is primary cause
obesity, chronic illness, esp heart disease, dehydration, alcohol Ascending too rapidly
30 to 2 = Can Do •RR <30 = .... •RR > 30 = .... •Mental status - follows commands and/or oriented = ...Not =... •All above ok = ...
ok Red OK Red Yellow or Green
Snakebite Hospital Care •Supplemental ... •IV lines for ... •Continuous ... •... •... prophylaxis •... care •... for pit viper bites - ... •Give CroFab within ... of bite - assess for ...
oxygen NS or RL cardiac, BP monitoring Opioids Tetanus Wound Antivenom Crotalidae Polyvalent Immune Fab (CroFab) 6 hour pineapple or papaya
Geriatric Population •Important points to remember when triaging geriatric patients: •Altered ...is common •Delayed... is common •__________________, ______________________, and _______________________________ = RED FLAG •Older patients are uniquely prone to ... •... symptoms
pain perception presentation Upper abdominal pain, ill appearance, and abnormal vital signs delirium Vague
Roll and look for insidious issues 2/2 •Auscultate for bowel sounds. Decreased bowel sounds may indicate a temporary... Bowel sounds in the chest may indicate a ... •Percuss the abdomen for distention (e.g.,...), and palpate for tenderness. •If you suspect intraabdominal hemorrhage, a ... to identify blood in the peritoneal space (hemoperitoneum) is preferred. •This procedure is noninvasive and performed quickly at the bedside. •A FAST cannot rule out a .... If one is suspected, a ...is usually ordered.
paralytic ileus. diaphragmatic rupture. tympany [excessive air] and dullness [excessive fluid] focused abdominal sonography for trauma (FAST) retroperitoneal bleed CT scan
Emergency and Mass Casualty Incident Preparedness •Communities have initiated programs to develop community emergency response teams (CERTs). •CERTs are ..... •All health care providers have a role in emergency and MCI preparedness. ... •Also keep in mind post incident, PTSD (think about s/s), debriefing, learning, making change
partners in emergency preparedness, and training helps citizens to understand their personal responsibility in preparing for natural/manmade disaster •Knowledge of the hospital's emergency response plan •Participation in emergency/MCI preparedness drills is required. •This includes debriefing for drills and real situations. •Educate consumers and community •Have a plan for home - a place to meet, communication methods, emergency supplies •Know your role before during and after the disaster
Rewarming •Mild hypothermia: ... •Passive external rewarming: ... •Active external rewarming: ...
passive or active external rewarming Move patient to warm, dry place; remove damp clothing; place warm blankets on patient. body-to-body contact, fluid- or air-filled warming blankets, radiant heat lamps
Venomous Snake Bites •Symptoms- ...
puncture wounds, severe pain, swelling, and redness or bruising, muscle twitching, seizures and coagulopathy or DIC, parasthesias, confusion
Cardiac Arrest and Therapeutic Hypothermia •CPR - family in room - DNR? Therapeutic hypothermia Provided for 24 hours after the... ↓ ... rates ↑ ... outcomes For all patients who are comatose or who do not follow commands after ROSC ...
return of spontaneous circulation (ROSC) Mortality Neurologic Induction Maintenance Rewarming
Watch for change •Gently palpate the pelvis to determine stability. Do not ... the pelvis. Pain may indicate a pelvic fracture and the need for an x-ray. •Inspect the genitalia for .... •Assess for ... •The HCP may perform a ... •Provide ... based on vaccination history and the condition of any wounds. •Regardless of the patient's chief complaint, ... of interventions are critical. •Provide appropriate care and assess the patient's response. •The evaluation of airway patency and the effectiveness of breathing will always be the highest priority. •Monitor respiratory rate and rhythm, O2 saturation, and ABGs (if ordered) to evaluate the patient's respiratory status. •Obtain a ...to confirm exact placement of tubes (e.g., endotracheal, gastric).
rock bleeding, priapism, and obvious injuries. bladder distention, hematuria, dysuria, or inability to void. rectal examination to check for blood, a high-riding prostate gland (e.g., urethral injury), and loss of sphincter tone (e.g., spinal cord injury). tetanus prophylaxis ongoing monitoring and evaluation portable chest x-ray
Emergency and Mass Casualty Incident Preparedness •Casualties need to be treated and stabilized. •If known or suspected contamination, decontaminate at...., then ... to hospitals. •Many casualties will arrive at hospitals on their own (i.e., "walking wounded"). •Total number of casualties a hospital can expect is estimated by ... •Generally, 30% will require admission to hospital, and half of these will need surgery within ...•
scene transport doubling number of casualties that arrive in first hour. 8 hours.
Poisonings *Hemodialysis/hemoperfusion Reserved for... *Urine alkalinization - ... *... agents - for metals *Antidotes .... - salicylate, and phenobarb ... for amphetamines and quinidine ...for opioids ... for Benzos ... for tylenol
severe acidosis Na Bicarb Chelating NaHCO3 Vit C Narcan Romazicon Mucoumyst
Frostbite •Clinical manifestations •Superficial- involves ... and ... tissue •Skin may be ... •Deep- involves ... •Skin ...
skin subcut waxy, pale yellow, blue, mottled muscle, bone and tendon hard, white and insensitive to touch
Venomous Snake Bites •Move person to a safe area - do not bring the ... •...to decrease venom circulation •Remove... before swelling worsens •Immobilize affected extremity in ... •Maintain extremity at ... •Keep person ... •No ..., can cause venom to spread through vasodilation
snake to the ER Rest jewelry or restrictive clothing position of function with a splint level of the heart warm and calm alcohol
Emergency and Mass Casualty Incident Preparedness •System of colored tags designates both seriousness of injury and likelihood of survival. - this is different than your ER triage •Green (minor injury)(non-life-threatening injury) tag indicates noncritical injury. •Yellow indicates treatment is needed, but can be delayed. •.... should be treated within 30 minutes to 2 hours, and therefore should be identified with yellow tags •Red tag indicates .... •Black tag identifies the ....
spine, eye, and stable abdominal injuries life-threatening injury. dead or indicates those who are expected to die.
Heatstroke •Treatment: ... •Start several IV lines with IV fluids of (...) •Continuous ... monitoring •Labs- electrolytes and CBC; insert urinary catheter •Give 100% O2 - hypermetabolic state, BVM or ventilator •Cooling methods - slow down at 102, stop at 100 •Remove ... •Cover with ...sheets. •Place patient in front of large ... •Immerse in ... water bath. •Administer cool ... or ... with cool fluids-... •Ice on pulse points - ... •Cooling blanket •Watch for shivering, can use IV benzodiazepine (...). ... too
stabilize patient's ABCs and rapidly reduce temperature NS ECG and pulse ox clothing. wet fan. cool IV fluids lavage NG and Foley groin, axilla, neck and head diazepam Chlorpromazine
Monitoring and Transport -Evaluate Evaluate need for ... -Provide Provide ongoing monitoring, and evaluate patient's response to interventions. -Prepare Prepare to ...
tetanus prophylaxis. Transport for diagnostic tests (e.g., x-ray) Admit to general unit, telemetry, or intensive care unit Transfer to another facility
ESI - Description -First, assess the patient for any ... (ESI-1) (e.g., Is the patient dying?) -Assess for the presence of a ... (ESI-2) (e.g., Is this a high-risk patient who should not wait to be seen?). -Next, evaluate patients who do not meet the criteria for ... -Assign patients to ESI level 3, 4, or 5 based on this determination. -... are required for patients assigned to ESI level 3. -Patients with abnormal vital signs may be reassigned to ...
threats to life high-risk situation ESI-1 or ESI-2 for the number of anticipated resources that they may need. Normal vital signs ESI level 2.
Altitude-Related Illness -S/S ...
throbbing headache, anorexia, N&V, feeling chilled, irritable, apathetic (affects similar to alcohol-induced hangover -Tachycardia or bradycardia; normal BP or hypotension; dyspnea at rest -May progress to pulmonary edema, stupor, coma and death```
Black Widow Spider Bite •Initial bite- ... •Systemic s/s within... and involve the ... system •Venom causes ... •s/s
tiny papule or red puncture mark 1 hr neuromuscular neurotransmitter release from nerve endings Severe abd pain, muscle rigidity and spasms, HTN, N&V, painful tingling or numbness
Chemical Agents of Terrorism •Categorized by target organ or effect •Sarin: .... •Enters body through ... •Acts by paralyzing ... •Antidotes for nerve agents: ... •Decontaminate with soap and water unless it is ...
toxic nerve gas that can cause death within minutes of exposure eyes and skin respiratory muscles atropine, pralidoxime chloride lyme
Poisonings •Dermal cleansing/eye irrigation •Skin and ocular decontamination: removal of ... •With the exception of ..., toxins can be removed with water or saline. *Water mixes with ... and releases chlorine gas . •... takes priority over all interventions except basic life support measures.
toxins from skin and eyes using water or saline nasal cannula works great mustard gas mustard gas Decontamination
Primary Survey •A-Airway with cervical spine stabilization and/or immobilization •Determine level of consciousness (LOC) by assessing the patient's response to .... •A simple mnemonic to remember is AVPU: A = ..., V = ..., P = ..., and U = .... •Nearly all immediate trauma deaths occur because of airway obstruction. •Remember .... •... can obstruct the airway. •Suction •Patients at risk for airway compromise include those who have .... •Possible intubation
verbal and/or painful stimuli. alert responsive to voice responsive to pain unresponsive jaw thrust Saliva, bloody secretions, vomitus, laryngeal trauma, dentures, facial trauma, fractures, and the tongue seizures, drowned, anaphylaxis, foreign body obstruction, or cardiopulmonary arrest.
Hypothermia •Moderate (86º to 93.2º F [30º to 34º C])
•Rigidity •Bradycardia, bradypnea •Blood pressure only by Doppler •Metabolic and respiratory acidosis •Hypovolemia •Shivering disappears at temperature 86º F (30º C) •Decreased clotting (caused by impaired platelets and thrombocytopenia) •Increased confusion, slurred speech, slowed responses
Hypothermia •Mild (93.2º to 96.8º F [34º to 36º C]) ...
•Shivering •Lethargy •Confusion •Rational to irrational behavior •Minor heart rate changes
