Med Surg Exam 4
Action alert boxes on page 193
- Help patients move slowly from a supine to an upright position. Assist when ambulating. - When the patient is on a stretcher, confirm that side rails are up and locked, that the call light is within reach, and that a patient's fall risk is communicated clearly to staff members who may assume responsibility for care, as well as caregivers. - Some older adults have difficulty adjusting to the noise and pace of the ED and/or have illnesses or injuries that cause delirium, an acute state of confusion. - Reorient the patient frequently and reassess mental status. Undiagnosed delirium increases the risk for mortality for older adults who are admitted to the hospital. - Assess the need for a caregiver or safety companion to stay with the patient to prevent falls and help with reorientation.
Heat Exhaustion
- a syndrome resulting primarily from dehydration from heavy perspiration and inadequate fluid and electrolyte intake during heat exposure. - can take days or hours - can lead to profound, even fatal, dehydration and hyponatremia caused by excessive sodium lost in perspiration. - can lead to heat stroke - flulike symptoms with headache, weakness, nausea, and/or vomiting. may continue to perspire despite dehydration. - assess for orthostatic hypotension, tachycardia, acute confusion - immediately stop physical activity and move to a cool place. interventions: - placing cold packs on the neck, chest, abdomen, and groin. - Soak in cool water or use fan while spraying water on skin. - Remove constrictive clothing. - Sports drinks or an oral rehydration-therapy - plain water can worsen the sodium deficit. - salt tablets can cause stomach irritation, nausea, and vomiting. In the hospital: - monitor vital signs. - Rehydrate with intravenous solution - Draw blood for serum electrolyte analysis. - admission is indicated for patients with other health problems that are now exacerbated or have severe dehydration and evidence of physiologic compromise.
Lightning Injuries
- Most occur in the summer during the afternoon and early evening because of increased thunderstorm activity and greater numbers of people outside. - Anyone without adequate shelter, including golfers, hikers, campers, beach-goers, and swimmers, is at risk. - Lightning produces injury by directly striking a victim, splashing off a nearby object, or traveling through the ground. - can cause death or permanent disabilities. - water makes it worse - flashover is an explosive force that can injure victims directly and cause them to fall or to be thrown. classified as mild, moderate, or severe: mild = stunned or confused. moderate = confusion or comatose, and temporary paralysis - can have serious myocardial complications seen on ECG, and myocardial perfusion abnormalities such as angina and dysrhythmias. severe = cardiac arrest = the most lethal initial effect - respiratory arrest from impairment of the respiratory center so with multiple victims provide care to those who are in cardiopulmonary arrest first. - Priority is ABCs Lightning Strike Prevention: • Observe weather forecasts when outside. • A lightning strike is imminent if your hair stands on end, you see a blue halo around objects, and you hear high-pitched or crackling noises. - crouch on the balls of your feet and tuck your head down to minimize the target size; do not lie on the ground or make contact with your hands to the ground. • Seek shelter - Do not stand under an isolated tall tree or structure; lightning tends to strike high points. seek a low area under a thick growth of saplings or small trees. • Leave water immediately (including an indoor shower or bathtub) and move away from any open bodies of water. • Avoid metal objects such as chairs or bleachers; put down tools, fishing rods, garden equipment, golf clubs, and umbrellas; stand clear of fences, exposed pipes, motorcycles, bicycles, tractors, and golf carts. • If inside a car with a solid hood, close the windows and stay inside. If in a convertible, leave the car at least 49 yards (45 meters) away and huddle on the ground. • If inside a tent, stay away from the metal tent poles and wet fabric of the tent walls. • place insulating material between you and the ground • If inside a building, stay away from open doors, windows, fireplaces, metal fixtures, and plumbing. • Turn off electrical equipment, including computers, televisions, and stereos to avoid damage. • Stay off land-line telephones. Lightning can enter through the telephone line and produce head and neck trauma, including cataracts and tympanic membrane disruption. Death can result. - Avoid use of cellular phones, which can transmit loud static that can cause acoustic damage. S/SX: - mottled skin and absent peripheral pulses - Central nervous system (CNS) injury - Temporary paralysis, keraunoparalysis, in lower limbs - evaluate for spinal injury. - cataracts, tympanic membrane rupture, cerebral hemorrhage, depression, and posttraumatic stress disorder. - skin burns from superficial to full-thickness burns. - Lichtenberg figures or keraunographic markings are characteristic findings on those struck by lightning (pictured) from coagulation of blood cells in the capillaries. First Aid/Prehospital Care: - spinal stabilization with priority attention to maintenance of an adequate airway, effective breathing, and circulation - CPR immediately with cardiac arrest. - lightning can and does strike in the same place more than once. Hospital Care: - advanced life support management, including cardiac monitoring and a 12-lead ECG. - may require mechanical ventilation until spontaneous breathing returns. - look for other traumatic injuries from a fall or blast effect during the strike. - CT scan for intracranial hemorrhage. - CK measurement to detect skeletal muscle damage - rhabdomyolysis (circulation of by-products of skeletal muscle destruction) can lead to renal failure. - Burn wounds are assessed and treated according to standard burn care protocols - maybe a burn center - Tetanus prophylaxis is necessary if the patient has experienced burns or any break in skin integrity.
Triage Nonurgent, urgent, emergent
- an organized system for sorting or classifying patients into priority levels, depending on illness or injury severity. - highest-acuity needs = quickest evaluation; treatment; and prioritized resource utilization such as x-rays, laboratory work, computed tomography (CT) scans, operating room or cardiac catheterization laboratory. - lower-acuity = wait longer in the ED because a high-acuity patient is moved to the "head of the line." communicate with patient and family about why other patients are treated first - registered nurse (RN), physician, physician assistant (PA), or nurse practitioner (NP) can determine the triage priority. - triage nurse requires appropriate training and experience in emergency nursing and triage decision-making Based on the triage priority, patients Variations include: • Triage nurse-initiated protocols for laboratory work or diagnostic studies that may be performed before the patient is actually evaluated by an ED provider of care • Initiation of care while the patient is on a stretcher in the hallway of a crowded ED - most used is the three-tiered model of "emergent, urgent, and nonurgent"
Hypothermia
= a core body temperature below 95°F (35°C). Risks: • Cold-water immersion • Acute illness (e.g., sepsis) • Traumatic injury • Shock states • Immobilization • Cold weather (especially homeless or work outdoors) • Older age • Use of medications (e.g., phenothiazines, barbiturates) • Inappropriate alcohol and substance use • Undernutrition • Hypothyroidism • Inadequate clothing or shelter (e.g., the homeless population) An environmental temperature below 82°F (28°C) can produce impaired thermoregulation and hypothermia categories: mild - 90° to 95°F [32° to 35°C] • Shivering • Dysarthria (slurred speech) • Decreased muscle coordination • Impaired cognition ("mental slowness") • Diuresis (caused by shunting of blood to major organs) moderate - 82.4° to 90°F [28° to 32°C] • Muscle weakness • Increased loss of coordination • Acute confusion • Apathy • Incoherence • Possible stupor • Decreased clotting from impaired platelet aggregation and thrombocytopenia severe - below 82.4°F [28°C]. • Bradycardia • Severe hypotension • Decreased respiratory rate • Cardiac dysrhythmias, including possible v-fib or asystole • Decreased neurologic reflexes to coma • Decreased pain responsiveness • Acid-base imbalance Treatment is based on severity First Aid/Prehospital Care: - shelter from the cold, remove all wet clothing, undergo passive or active external rewarming. - Passive = applying warm clothing or blankets. - Active = heating blankets, warm packs, and convective air heaters or warmers. - If a heating blanket is used, monitor the patient's skin at least every 15 to 30 minutes to reduce the risk for burn injury. - for mild drink warm high-carbohydrate liquids with no alcohol or caffeine Hospital Care: - Protect patient from further heat loss and handle gently to prevent v-fib. - supine prevents orthostatic changes in blood pressure - Follow airway, breathing, and circulation • Administer drugs with caution because metabolism is unpredictable in hypothermic conditions. • Remember that drugs can accumulate without obvious therapeutic effect while the patient is cold but may become active and potentially lead to drug toxicity as effective rewarming is under way. • withhold IV drugs, except vasopressors, until the core temperature is above 86°F (30°C). • defibrillation attempts may be ineffective until the core temperature is above 86°F (30°C). - After-drop is the continued decrease in core body temperature after the victim is removed from the cold environment from the return of cold blood from the periphery to the central circulation. - warm trunk before extremities. Core rewarming methods for moderate hypothermia: - administration of warm IV fluids - heated oxygen or inspired gas - heated peritoneal, pleural, gastric, or bladder lavage. Critical Rescue: severe hypothermia = high risk for cardiac arrest. avoid active external rewarming with heating devices because it is dangerous and contraindicated due to rapid vasodilation. - treatment of choice for severe hypothermia is extracorporeal rewarming like cardiopulmonary bypass (fastest) or hemodialysis. complications that can occur after rewarming: - fluid, electrolyte, and metabolic abnormalities; acute respiratory distress syndrome (ARDS); acute renal failure; and pneumonia. "no one is dead until he or she is warm and dead."
What is the nurse's priority action for the unconscious patient who is breathing who has been brought to the ED? A. Assess breath sounds and respiratory efforts B. Establish vascular access with a large-bore catheter C. Remove clothing to perform a complete physical assessment D. Evaluate level of consciousness (LOC) using the Glasgow Coma Sale (GCS)
A. Assess breath sounds and respiratory efforts
When caring for a client who become ill while mountain climbing, which assessment finding requires immediate nursing intervention? Select all that apply. A. Blue nail beds B. Lung crackles C. Tachypnea at rest D. Pink, frothy sputum E. Persistent dry cough F. Pulmonary infiltrates per x-ray G. Increased pulmonary artery pressure
A. Blue nail beds B. Lung crackles C. Tachypnea at rest D. Pink, frothy sputum E. Persistent dry cough F. Pulmonary infiltrates per x-ray G. Increased pulmonary artery pressure
After assessing four clients, which will the triage nurse identify to be seen first in the ED? A. Client with fever of 101.2°F B. Client who reports slurred speech C. Client who reports bilateral ear pain D. Client with urinary burning and frequency
A. Client with fever of 101.2°F
Which assignment will the ED charge nurse make when nurses from within the hospital are floated to the ED to care for clients affected by an earthquake? Select all that apply. A. GI laboratory nurse assigned to clients needing sedation B. Psychiatric nurse assigned to care for clients with lacerations C. Orthopedic nurse assigned to accompany clients to radiology D. Nurse administrator assigned to sit with loved ones in the waiting room E. Medical-surgical nurse assigned to health care worker who is feeling overwhelmed
A. GI laboratory nurse assigned to clients needing sedation C. Orthopedic nurse assigned to accompany clients to radiology D. Nurse administrator assigned to sit with loved ones in the waiting room
What teaching will the nurse provide to an older adult who has a history of heat exhaustion? Select all that apply. A. Take frequent rest breaks when doing activities B. Drink caffeinated beverages before going in the sun C. Wear dark clothing to protect the skin from burning D. Stay indoors in an air-conditioned room when possible E. Take warm baths or showers to regulate the body temperature
A. Take frequent rest breaks when doing activities D. Stay indoors in an air-conditioned room when possible E. Take warm baths or showers to regulate the body temperature
B: Breathing
After the airway has been successfully secured, breathing becomes the next priority to determine whether or not ventilatory efforts are effective—not only whether or not the patient is breathing. - Both apneic patients and those with poor ventilatory effort need BVM ventilation for support until endotracheal intubation is performed and a mechanical ventilator is used. - If cardiopulmonary resuscitation (CPR) becomes necessary, the mechanical ventilator is disconnected, and the patient is manually ventilated with a BVM device. - Lung compliance can be assessed through sensing the degree of difficulty in ventilating the patient with the BVM. Assess breath sounds and respiratory effort. Observe for chest wall trauma or other physical abnormality. Prepare for chest decompression if needed. Prepare to assist ventilations if needed.
After a mass casualty event, which client will the nurse triage with a yellow tag? A. 29-year old with third-degree burns over 80% of the body B. 36-year old with closed fractures of both legs C. 48-year old with wheezing and difficulty breathing D. 52-year old with multiple abrasions and contusions
B. 36-year old with closed fractures of both legs
What mechanism of injury will the nurse document for a client in a motor vehicle accident whose airbag deployed when the car struck a tree at 40 miles per hour? Select all that apply. A. Blast B. Blunt C. Laceration D. Penetration E. Acceleration-deceleration
B. Blunt E. Acceleration-deceleration
What is the priority nursing action when a nurse observes an adult drowning in a lake? A. Stabilize the spine with a board B. Consider personal swimming abilities C. Safely remove person from the water D. Initiate airway clearance and deliver rescue breaths
B. Consider personal swimming abilities
Why do homeless people often seek care in the ED
Because the ED is open 24 hours per day and is mandated by federal law to perform an emergency medical screening examination on all of its patients, those who are homeless may know that they will gain entry despite an inability to pay for services. The ED represents a safe place to go for shelter in poor weather and to obtain food, medical care, pain relief, and human interaction. Some patients who are homeless simply seek a temporary respite from their current living conditions, which may be a park, shelter, car, abandoned building, or cardboard box.
Arthropod Bites and Stings
Brown recluse and black widow spiders, scorpions, bees, and wasps are examples of venomous arthropods that can cause toxic reactions in humans. Arthropod Bite/Sting Prevention: • Wear protective clothing • Cover garbage cans. Bees and wasps are attracted to them • Use screens in windows and doors • Inspect clothing, shoes, and gear fs before putting on • Shake out clothing and gear that have been on the ground • exterminator • Identify nesting areas & remove them • Do not place hands where the eyes cannot see. • Avoid handling or keeping them as "pets." • Do not swat insects, wasps, and Africanized bees because they can send chemical signals that alert others to attack. • Carry a prescription epinephrine autoinjector and antihistamines if known to be allergic to bee and wasp stings. - Ensure that at least one significant other person is also able to use the autoinjector. - wear a medical alert bracelet reactions: - mild discomfort to severe pain - multisystem problems - life-threatening anaphylaxis Bumblebees, hornets, and wasps can sting repeatedly. Honeybees can sting just once and dies. "Africanized" bees, "killer bees," are found from mid-California across the southern border into Florida - attack in groups - outrun and seek shelter - and keep mouth and eyes protected - never go into a body of water because the bees will attack when you come up for air. All patients who have sustained multiple stings (particularly more than 50) = critical care.
On entry to the ED of a client who fell from a roof, what is the nurse's priority action? A. Place nasal cannula to administer oxygen. B. Apply pressure to small bleeding wounds. C. Assess airway and stabilize cervical spine. D. Initiate large-bore IV to infuse normal saline.
C. Assess airway and stabilize cervical spine.
Safe and Effective Care Environment ch 11
• Collaborate with the interprofessional health care team to provide the most comprehensive care for patients with environmental emergencies.
emergency nurse interactions beyond the walls of the ED
Communication with nurses from the inpatient units is necessary to ensure continuity of patient. Hand off communication is essential for patient safety should and should include the patient's: • Situation (reason for being in the ED) and admitting diagnosis • Pertinent medical history, including implantable devices and any history of organ transplant • Assessment and diagnostic findings, particularly critical results • Transmission-Based Precautions and safety concerns (e.g., fall risk, allergies) as indicated • Interventions provided in the ED and response to those interventions It's basically SBAR but with precautions added
Which client does the oncoming ED nurse see first when assigned to care for four clients? A. 21-year-old with a skin rash who has been waiting 2 hours to see a provider B. 30-year-old with influenza who has infusing IV fluids and is resting quietly C. 47-year-old who fell off of a curb, resulting in a sprained ankle D. 56-year-old reporting chest pain and diaphoresis that started 30 minutes prior
D. 56-year-old reporting chest pain and diaphoresis that started 30 minutes prior
When caring for four clients, which does the nurse identify as at the highest risk for frostbite? A. 19-year old who takes antihistamines B. 28-year old who is a vegetarian C. 41-year old who is being treated for hypothyroidism D. 57-year old who drinks 4-5 beers per day
D. 57-year old who drinks 4-5 beers per day
In addition to calling 911, what is the appropriate nursing response when a client calls the telehealth nurse to report being bitten on the arm by an unknown type of snake? A. Apply ice to the site of the wound B. Extract venom by sucking the wound C. Apply a tourniquet to the affected arm D. Immobilize the extremity at the level of the heart
D. Immobilize the extremity at the level of the heart
A: Airway/Cervical Spine
Establishing a patent airway = highest-priority intervention when managing a trauma patient unless massive, life-threatening external hemorrhage is present because even minutes without an adequate oxygen supply can lead to brain injury that can progress to anoxic brain death. - provide oxygen as needed - nonrebreather mask for the spontaneously breathing patient. - Bag-valve-mask (BVM) ventilation with the appropriate airway adjunct and a 100% oxygen for the person who needs ventilatory assistance during resuscitation. Establish a patent airway by positioning, suctioning, and administering oxygen as needed. Protect the cervical spine by maintaining alignment; use a jaw-thrust maneuver if there is a risk for spinal injury. If the Glasgow Coma Scale (GCS) score is 8 or lower or the patient is at risk for airway compromise, prepare for endotracheal intubation and mechanical ventilation.
What are the patient safety considerations?
Hospital emergency departments have unique factors that can affect patient safety . These factors include the provision of complex emergency care, constant interruptions, and the need to interact with the many providers involved in caring for one patient. Some of the most common patient safety issues noted in the ED are: • Fall risk • Medical errors or adverse events • Patient misidentification • Skin breakdown Correct patient identification is critical in all health care settings. All patients are issued an identification bracelet at their point of entry in the ED—generally at the triage registration desk or at the bedside if emergent needs exist. For patients with an unknown identity and those with emergent conditions that prevent the standard identification process (e.g., unconscious patient without identification, emergent trauma patient), hospitals commonly use a "Jane/John Doe" or other system of identification. National Patient Safety Goals Always verify the patient's identity using two unique identifiers before each intervention and before medication administration per The Joint Commission's (TJC) 2020 National Patient Safety Goals (TJC, 2020). Examples of appropriate identifiers include the patient's name, birth date, agency identification number, home telephone number or address, and Social Security number. Fall prevention starts with identifying patients at risk for falls and then implementing appropriate fall precautions and safety measures like application of a fall risk bracelet (Fig. 10.4). Patients can enter the ED without apparent fall risk factors, but because of interventions such as pain medication, sedation, or lower extremity cast application, they can develop a risk for falls. Falls can also occur in patients with medical conditions or drugs that cause syncope ("blackouts"). Some older adults experience orthostatic (postural) hypotension as a side effect of cardiovascular drugs. In this case patients become dizzy when changing from a lying or sitting position (see Chapter 4). Nursing Safety Priority Action Alert Help patients move slowly from a supine to an upright position. Assist when ambulating. When the patient is on a stretcher, confirm that side rails are up and locked, that the call light is within reach, and that a patient's fall risk is communicated clearly to staff members who may assume responsibility for care, as well as caregivers. Older adults who are on beds or stretchers should always have side rails up and the bed or stretcher in the lowest position. Access to a call light is especially important; instruct the patient to call for the nurse if assistance is needed rather than attempting independent ambulation. Some older adults have difficulty adjusting to the noise and pace of the ED and/or have illnesses or injuries that cause delirium, an acute state of confusion. Reorient the patient frequently and reassess mental status. Undiagnosed delirium increases the risk for mortality for older adults who are admitted to the hospital. Assess the need for a caregiver or safety companion to stay with the patient to prevent falls and help with reorientation. Additional safety strategies are listed in the Best Practice for Patient Safety & Quality Care: Maintaining Patient and Staff Safety in the Emergency Department box. Some patients spend a lengthy time on stretchers while awaiting unit bed availability. During that time, basic health needs require attention, including providing nutrition, hygiene, safety , and privacy. Waiting in the ED can cause increased pain in patients with back pain or arthritis. Protecting skin integrity also begins in the ED. Emergency nurses need to assess the skin frequently and implement preventive interventions as part of the ED plan of care, especially when caring for older adults or people who are immobilized. Interventions that promote clean, dry skin for incontinent patients, pressure-relieving skin care products placed over pressure points, mobility techniques that decrease shearing forces when moving the immobile patient, and routine turning help prevent skin breakdown. Chapter 23 describes additional nursing interventions for preventing skin breakdown. A significant safety risk for all patients who enter the emergency care environment is the potential for medical errors or adverse events, especially those associated with medication administration. The episodic and often chaotic nature of emergency management in an environment with frequent interruptions can easily lead to errors. To reduce error potential, the emergency nurse makes every attempt to obtain essential and accurate medical history information from the patient and caregivers. When working with patients who arrive with an altered mental status, a quick survey to determine whether the person is wearing a medical alert bracelet or necklace is important. A two-person search of patient belongings may yield medication containers or a medication list; or the name of a health care provider, pharmacy, or caregiver contact. Some EDs employee pharmacists or pharmacy technicians to help gather medication history to improve timeliness and accuracy of the information recorded. Through these processes the nurse may find information that promotes safety and influences the overall emergency treatment plan. Automated electronic tracking systems are also available in some EDs to help staff identify the location of patients at any given time and monitor the progress of care delivery during the visit. These valuable safety measures are especially important in large or busy EDs with a high population of older adults (Laskowski-Jones, 2008). In addition to falls and pressure injury development, another adverse event that can result from a prolonged stay in the ED is a hospital-acquired infection (HAI). Older adults in particular are at risk for urinary tract or respiratory infections. Patients who are immunocompromised, especially those on chronic steroid therapy or immunomodulators, are also at a high risk. Nurses and other ED personnel must wash their hands frequently and thoroughly or use hand sanitizers to help prevent pathogen transmission.
What are the roles of the personnel in the hospital incident command system
Officers - to oversee essential emergency preparedness functions such as public information, safety and security, and medical command. Chiefs - to manage logistics, planning, finance, and operations as appropriate to the type and scale of the event. delegate specific duties to other departmental officers and unit leaders. Leaders are identifiable by vests and job action sheets are distributed to all personnel with leadership roles in HICS that predefine reporting relationships and list prioritized tasks and responsibilities. hospital incident commander - Physician or administrator who assumes overall leadership for implementing the institutional plan. medical command physician - physician who focuses on determining the number, acuity, and medical resource needs of victims arriving from the incident scene to the hospital and organizing the emergency health care team response to the injured or ill patients. Responsibilities include identifying the need for and calling in specialty-trained providers such as: • Surgeons (trauma, neuro, orthopedic, plastic, and/or burn) • Anesthesiologists • Radiologists • Pulmonologists • Infectious disease physicians • Industrial hygienists • Radiation safety personnel Or in smaller hospitals, the medical command physician might also help determine which patients should be transported out of the facility to a higher level of care or to a specialty hospital triage officer - Physician or nurse who rapidly evaluates each person who presents to the hospital, even those who come in with triage tags in place. Patient acuity is re-evaluated for appropriate disposition to the area within the ED or hospital best suited to meet the patient's needs. community relations or public information officer - can draw media away from the clinical areas so essential hospital operations are not hindered and serve as the liaison between hospital administration and the media to release only appropriate and accurate information.
Paramedics
Paramedics are advanced life support (ALS) providers who can perform advanced techniques, which may include cardiac monitoring, advanced airway management and intubation, needle chest decompression, establishing IV or intraosseous access, and administering drugs en route to the ED
Maintaining patient and staff safety in the ED box- page 192
Patient considerations & Interventions to minimize risk Patient identification Provide an identification (ID) bracelet for each patient. Use two unique identifiers (e.g., name, date of birth). If identity is unknown, use a special identification system. Injury prevention for patients Keep rails up on stretcher. Keep stretcher in lowest position. Remind patient to use call light for assistance. Reorient the confused patient frequently. If confused, ask someone to stay with patient Implement measures to prevent skin breakdown. Risk for errors and adverse events Obtain a thorough patient and family history. Check patient for a medical alert bracelet or necklace. Search patient's belongings for weapons, drugs and drug paraphernalia when patient has an altered mental status or presents with behaviors Injury prevention for staff Use Standard Precautions at all times. Anticipate violence Plan and practice options if violence occurs, including assistance from the security department.
Primary Survey (ABCDE)
Safety first!! - initial assessment of the trauma patient is called the primary survey, which is an organized framework used to rapidly identify and effectively manage immediate threats to life. - airway/cervical spine (A); breathing (B); circulation (C); disability (D); and exposure (E). - Resuscitation efforts occur simultaneously with each element of the primary survey - issues identified in the primary survey are managed before the team engages in interventions of lower priority such as splinting fractures and dressing wounds.
Cold-Related Injuries
Two common = hypothermia and frostbite. Both are preventable: - proper clothing - synthetic moves moisture away from the body and dries fast. NO COTTON - Wearing too many pairs of socks can decrease circulation and lead to frostbite. - layer clothing so that it can be added or removed as the temperature changes. - Body heat is lost through the head, so wear a hat, also facemask, sunscreen, sunglasses. - keep water, extra clothing, blankets, food, and essential medications in the car when driving in cold - Maintain personal fitness and conditioning - Undernutrition and dehydration contribute to cold-related illnesses and injuries. - know physical limits and to come in out of the cold before those limits have been reached.
Heat-Related Illnesses
Usually in temps above 95°F and humidity above 80%. includes heat exhaustion and heat stroke. at-risk populations: older adults (who have less body fluid volume and can easily become dehydrated), people with mental health/behavioral health conditions, those who work outside, homeless individuals, those who use substances, athletes who engage in outdoor sports, and military members stationed in hot climates. risk: obesity, heart disease, fever, infection, strenuous exercise, seizures, mental health disorders, and all degrees of burns (even sunburn) drugs that increase risk: lithium, neuroleptics, beta-adrenergic blockers, anticholinergics, angiotensin-converting enzyme (ACE) inhibitors, and diuretics - Check on older adults in hot weather 2x a day • Avoid alcohol and caffeine. • Prevent overexposure to the sun; - use sunscreen with SPF of 30 with UVA & UVB protection. • Rest frequently and take breaks from the heat - Plan to limit activity at the hottest time of day. • Lightweight, light-colored, and loose-fitting clothing • Pay attention to personal physical limitation - takes 2 week to acclimate to heat • Take cool baths or showers to help reduce body temperature. • Stay indoors in air-conditioned buildings if possible.
E: Exposure
What caused the condition? evidence preservation if needed: articles of clothing, impaled objects, weapons, drugs, and bullets from rape, abuse of a child or older adult, domestic violence, homicide, suicide, drug overdose, and assault. Remove all clothing to allow for thorough assessment. Always carefully cut away clothing with scissors: • During resuscitation when rapid access to the patient's body is critical • When manipulating a patient's limbs to remove clothing could cause further injury • When thermal or chemical burns have caused fabrics to melt into the patient's skin Remove all clothing for a complete physical assessment. Prevent hypothermia (e.g., cover the patient with blankets, use heating devices, infuse warm solutions). hypothermia = body temperature less than or equal to 96.8°F poses a risk to injured patients, especially those with burns and traumatic shock states.
The Secondary Survey
a more comprehensive head-to-toe assessment after immediate life threats are addressed to identify other injuries or medical issues that need to be managed or that might affect the course of treatment.
Heat Stroke
a true medical emergency that has a very high mortality rate. - thermoregulation mechanisms fail and cannot adjust for the critical elevation in body temperature that can cause organ dysfunction and death Exertional heat stroke: - sudden onset - often the result of strenuous activity and heavy clothing in hot, humid conditions. Classic heat stroke: - non-exertional heat stroke - from chronic exposure to a hot, humid environment like a home without air conditioning in the high heat of summer. S/Sx: - elevated body temperature above 104°F. - skin is hot and dry - people with heat stroke may continue to perspire. - Mental status changes from thermal injury to the brain - Cardiac troponin I (cTnI) elevated - can predict severity of organ damage at the beginning of heat stroke • Hypotension • Tachycardia • Tachypnea (increased respiratory rate) • Electrolyte imbalances, especially sodium and potassium • Decreased renal function (oliguria) • Coagulopathy (abnormal clotting) • Pulmonary edema (crackles) Interventions: • Ensure a patent airway. • move the patient into air-conditioning or shade. • Call ambulance • Remove the patient's clothing. • Pour or spray cold water on the patient's body and scalp. • all surrounding people should fan the patient • place ice in cloth or bags and position the packs on the patient's scalp, in the groin area, behind the neck, and in the armpits. • support the patient in cold water for rapid cooling and protect the patient's airway. best method to treat heat stroke. At the Hospital: - first priority is to monitor and support the patient's airway, breathing, and circulatory status • oxygen by mask or nasal cannula; & prepare to intubate. • Start at least one IV with a large-bore needle or cannula. • Administer fluids, using cooled solutions if available. • Use a cooling blanket. - Obtain baseline laboratory tests as quickly as possible: urinalysis, serum electrolytes, cardiac enzymes, liver enzymes, and complete blood count (CBC). • Do not administer aspirin or any other antipyretics. • Insert a rectal probe for core body temperature continuously or use a rectal thermometer every 15 minutes. • Insert an indwelling urinary drainage catheter and monitor urine output and specific gravity to determine fluid needs. • Monitor vital signs frequently as clinically indicated. • Assess ABGs • muscle relaxants or benzodiazepines for shivering • Measure and monitor urine output and specific gravity to determine fluid needs. - midazolam or propofol for shivering- midazolam places the patient at high risk for delirium, and propofol carries a risk of hypotension - IV benzodiazepine for seizures - after stabilization monitor for multisystem organ dysfunction syndrome and severe electrolyte imbalances • Stop cooling interventions when core body temperature is reduced to 102°F (39°C). Critical Rescue After ensuring that the patient has a patent airway, effective breathing, and adequate circulation, use rapid cooling as the first priority of care. Methods for rapid cooling include removing clothing; placing ice packs on the neck, axillae, chest, and groin; immersing the patient or wetting the patient's body with cold water; and fanning rapidly to aid in evaporative cooling. Do not give food or liquid by mouth because vomiting and aspiration are risks in patients with neurologic impairment.
Understand the members of the interprofessional team including the special nursing teams and those that the ED nurses work with inside the ED and outside of the ED Forensic nurse examiners (RN-FNEs)
are educated to obtain patient histories, collect forensic evidence, and offer counseling and follow-up care for victims of rape, abuse, and domestic violence—also known as intimate partner violence (IPV) Forensic nurses who specialize in helping victims of sexual assault are called sexual assault nurse examiners (SANEs) or sexual assault forensic examiners (SAFEs). Interventions performed by forensic nurses: - providing information about developing a safety plan or how to escape a violent relationship. - document injuries, collect physical and photographic evidence. - may provide testimony in court as to what was observed during the examination and information about the type of care provided.
Nonurgent
could wait several hours if needed without fear of deterioration - may be asked to sit in the waiting room. can generally tolerate waiting several hours without a significant risk for clinical deterioration. Examples: simple fracture, rash, sprain, UTI
What are the nursing actions of caring for homeless individuals who seek care from the ED
demonstrate nonjudgmental behaviors that promote trust: making eye contact (if culturally appropriate) speaking calmly avoiding any prejudicial or stereotypical remarks being patient showing genuine care and concern by listening following through on promises exercising caution when there is a need to enter into the patient's personal space maintain situational awareness attend to own needs for personal safety. use standard precautions assess the need for a negative pressure room collaborating with the emergency care provider and social worker or case manager
What factors contribute to becoming homeless
economic hardship, the need to escape domestic abuse, behavioral health issues, and substance abuse
mental health/behavioral health nurses psychiatric crisis nurse team
evaluates patients with emotional behaviors or mental illness and facilitates the follow-up treatment plan, including possible admission to an appropriate facility. interact with patients and families when sudden illness, serious injury, or death of a loved one may have precipitated a crisis.
Types of Disasters
internal disaster - an event occurring inside a facility that could endanger the people inside. creates a need for evacuation or relocation. Examples include fire, explosion, loss of critical utilities, and violence. most important outcome is to maintain safety. external disaster - An event outside a facility, somewhere in the community, that requires the activation of the facility's emergency management plan. Examples include hurricane, earthquake, or tornado, terrorism, malfunction of a nuclear reactor, COVID, mass shooting - Both require specific response plans to activate necessary resources. - Local, State, regional, and/or national resources may be needed depending on multicausality or mass casualty - Trauma centers provide a critical level of expertise and specialized resources for complex injury management and - all facilities do drills regularly - preparedness means "all-hazards approach" to disaster planning and drills focus on events most likely to occur in a particular community. - Nursing home plans should include evacuation of residents in a timely and safe manner - National Fire Protection Association provides guidelines for building construction, design, maintenance, and evacuation. - The CMS requires every health care facility practice at least one fire drill or actual fire response and all facility personnel have fire training once a year
Emergent
life threatening - may be rushed into a treatment room condition exists that poses an immediate threat to life or limb. Examples: Chest pain with diaphoresis Hemorrhage Respiratory distress Stroke Vital sign instability
Understand the different Mechanisms of Injury and why it is important to understand theseterms
mechanism of injury (MOI) describes how the patient's traumatic event occurred, such as a high-speed motor vehicle crash, a fall from a standing height, or a gunshot wound to the torso. Knowing key details about the MOI can provide insight into the energy forces involved and may help trauma care providers predict injury types and, in some cases, patient outcomes. - Prehospital care providers report MOI during handoff. - self transported patients will often relate the MOI by describing the particular chain of events that caused their injuries. most common MOI: - blunt trauma from impact forces like a motor vehicle crash, fall, assault, blast effect from bomb produces injury by tearing, shearing, and compressing anatomic structures like bones, blood vessels, and soft tissues occurs. - penetrating trauma from sharp objects and projectiles like knives or other comparable implements, and bullets, pellets or shrapnel.
emergency medicine physician
medical professionals receive specialized education and training in emergency patient management.
exception to the standard ABCDE trauma resuscitation approach
n the presence of massive, uncontrolled external bleeding, hemorrhage control techniques are the highest-priority intervention and the sequence of priorities shifts to CAB (circulation, airway, breathing), whereby the initial focus of resuscitation is to effectively stop the active bleeding
Urgent
needs quick treatment, but not immediately life threatening - may be directed to a lower-acuity area within the ED should be treated quickly but that an immediate threat to life does not exist at the moment. Examples: Abdominal pain (severe) Fractures (displaced or multiple) Renal colic Respiratory infection (especially pneumonia in older adults) Soft-tissue injuries (complex or multiple)
What is the role of the nurse in health care facility emergency preparedness
nursing process: identification of needs, capabilities, and priorities (assessment and determination of need) planning, implementing, and evaluating the disaster response. Before an event: develop emergency response plans, determine what is needed for the plan, test it, and modify it if needed During an actual disaster they organize on hand resources and get backup if needed to meet patient needs. apply principles of triage to prioritize care delivery as disaster victims enter the system and direct patients to the designated areas best suited to meet their needs. Patients who are the most medically stable may be discharged early, including those who: • Were admitted for observation and are not bedridden • Are having diagnostic evaluations and are not bedridden • Are soon scheduled to be discharged or could be cared for at home with support from family or home health care services • Have had no critical change in condition for the past 3 days • Could be cared for in another health care facility such as rehabilitation or long-term care
Others
staff and community health care providers, other physician specialists, nurse practitioners (NPs), physician assistants (PAs), resident physicians, radiology and ultrasound technicians, respiratory therapists, laboratory technicians, social workers, case managers, nursing assistants, and clerical staff
Psychosocial Integrity ch 10
• Collaborate with the behavioral health crisis team as needed.
Emergency medical technicians (EMTs)
offer basic life support (BLS) interventions such as oxygen, basic wound care, splinting, spinal motion restriction, and monitoring of vital signs.
Snakebites
poisonous snakes in North America: pit vipers (Crotalidae) and coral snakes (Elapidae). snakebite prevention: • Do not keep venomous or constricting snakes as pets. • Be careful in tall grass, rock piles, ledges and crevices, woodpiles, brush, boxes, and cabinets. - know snakes are most active on warm nights. • Wear protective boots, heavy pants, and leather gloves. • When hiking, use a walking stick or trekking poles. • look before placing hands and feet in areas • Do not harass any snakes you may encounter. - Striking distance is up to two thirds the length of the snake. - snakes are venomous from birth • newly dead or decapitated snakes can bite for up to an hour after death because of persistence of the bite reflex. • Do not transport snake with the victim, take a photo of it Critical Rescue: first priority is to move the person away from snake and encourage rest to decrease venom circulation. - remove jewelry and constricting clothing before swelling - Call for immediate emergency assistance. - Do not capture or kill it, take a photo for identification. - Coral snakes - "red on yellow, kill a fellow" and "red on black, venom lack." Grades of snake bites: None = Fang marks, but no local or systemic reactions Minimal = Fang marks, local swelling and pain, but no systemic reactions Moderate = Fang marks and swelling progressing beyond the site of the bite; systemic signs and symptoms such as nausea, vomiting, paresthesias, or hypotension Severe = Fang marks present with marked swelling of the extremity; subcutaneous ecchymosis; severe symptoms including coagulopathy the most significant risk to the victim of a snakebite is airway compromise and respiratory failure. - patent IV lines and resuscitation equipment. - Contact Poison Control for antivenom administration and patient management.
D: Disability
provides a rapid baseline assessment of neurologic status using • A: Alert • V: Responsive to voice • P: Responsive to pain • U: Unresponsive or the Glasgow Coma Scale that scores eye opening, verbal response, and motor response where the lowest score is 3, and normal is 15. - Metabolic abnormalities (e.g., severe hypoglycemia), hypoxia, neurologic injury, and illicit drugs or alcohol can impair level of consciousness. Re-evaluate the patient's LOC frequently.
Frostbite
occurs when body tissue freezes and causes damage to tissue main risk factor = inadequate insulation against cold weather, exposed skin, and wet clothing - Fatigue, dehydration, and poor nutrition are other factors. - smoke, consume alcohol, impaired peripheral circulation, previous history of frostbite Assessment: - superficial - frostnip - pain, numbness, pallor or waxy appearance of affected area - easily relieved with warmth - typically on face, nose, finger, or toes - can progress to more severe forms of frostbite. - Grade I - least severe - hyperemia (increased blood flow) of area and edema. - Grade 2 - large, clear-to-milky, fluid-filled blisters with partial-thickness skin necrosis. - Grade 3 - small blisters with dark fluid on affected body part that is cool, numb, blue or red, and does not blanch. Full-thickness necrosis will require debridement. - Grade 4 - most severe - blisters over the carpal or tarsal (instead of just the digit); the part is numb, cold, bloodless - full thickness necrosis extends into the muscle and bone - gangrene - may require amputation. - degrees may look the same until part is thawed - Gangrene may evolve over days to weeks after injury. First Aid/Prehospital Care: Early recognition & intervention is essential. - observe for early signs = white, waxy appearance to exposed skin, especially on the nose, cheeks, and ears, is an effective. - dark skin = skin becomes paler, waxy, and somewhat gray. - have the person seek shelter from the wind and cold and warm body part. - with superficial use body heat - place warm hands over the affected areas or cold hands under the arms. Hospital Care: - all partial-thickness-to-full-thickness frostbite require rapid rewarming in a water bath at a temperature range of 99° to 102°F (37° to 39°C) to thaw the frozen part - part should be swirled in water and not allowed to touch the sides of the container to prevent tissue damage. - patients experience severe pain during rewarming - analgesics, IV opiates, IV rehydration, Ibuprofen for inflammation, antibiotics - tetanus shot - Apply only loose, nonadherent sterile dressings - Avoid compression of the injured tissues - diagnostics like arteriography to evaluate perfusion Critical Rescue: - NO dry heat or massage for warming because it can further damage tissue. - after rewarming, handle the injured areas gently and elevate them above heart level to decrease edema. - if a splint is used assess hourly for compartment syndrome Early s/sx of compartment syndrome: - increasing pain (even after analgesics are given) and paresthesias (painful tingling and numbness), pulselessness (faint pulse) and paralysis (weakness with movements)
Prehospital care providers
the first caregivers that patients see before transport to the ED by an ambulance or helicopter.
What are the vulnerable populations who visit the ED
the homeless, the poor, patients with mental health needs, those with substance use concerns, and older adults.
Physiological Integrity ch 11
• Assess tissue integrity for patients with bites, stings, lightning injury, and cold injury. • Establish the airway and cool the patient with heat stroke as quickly as possible. • Management of a patient who has a snakebite depends on the severity of envenomation (venom injection) • Administer antivenin drugs as prescribed for the patient with a poisonous snakebite. • Recommend cold applications, such as ice, to be used as first aid/prehospital care for the patient with a poisonous spider bite. • Be prepared to administer epinephrine as prescribed for bee and wasp sting allergic reactions, followed by antihistamine drugs. • Assess the patient with lightning injury for central nervous system and cardiovascular complications, and skin burns. • Assess for signs and symptoms of coagulopathy (abnormal clotting) or cardiac failure in the patient with moderate-to-severe hypothermia. • Avoid alcohol as a means of warming for the patient with a cold injury. • Prepare to administer cardiopulmonary support, including CPR, for a drowning victim. • Assess the drowning victim for pulmonary edema, infection, ARDS, and central nervous system impairment.
Safe and Effective Care Environment ch 10
• Emergency departments (EDs) are fast-paced, often crowded environments where the interprofessional team cares for patients with a variety of health problems across the life span. • Vulnerable populations who seek ED care include older adults and patients who are uninsured or underinsured, economically disadvantaged, or homeless. • Patients commonly seek ED care for chest or abdominal pain, difficulty breathing, injury, headache, fever, and generalized pain. • Members of the interprofessional team collaborate at all points of emergency care. • ED nurses are accountable for preventing or reducing risks such as falls, medication errors, pressure injuries, and hospital-acquired infections. • Core competencies for ED nurses include patient assessment, priority setting, clinical decision making, documentation, communication, and a sound cognitive knowledge base. • The three-level triage model categorizes patients as emergent, urgent, and nonurgent. • Trauma centers are categorized as Levels I through IV, based on their resource capabilities. • Two common injury-producing mechanisms are blunt trauma and penetrating trauma. • Prioritize resuscitation interventions based on the primary survey of the injured patient.
Health Promotion and Maintenance ch 11
• Teach people methods of preventing all types of environmental emergencies.
Physiological Integrity ch 10
• The expected sequence of events in the ED includes (1) treatment, (2) stabilization, and (3) discharge or admission. • Older adults who visit the ED are frequently admitted to the hospital. • Communication with the older adult may be challenging if the patient has memory loss or acute delirium while in the ED.
Level 1 Trauma Center
- capable of providing leadership and total collaborative care for every aspect of injury, from prevention through rehabilitation. - offer professional and community education programs, conduct research, participate in system planning. - a significant resource and experience commitment is required to maintain strict accreditation standards - usually located in large teaching hospitals and serve dense population areas - provide a full continuum of trauma services for adult and/or pediatric patients - Conducting research is a requirement for trauma center verification
Level III trauma center
- critical link to higher-capability trauma centers. - primary focus is initial injury stabilization and emergent patient transfer if necessary. - often found in smaller, rural hospitals and serve areas with lower population density. - have general surgeons and orthopedic surgeons immediately available, some major injuries may be admitted for care. - if the injuries are severe or critical, transfer to a Level I or II trauma center occurs after ED assessment, resuscitation, stabilization, and sometimes after emergent, lifesaving surgery. - typically transported out in either an advanced life support ambulance or helicopter, with critical care personnel • Stabilizes patients with major injuries • Transfers patient if needs exceed resource capabilities
Notification and Activation of Emergency Preparedness/Management Plans
- each facility decides when criteria to declare a disaster have been met based on available resources - activation of the emergency preparedness plan brings in extra resources - Notification occurs by radio, cellular, or electronic communication from the scene to the ED - A state or regional emergency management agency may also notify the ED of the event. - Group texting or paging systems, telephone trees, and instant computer-based automated alert messages are the most common means of notifying essential personnel of a mass casualty incident or disaster. - The media may be used for citizen reporting, community organizing, problem solving, and volunteer recruitment - the National Guard, the American Red Cross, the public health department, various military units, a Medical Reserve Corps (MRC), or a Disaster Medical Assistance Team (DMAT) can be activated by state and federal government authorities. - Before going to the incident in the field, all members of the interprofessional team must have adequate training, obtain prophylactic vaccinations, have a personal evacuation plan, and ensure access to necessary supplies and protective equipment so they do not become victims as well. - FEMA provides online resources, including Community Emergency Response Team (CERT) training so people are better prepared for disasters and are able to respond more self-sufficiently to incidents and hazard situations in their own communities.
What are the staff safety considerations?
- personal safety when working with patients or visitors who are aggressive, agitated, or violent. Be alert for volatile situations or people through monitoring verbal or nonverbal behaviors. hospital security plan may include nearest escape route, de-escalation strategies, and notifying security and supervisor of situation. ED visits from gang or domestic violence can be hazardous. Report all episodes of assaultive or violent behaviors through the hospital event documentation process so everyone is aware and can prepare accordingly. - potential for transmission of disease use Standard Precautions at all times tuberculosis or other airborne pathogens = negative-pressure room & powered air-purifying respirator (PAPR) or specially fitted facemask
Trauma centers
- personnel from all levels of trauma centers participate in focused system improvement and patient safety initiatives that enhance quality of care and solve identified problems.
Level IV trauma center
- priority is to offer advanced life support care in rural or remote - Patients are stabilized to the best degree possible before transfe - may not have a physician - Transport time to the final care center can be prolonged because of distance and weather - Usually located in rural and remote areas - Provides basic trauma patient stabilization and advanced life support within resource capabilities - Arranges transfer to higher trauma center levels as necessary
Altitude-Related Illnesses
- result of exposure to low partial pressure of oxygen at high elevations. - high-altitude environments are considered to be at an elevation of 1500 meters (4921 ft) or higher, 18,000 feet is extreme altitudes As altitude increases, atmospheric (barometric) pressure decreases and so does oxygen which causes hypoxia Supplemental oxygen is necessary for unacclimatized people to prevent illnesses and death an interaction of environmental and genetic factors: obesity or chronic illnesses like cardiovascular problems, dehydration, CNS depressants like alcohol, age is NOT a factor, Tibetans, variations in hypoxia-related genes and the genes responsible for the human leukocyte antigen (HLA) system. - no clinical genetic testing is available - adapting to high altitude is acclimatization = physiologic changes that help the body adapt to less available oxygen in the atmosphere. - PaO2 decreases so RR increases - mechanism is called the hypoxic-ventilatory response - Increased RR causes hypocapnia (decreased carbon dioxide) and respiratory alkalosis. REM sleep is impaired. Hypoxia can occur from periods of apnea. - Within 24 to 48 hours, the kidneys excrete the excess bicarbonate, which helps the pH to return to normal and ventilatory rate to again increase. - Increased sns activity increases heart rate, blood pressure, and cardiac output. Pulmonary artery pressure rises from hypoxia-induced pulmonary vasoconstriction. - Cerebral blood flow increases to maintain cerebral oxygen delivery. Hypoxia induces red blood cell production by stimulating the release of erythropoietin. - increase in red blood cells and hemoglobin concentration causes polycythemia ascend slowly, over the course of days or even weeks Ascending too rapidly is the primary cause of altitude-related illnesses (and less commonly, death), particularly for those who sleep at elevations above 8000 feet. acute mountain sickness (AMS), high-altitude cerebral edema (HACE), and high-altitude pulmonary edema (HAPE) = hypoxia. Chronic mountain sickness = people who live at high elevations. Health Promotion and Maintenance: Acetazolamide, a carbonic anhydrase inhibitor, to prevent or treat AMS by causing bicarbonate diuresis, which rids the body of excess fluid and induces metabolic acidosis to increase respiratory rate and decrease apnea. helps patients acclimate faster. should be taken 24 hours before ascent and continued for the first 2 days of the trip. sulfa drug. Ask about allergy. Assessment: throbbing headache, anorexia, nausea, vomiting, chills, irritability, and apathy; similar to an alcohol-induced hangover, a feeling of extreme illness. Vital signs are variable: tachycardic or bradycardic, have normal blood pressure, or have postural hypotension, dyspnea at rest. Exertional dyspnea is expected as a person adjusts to high altitude. high-altitude cerebral edema (HACE) = the patient cannot perform ADLs, has extreme apathy, ataxia (defective muscular coordination, change in mental status with confusion and impaired judgment, Cranial nerve dysfunction and seizures may occur, stupor, coma, and death from brain swelling and damage caused by increased ICP High-altitude pulmonary edema (HAPE) = within the first 2 to 4 days of a rapid ascent to high altitude, commonly on the second night - most common cause of death with high altitude - poor exercise tolerance, prolonged recovery time after exertion, fatigue, weakness, persistent dry cough and cyanosis, Tachycardia and tachypnea at rest, crackles in one or both lungs. Pink, frothy sputum is a late sign of HAPE. chest x-ray will show infiltrates and edema. Pneumonia - ABGs will show respiratory alkalosis and hypoxemia (decreased oxygen). elevated Pulmonary artery pressure from pulmonary edema. First Aid/Prehospital Care/Hospital Care: most important intervention is descent to a lower altitude. - mild AMS = rest and acclimate at the current altitude. do not ascend until symptoms lessen. - oxygen should be administered - dexamethasone anti-inflammatory to reduce cerebral edema - tadalafil and sildenafil = pulmonary vasodilator - nifedipine = decrease pulmonary vascular resistance. HAPE is a serious condition that requires quick evacuation to a lower altitude, oxygen administration, and bedrest to save the patient's life. - Keep the patient warm at all times. - Hospital admission is required. In uncomplicated cases of HAPE, recovery occurs quickly, but effects such as weakness and fatigue may persist for weeks. Preventing, Recognizing, and Treating Altitude-Related Illnesses: • Plan a slow ascent to allow for acclimatization. • Learn to recognize signs and symptoms of altitude-related illnesses. • Avoid overexertion and overexposure to cold; rest at present altitude before ascending further. • Ensure adequate hydration and nutrition. • Avoid alcohol and sleeping pills when at high altitude. • For progressive or advanced acute mountain sickness (AMS), recognize symptoms and implement an immediate descent; provide oxygen at high concentration. • To prevent the occurrence of AMS, discuss the use of acetazolamide or dexamethsone as indicated with your health care provider. • Protect skin and eyes from the harmful ultraviolet rays of the sun at high altitude. Wear sunscreen (at least SPF 30) and high-quality wraparound sunglasses or goggles.
Level II trauma center
- usually located in community hospitals and are capable of providing care to the vast majority of injured patients. - may not be able to meet the needs of patients who require very complex or multisystem injury management and will transfer them to a level 1 - play a significant leadership role in injury management • Provides care to most injured patients • Transfers patient if needs exceed resource capabilities
What occurs during debriefing and crisis support
Two general types of debriefing, or formal systematic review and analysis, occur after a mass casualty incident or disaster. The first type entails bringing in crisis support teams to provide sessions for small groups of staff, to promote effective coping strategies. The second type of debriefing involves an administrative review of staff and system performance during the event to determine whether opportunities for improvement in the emergency management plan exist.
C: Circulation
When effective ventilation is ensured, the priority shifts to circulation. Monitor vital signs, especially blood pressure and pulse. Maintain vascular access with a large-bore catheter. Use direct pressure for external bleeding; anticipate need for a tourniquet for severe, uncontrollable extremity hemorrhage, wound packing, and/or use of a hemostatic dressing. - Common threats to circulation include cardiac arrest, myocardial dysfunction, and hemorrhage leading to a shock state. - Interventions are targeted at restoring effective circulation through cardiopulmonary resuscitation, hemorrhage control, IV vascular access with fluid and blood administration as necessary, and drug therapy. - palpating for the presence or absence of peripheral and central pulses means BP: • Presence of a radial pulse: BP at least 80 mm Hg systolic • Presence of a femoral pulse: BP at least 70 mm Hg systolic • Presence of a carotid pulse: BP at least 60 mm Hg systolic
Drowning
a leading cause of accidental death in the US. Prevention: • observe people who can't swim and are in or around water. • Do not swim alone. • Test water depth before diving; never dive into shallow water. • Avoid alcohol and drugs when around water. • have rescue equipment, life jackets, flotation devices, and rope immediately available Assessment: - Aspiration of water causes surfactant to wash out of the lungs which destabilizes the alveoli and leads to increased airway resistance causing pulmonary edema. - contaminants in the water such as chemicals, algae, microbes, sand, and mud can worsen lung injury and cause infection. duration and severity of hypoxia are the two most important factors that determine outcomes for victims of drowning. - determine cause of the drowning like a seizure, myocardial infarction, brain attack, or spinal cord injury. First Aid/Emergency Care: - Priority is safe removal from the water. Then ABCs - Spine stabilization with a board or flotation device - Time is critical - airway clearance and ventilatory support measures, including delivering rescue breaths, as soon as possible while the patient is still in the water. - hypothermia =, handle gently to prevent v-fib. Critical Rescue: Getting the water out of the lungs is not priority, only give abdominal or chest thrusts if airway obstruction is suspected. Hospital Care: - ABCs, oxygen administration, intubation, CPR, and defibrillation, gastric decompression with an ng tube is needed to prevent aspiration of gastric contents and improve ventilatory function. - artificial ventilation by mask = distended abdomen = impairs movement of the diaphragm and decreases lung ventilation. - assess for pulmonary edema, infection, acute respiratory distress syndrome (ARDS), and CNS impairment.
Mass Casualty Triage
rapidly sort ill or injured patients into priority categories based on their acuity and survival potential. tag system categorizes triage priority by color and number: • Emergent (class I) patients are identified with a red tag. = immediate life-threatening conditions such as airway obstruction or shock and require immediate attention. • Patients who can wait a short time for care (class II) are marked with a yellow tag. = major injuries such as open fractures with a distal pulse and large wounds that need treatment within 30 minutes to 2 hours. • Nonurgent or "walking wounded" (class III) patients are given a green tag. = minor injuries that can be managed after more than 2 hours like closed fractures, sprains, strains, abrasions, and contusions. • Patients who are expected (and allowed) to die or are dead are issued a black tag (class IV). = massive head trauma, extensive full-thickness body burns, and high cervical spinal cord injury necessitating mechanical ventilation. to do the greatest good for the greatest number of people. The triage process should also accommodate vulnerable patients like very young infants and children, older adults, people with disabilities, psychological concerns, and people who need medical devices like a ventilator or home oxygen.
