Environment Emergency Nursing

Lightning Injury

-Cardiopulmonary an central nervous systems profoundly affected -Asystole is most lethal initial effect on cardiopulmonary system -treatment is CPR immediate -No danger to rescuer from contact with victim

Poisoning

Chemicals that harm body accidentally , occupationally, recreationally, intentionally. severity depends on type of concentration and route of exposure, more than5 million cases of human poisoning each year. US Natural or manufactured toxins can be ingested , inhaled, injected, splashed in eye, absorbed through skin. MANAGEMENT: - decrease absorption -enhance elimination -implement toxin- specific interventions per poison control center. options: activated charcoal dermal cleansing eye irrigation less frequent gastric lavage admin of cathartics, whole bowel irrigation, hemodialysis, urine alkalinization, chelating agents, antidotes, increases elimination of poison Gastric lavage: intubate before lavage if altered level of consciousness or diminished gag reflex. Perform lavage within 2 hours of ingestion of most poisons Contraindicated in: Caustic agents Co-ingested sharp objects ingested nontoxic substances Activated Charcoal: -most effective intervention: administer orally or via gastric tube within 60 minutes of poison ingestion Contraindications: diminished bowel sounds" paralytic illeus ingestion of substance poorly absorbed by charcoal Charcoal can absorb and neutralize antidotes: Do not give immediately before, with , or shortly after charcoal. Patients have hard time drinking this. DERMAL CLEANSING/ EYE IRRIGATION - skin and ocular decontamination: removal of toxins from skin and eyes using water or saline -with exception of mustard gas, toxins can be removed with water or saline water mixes with mustard gas and releases chlorine gas Decontamination takes priority overall interventions except basic life support measures. Enhance elimination -cathartics (sorbitol) give with first dose of charcoal to stimulate intestinal motility/ increase elimination -Whole bowel irrigation HEMODIALYSIS/ HEMOPERFUSION - reserved for severe acidosis - urine alkalinzation - chelating agents -antidotes WHOLE BOWEL IRRIGATION can be effective for swallowed objects such as cocaine filled balloons or condoms, heavy metals such as lead and mercury - Hemodialysis - reserved for pt who develop severe acidosis from ingestion of toxic substances (aspirin) -Sodium bicarb administered raises PH which is effective for Phenobarbital and salicylate poisoning Vitamin C is added to IV fluids to enhance secretion of amphetamines and quinidine Chelation threapy considered for heavy metal poisoning edetate calcium disodium for lead poisonig EDTA

Animal Bites

Children at greater risk Animal bites form dogs and cats most common wild or domestic rodents complications: infection mechanical destruction of skin muscle, tendons, blood vessel, bone bite may cause simple laceration or be associated with crush injury, puncture wound, tearing of multiple layers of tissue Dog bites: -usually on extremities - may involve significant tissue damage: deaths are reported, usually children facial bites- chilren victims own dogs Plastic surgeon should eval all disfiguring wounds of face Cat bites: -Deep puncture wounds that can involve tendons and joint capsules -greater incidence of infection septic arthritis osteomyelitis Tenosynovitis Most common organism of infection: Pasteurella species P multocida most cats and dogs carry this if through and through higher chance of healing faster and better. effectively flushed and treated puncture wound- makes for perfect incubation area of bacteria

Environmental Emergencies

Common environmental emergencies deal with HEAT and COLD exposure, snakes and ticks vector borne disease (LYME) vector borne- illness caused by an infectious microbe that is transmitted to people by blood sucking arthropoids mosquitoes, fleas, lice, biting flies, bugs blood sucking arachnids mites and ticks vector: any arthrapod that transmits disease through feeding activity Environmental emergencies may include: poisoning hypothermia hyperthermia snakebites spider bites drowning

COMPLICATIONS OF HYPOTHERMIA

FROSTBITE Cold weather problem may or may not be involved with hypothermia Like burns- can be superficial, partial or full thickness FROST NIP occurs in superficially exposed areas : nose, face, fingers, toes. causes pain, numbness, pallor Left untreated: frost bite precursor FROST BITE 1st degree: increases circulation to area 2nd degree: large fluid filled blisters form with partial thickness skin necrosis 3rd degree: small blisters appear with dark fluid and affected body part is cool numb, blue or red, and does not blanch. FULL THICKNESS and SC tissue necrosis occurs and requires debridement 4th degree: most severe no blisters or edema part is cold and numb, bloodless full thickness then extends into muscle and bone. GANGRENE develops which may require amputation

Heat stroke

Failure of hypothalmic thermoregulatory processes Vasodilation, increased sweating and respiratory rate depletes fluids and electrolytes, specifically sodium Sweat glands stop functioning and core temperature increases (>104) heat stroke serious form of heat stress altered mentation, absence of perspiration, circulatory collapse. Skin is hot, dry and ashen Cerebral edema and hemorrhage occur as a result of direct thermal injury to the brain and decreased cerebral blood.

Hypothermia treatment

Mild hypothermia- passive or active external rewarming - passive external rewarming: move patient to warm dry place, remove damp clothes, place warm blankets on - active external rewarming body to body contact fluid or airfilled warming blankets radiant heat lamps MODERATE to SEVERE hypothermia: ACTIVE CORE REWARMING: - use heated , humidified oxygen -warmed IV fluids -Peritoneal, gastric, or colonic lavage with warmed fluids gentle handling is essential , to prevent stimulation to cold myocardium closely monitor patient for marked vasodilation and hypotension during rewarming consider cardiopulmonary bypass or continuous arteriovenous rewarming in severe hypothermia.

Hypothermia

Mild- temp 93.2- 06.8 shivering lethargy confusion rational or irrational behavior minor heart rate changes Moderate hypothermia temp 86- 93.3 Rigidity bradycardia, bradypnea bp by doppler metabolic and respiratory acidosis hypovolemia shivering disappears at temp 86 Severe<86 makes person appear dead bradycardia asystole ventricular fibrillation WARM PATIENT TO ATLEAST 90 before pronouncing dead CAUSE OF DEATH- refractory ventricular fibrillation Treatment of hypothermia - Manage and maintain ABC's Rewarm patient Correct dehydration and acidosis Treat cardiac dysrhythmias Metabolic rate, heart , respirations slow cant be detected reflexes absent pupils fixed and dilated

Heat Exhaustion

Prolonged exposure to heat over hours or days leads to heat exhaustion thermoregulatory mechanisms: sweating vasodilation and Increased Respirations cannot compensate for exposure to increased ambient temperatures Strenuous activities in hot or humid environments, clothing that interferes with perspiration, high fever, and pre existing illnesses predispose individuals to heat stress Clinical syndrome characterized by: -fatigue -light headedness -nausea vomiting -diarrhea -feelings of impending doom -tachypnea - tachycardia -dilated pupils -mild confusion -ashen color -profuse diaphoresis -hypotension and mild to severe temperature elevation (99.6-104 due to dehydration Place pt in cool area, remove constricting clothing Place moist sheet over patient to decrease temperature Provide Oral fluid Replace electrolytes Initiate normal Saline IV solution if oral solutions are not tolerated *** Monitor for ABC's Cardiac dysrhythmias (electrolyte imbalances) Salt tablets not used because of potential gastric irritation and hypernatremia Consider hospital admission for elderly, chronically ill, or those who do not improve within 3-4 hours.

Human Bites

Result in puncture wound or lacerations HIGH RISK OF INFECTION Oral bactera flora hepatitis virus Staphylococcus aureus, streptococcus, hep hands, fingers, ears, nose, vagina, penis most common sites of human bites- violence or sexual activity INITIAL TREATMENT - clean with copious irrigation debridement, tetanus prophy, analgesics - prophy antibiotics for bites at risk of infection wounds over joints wounds less than 6-12 hours old Puncture wounds Bites on hand or foot Puncture wounds left open lacerations loosely sutured wounds over joints splinted. Individuals at greatest risk for infection: Infants older adults Immunocompromised Alcoholics Diabetics Pt taking corticosteroids incidence of cellulitis, osteomyelitis, septic arthritis -IV Antibiotics -report animal and human bites to police RABIES PROPHYLAXIS very painful injections Rabies immuno globulin Series of five injections of HUman diploid cell vaccine 0,3,7,14,28 DAYS

Hypothermia treatment

Risks of rewarming: -afterdrop- a further drop in core temp -hypotension -dysrhythmias Rewarming should be discontinued once core temP reaches 95 AFTERDROP OCCURS WHEN COLD PERIPHERAL BLOOD RETURNS TO CENTRAL CIRCULATION

Heat stroke treatment

Stabilize ABC rapidly reduce temp COOLING METHODS: remove clothing cover with wet sheets place patient in fron of large fan immerse in ice water bath administer cool fluids or lavage with cool fluids Administer 100% oxygen compensates for the patient's hypermetabolic state Ventilation with a BVM or intubation and mechanical ventilation may be required HEAT STROKE Shivering: increases core temperature complicates cooling efforts treated with IV chlorpromazine Aggressive temperature reduction until core temp reaches 102 Monitor for signs of rhabdomyolysis myoglobinuria disseminated intravascular coagulation muscle breakdown leads to myoglobinuria, places KIDNEYS at risk for AKF Myoglobinuria excretion of myoglobin in urine results from muscle degeneration, releases myoglobin into the blood; occurs in certain types of trauma (crush syndrome) , advanced or protracted ischemia of muscle, or as paroxysmal process of unknown etiology Rhabdomyolysis - syndrome caused by injury to skeletal muscle and involves leakage of large quantities of potentially toxic intracellular contents into plasma Its final common pathway may be a disturbance in myocyte calcium homeostasis. Myoglobin is an important myocyte compound released into plasma. After muscle injury , massive plasma myoglobin levels exceed protein binding (haptoglobin) and can precipitate glomerular filtrate. Excess myoglobin may thus cause renal tubular obstruction, direct nephrotoxicity (ischemia and tubular injury) intrarenal vasoconstriction, acute kidney injury

Treatment of Submersion injuries

VENTILATION OXYGENATION - primary techniques for resp failure MANNITOL or furosemide is used to decrease free water and treat cerebral edema -correct hypoxia -correct acid-base and fluid imbalances -support basic physiologic functions -rewarm if hypothermia present initial evaluation:ABCD Mechanical ventilation with PEEP or CPAP to improve gas exchange when pulmonary edema is present Near drowning victims may also have head and neck injuries that cause prolonged alterations in level of consciousness Complications can develop in pts who are essentially free of symptoms immediately after near drowning episode Secondary drowning refers to delayed death from drowning due to pulmonary complications Deterioration in neurologic status: cerebral edema, worsening hypoxia profound acidosis observe min 4-6 hours secondary drowning is concern for patients who are symptom free

Vector borne illness

high prevalence of LYMES among other diseases from TICKS BEES and Wasps potential anaphylactic reaction emergency care to remove stinger and apply ice advanced emergency hospital care to ensure airway breathing circulation epi pen administration especially valuable for allergic patients VERY COMMON EMERGENCY honey bees- can only sting one, sac detaches and bee dies. venom sack pumps venom into body your body after it is detached KEEP EPI PEN AVAILABLE! ANAPHYLAXIS - -life threatening allergic response -TRUE medical emergency Symptoms: -resp distress w bronchospasm -laryngeal edema -hypotension -decline in mental status -cardiac dysrhythmias Allergic reaction vs toxic venom reaction -may be indistinguishable , both can cause same early signs and symptoms bee sting- seek emergency treatment without delay

Submersion Injury

over 50,000 submersion events and 4,00 deaths per year in US most victims are children <5 years of age or boys between 15-25 Primary risk factor for submersion include: ability to swim use of alcohol drugs trauma seizures hypothermia stroke child neglect Drowning: death from suffocation after submersion in fluid Immersion syndrome occurs with immersion in cold water, which leads to stimulation of vagus nerve and potentially fatal dysrhythmias Near drowning: survival from potential drowning PATHOphysiology of SUBMERSION INJURY Aspiration of water Freshwater- water rapidly leaks to capillary bed and circulation Saltwater- draws fluid into alveoli RESULT -surfactant destruction destruction of alveolar-capillary membrane - Noncardiogenic pulmonary edema - Acute respiratory distress syndrome AGGRESIVE RESUSCITATION EFFORTS MAMMALIAN DIVING REFLEX improve survival of near drowning victims

Hypothermia

wet clothing increases evaporative heat loss 5 times greater than normal, immersion in cold water (near drowning) increases evaporative heat loss 25 times greater than normal. Hypothermia mimics cerebral or metabolic disturbances, causing ataxia, confusion, withdrawal, so patient may be misdiagnosed. Core temp= <95 F Risk Factors: Elderly certain drugs alcohol diabetes Core temp <86 is life threatening