emergency and mass casualty incidents - exam 3

rapid primary assessment

A - airway maintenance with cervical spine protection B - breathing and ventilation C - circulation with hemorrhage control D - disability and neurologic status E - exposure/environmental control questions to be asking: -are they talking/breathing -looking for visible bleeding -> circulation -tell me what happened, where are you, who are you? -can you move? -push your feet against my hands -distal bilateral pulses -cap refill -warm or cold -wet -skin problems? -singed hair around mouth -> inhalation burn -pulse ox -draw ABG if you suspect O2 deficit!!

True of False: blunt abdominal trauma is typically associated with events such as falls and motor vehicle accidents.

True!

endotracheal tube

a catheter inserted into the trachea to provide or protect an airway reasons for an emergency intubation: -can't protect airway for some reason -stroke -spinal cord injury -massive trauma to the face -coding think like a nurse! -encourage deep breathing and coughing -small amount of bleeding is expected, continuous oozing is ABNORMAL -suction when needed -check placement -> equal, bilateral breath sounds, chest xray

multiple trauma

a single catastrophic event that causes life-threatening injuries to at least two organ systems

A - airway (primary survey)

diagnosis: ineffective Airway Clearance r/t obstruction or actual injury -immobilize cervical spine! -LOOK - is there obvious airway trauma, tachypnea, accessory muscle use, tracheal shift? is there swelling (occurs with inhalation burn)? -LISTEN - stridor, hyper-resonance, dullness to percussion -FEEL - for air exchange over the mouth -SECURE AIRWAY - oropharyngeal, nasopharyngeal, ETT, cricothyrotomy

doffing

gloves, goggles, gown, mask, hand hygiene

decontamination

goal is to prevent secondary contamination 1. first remove all of patient's clothing and jewelry and then rinsing them with water -ideally, this should be prior to patients entering the facility, to prevent accidental contamination of emergency services area and staff 2. second step consists of a thorough soap and water wash and rinse

traumatic wound care

goals: -restore tissue integrity -prevent hemorrhage -prevent infection may require irrigation and debridment

managing hemorrhage

goals: -control bleeding -maintain circulating blood volume for tissue oxygenation -prevent shock think like a nurse! -pt may require isotonic electrolyte solutions, colloids, and blood components -> IV fluids! -to stop active bleeding, firm pressure is applied over the bleeding area -nursing surveillance of the total patient is maintained

triage during MCI

greatest good for the greatest number of people

trauma assessment

patient is now considered "stable" while preforming head-to-toe assessment (ABCDE) -> other team members should prepare to treat life threatening injuries: -relieve increased ICP -thoracotomy for heart great vessel damage -laparotomy to GI perforation or splenic rupture -repair major vascular injury CT scan is defined as test of choice in evaluation of GU system for gross hematuria use abdominal ultrasound as adjunct or to replace Diagnostic Perineal Lavage (DPL)

primary vs secondary survey

primary survey focuses on stabilizing life-threatening conditions (airway, breathing, circulation, disability, exposure/environmental) secondary survey includes subsequent assessments and interventions

external mechanism of injury

radiation, electrical, thermal, chemical, and mechanical forms

carbon monoxide poisoning

-carbon monoxide binds with hemoglobin and reduces oxygen supply to tissues -cannot be seen. smelled, or tasted s/s: -nausea, vomiting -headache -weakness -unconsciousness management: -goals are to reverse hypoxia and to hasten elimination of carbon monoxide -nonrebreather mask at 100% O2! -assess HH, CBC, dissolved O2 where does the body store O2 in reserve? -> lungs, brain draw up ABG!! -pulse Ox will be at 100% and not indicate a problem! -PaO2 will be very low! -ABG -> arterial blood

type of agents

-chemical agents -blood agents -choking agents -nerve agents -incapacitating agents -radiological agents

psychological effects after MCI

-families and friends arriving in search of loved ones may be experiencing extreme grief, anxiety, or even shock -must be kept in separate area from triage -refer patients and families to therapists and social workers -discourage media replays and news articles stress management: -goal is to prevent and treat emotions caused by trauma -defusing -> recognition of stress reactions and management strategies for handling stress -debriefing -> discussion of emotional rxn to trauma -demobilization -> rest and food before returning to pre-incident routines -follow-up -> contact participants for follow up meetings

intra-abdominal injury

-penetrating or blunt -penetrating is harder to compress -major complications -> hemorrhage and infection

hospital emergency preparedness plans

-required by Joint Commission -patient tracking and triage are priorities -clear communication is imperative

phases of trauma care

1. at the time of injury = 50% at scene or en route -cause of death: laceration of brain, brainstem, high spinal cord injuries, injury to heart, aorta, or large vessels 2. second peak (minutes-few hours) = 30% occur in ED or OR -subdural or epidural hematoma, pneumothorax, ruptured spleen, liver laceration, pelvic injury, injuries associated with excessive blood loss 3. third peak (days-weeks) = 20% occur in ICU -sepsis, multiple organ failure

five levels of emergency triage

1. resuscitation 2. emergent 3. urgent 4. non-urgent 5. minor

blunt trauma

An impact on the body by objects that cause injury without penetrating soft tissues or internal organs and cavities most common -> MVC, contact sports, blunt force injuries or falls

Which of the following nursing actions would the emergency nurse prioritize in the care of a newly admitted patient? A. Identifying the patient's medication history B. Establishing intravenous access C. Providing adequate ventilation D. Facilitating an ECG

C. Providing adequate ventilation

critical care phase

admitted into ICU, from ED, OR on arrival to ICU -> use primary, secondary survey and resuscitative measures to assess status priority nursing care is ongoing physical assessment and monitoring of response assess for complications such as acute respiratory failure, sepsis, prolonged shock states, multi system organ dysfunction (MODS) one of the most important roles is assessment of balance of oxygen delivery and oxygen demand -if there are subtle changes -> implementation of timely therapy help prevent complications! also, consider the time that has elapsed from the actual traumatic event and how that may affect the patient (ex. MVA - patient releases a lot of adrenaline which eventually will wear off).

mass casualty incident

an influx of patients that overwhelms a hospital and affects its capability to care for patients begins at the local level with emergency responders and volunteers incident command center-local organizations that coordinates personal, facilities, equipment, and communication in emergency

secondary survey

begins when primary survey is completed, resuscitation is well established, patient is demonstrating normalization of vital signs head to toe approach thoroughly examine each body region history is one of most important aspects -AMPLE Allergies Medications Past medical illness/pregnancy Last meal Events/environment related to injury

mechanical energy => injury

blunt or penetrating traumatic injuries

managing airway obstruction

causes of airway obstruction -> maneuvers to restore airway: -abdominal thrusts -the head-tilt-chin-lift maneuver -the jaw-thrust maneuver -oropharyngeal airway endotracheal intubation -> may be necessary if respiratory insufficiency or hypoxia after airway is cleared, NURSE ensures adequate ventilation is maintained

poisoning

causes: OD, wrong med, household cleaners what should you do? -remove or inactivate the poison before it is absorbed -provide supportive care to maintain organ systems -administer a specific antidote -implement treatment to hasten elimination -call poison control!!

what happens after secondary phase?

definitive care/operative phase -definitive care related to specific injuries -trauma at times referred to as "surgical disease" -after surgery may need transfer to critical care

C - circulation (primary survey)

diagnosis: -decreased CO r/t actual injury -alteration in tissue perfusion r/t actual injury or shock -deficient fluid volume r/t actual loss of circulating volume assess pulse quality/rate ECG Monitoring IF NO pulse -basic CPR -initiate ACLS pulse but ineffective -assess & treat life threatening conditions (uncontrolled bleeding shock) -check distal pulses! initiate 2 large bore IV, IO, or central catheter; obtain labs fluid replacement -normal saline with blood! -LR before hospital

B - breathing (primary survey)

diagnosis: -ineffective breathing pattern r/t actual injury -impaired gas exchange r/t actual injury or disrupted tissue perfusion ASSESS for: -spontaneous breathing -respiratory rate, depth, symmetry -chest wall integrity IF ABSENT breathing: -intubate, mechanical ventilation IF breathing but ineffective: -assess life-threatening conditions (tension pneumo, flail chest) administer supplemental oxygen -ALL trauma patients should be on oxygen! initiate pulse oximetry!

D - disability (primary survey)

diagnosis: -ineffective cerebral tissue perfusion -risk for injury r/t actual injury of brain or spinal cord assess glasgow coma scale (GCS) assess pupil size & reactivity assure cervical spine immobilization

E - environment (primary survey)

diagnosis: -risk for imbalanced body temperature -could be caused by high altitude, hypothermia, Texas heat, dehydrated remove all clothing to inspect all body regions prevent hypothermia -remove wet clothing -doesn't always happen during winter! body needs to be WARM to be dead

donning

hand hygiene, gown, mask, goggles, gloves

trauma head-to-toe assessment

head -scalp -facial skeleton -eyes -ears -nose -mouth neck -c-spine -trachea -vein distention chest front and back -look for -feel for -auscultate -standard chest x-ray abdomen -look for -auscultate -further investigate x-ray, US, or DPL pelvic trauma -accompany other injuries frequently -GU damage occurs in 1 of 5 perineum -check meatus blood -prostate if elevated s/s of pelvic trauma -vaginal/rectal exam for blood, lacerations, foreign objects limbs -look for -feel for -ROM all joints -x-ray if suspicion

resuscitation phase

hypovolemic shock is most common type of shock that occurs with trauma patients hemorrhage must be identified and treated promptly IV therapy with LR, warmed fluids, high rates -if unresponsive to fluid, give O negative blood or type specific -place foley aim is to ensure adequate perfusion to the tissue with oxygen and nutrients to support cellular function -must assess for response - key to determine subsequent therapy goal is to attempt to improve oxygen delivery, to normalize base deficit, lactate or gastric pH during the 1st 24 hours after injury

penetrating trauma

injury caused by an object that passes through the skin or other body tissues causes: stabbing, fire arms, or accidents resulting in impalement damage occurs along path of penetration -> think of what is in the neighborhood! nursing considerations: -do NOT take out object -wear gloves!

PPE levels

level A -is worn when the highest level of respiratory, skin, eye, and mucous membrane protection is required -includes a self-contained breathing apparatus (SCBA) and a fully encapsulating, vapor-tight, chemical resistant suit with chemical resistant gloves and boots level B -requires highest level respiratory protection but lesser level of skin and eye protections -includes positive pressure, full faced piece SCBA, inner and outer chemical resistant gloves, face shield, hooded chemical resistant clothing, coveralls, and boots level C -includes air-purified respiratory, which uses filters or sorbent material to remove harmful substances from the air -a chemical resistant coverall with splash hood, chemical resistant gloves, and boots level D -work uniform that may include gloves, glasses, or face shield

triage under normal circumstances

resuscitation, emergent, urgent, non-urgent, and minor consider what resources are available red triage tag ("immediate" or priority 1): pts whose lives are in immediate danger and who require immediate treatment yellow triage tag ("delayed" or priority 2): pts whose lives are not in immediate danger and who will require urgent, not immediate, medical care green triage tag ("minimal" or priority 3): pts with minor injuries who will eventually require treatment black triage tag ("expectant" or no priority): pts who are either dead or who have such extensive injuries that they can not be saved with the limited resources available.

natural disaster

rule of 6: 1. look out for #1 2. what happened to you? 3. not on me -> PPE 4. is there anymore? 5. dead or alive 6. am I in a fix? -preparation is key, due to the unpredictability of natural disasters -the majority of the immediate casualties are trauma-related -later cases often involve excessive exposure to the natural elements and the need for food and water

anaphylactic reaction

severe reaction occurring immediately after exposure to a drug; characterized by respiratory distress and vascular collapse priorities: -establishing a patent airway, -ventilation -administration of epinephrine

crush injuries

sudden blow or blunt trauma -> occur when a person is caught between opposing forces -often results in internal injuries