Exam 6 NUR 222

When the nurse is performing a rapid neurologic assessment in the ED, what mnemonic is helpful?

A quick neurologic assessment baby performed using the AVPU mnemonic: A- alert; is the patient alert and responsive? V- verbal; does the patient respond to verbal stimuli? P- pain; does the patient respond only to painful stimuli? U- unresponsive; is the patient unresponsive to all stimuli, including pain?

Interventions for cerebral edema:

- Administer osmotic diuretics as prescribed and monitor serum osmolality. - Maintain head of bed elevation at 30 degrees. - Maintain head alignment.

Primary Survey: B is for Breathing

- Breathing: Assessment: Assess for dyspnea, cyanosis asymmetric chest wall movement, decreased/absent breath sounds, visible wound to chest wall, cyanosis, tachycardia, hypotension - Breathing: Interventions: Administer high-flow O2 via a nonrebreather mask - For life-threatening conditions: Bag-valve-mask (BVM) ventilation with 100% O2 Needle decompression Intubation Treatment of underlying cause - Adequate airflow through the upper airway does not mean the patient is getting proper ventilation. - Lots of conditions cause breathing changes such as fractured ribs, pneumothorax (decreases/absent breath sound on one side), tension pneumothorax (chest wall intact; puncture in lung that releases air in that space), penetrating injuries, PE, asthma. There is an increase in metabolic and oxygen demand.

Yellow

- Delayed: Injuries are significant and require medical care but can wait hours without threat to life or limb. Individuals in this group receive treatment only after immediate casualties are treated. - Second priority: 2 - Examples include: Stable abdominal wounds without evidence of significant hemorrhage; soft tissue injuries; maxillofacial wounds without airway compromise; vascular injuries with adequate collateral circulation; genitourinary tract disruption; fractures requiring open reduction, débridement, and external fixation; most eye and central nervous system injuries

Injuries to the brain can be focal or diffuse.

- Focal injuries include contusions and several types of hematomas. - Concussions and diffuse axonal injuries are the major diffuse injuries

In this category of predicted survival after radiation exposure patients present with n/v that persist for 24-48 hours 1. possible 2. probable 3. improbable 4. None of these are correct

1

The _____ of radiation determines if acute radiation syndrome develops 1. dose 2. source 3. both 1 & 2 4. None of the above

1

This chemical weapons works by inhibiting aerobic metabolism 1. cyanide 2. sarin 3. mustard gas 4. chlorine

1

The most common victims of snakebites are those between the ages of:

1 and 9

In carbon monoxide poisonings, pulse oximetry may reveal a _______hemoglobin saturation. 1. high 2. low 3. not able to read

1. high

Basilar skull fracture

A fracture at the base of the skull - Unique fracture at base of skull - Usually extends to the anterior, middle or posterior fossa - Results in CSF leakage from nose or ears

Drugs Producing Sedation, Intoxication, or Psychological and Physical Dependence (nonbarbiturate sedatives) manifestations

Acute intoxication: Respiratory depression Decreasing mental alertness Confusion Slurred speech, decreased blood pressure Ataxia Pulmonary edema Coma, death Flunitrazepam: Disinhibition with antegrade amnesia Weakness and unsteadiness with impaired judgment Powerlessness

Tissue damage is a product of

Animal size Characteristics of animal's teeth Strength of jaw - Tissue is lacerated, crushed or chewed, while teeth fangs, and/or stingers release the toxins and can have local/systemic effects. - Death results from blood loss, allergic reactions, lethal toxins, direct tissue damage.

Four federal agencies that provide disaster assistance are:

Department of Health and Human Services, Department of Justice, Department of Defense, Department of Homeland Security

T or F: Health care facilities are required by The Joint Commission to create a plan for emergency preparedness and to practice this plan once a year.

False - twice a year

Assessment of Neurogenic Bladder

Fluid Intake Urine output Residual urine volume UA Assessment of sensory awareness & motor control Urodynamic studies Complications: Infection, stones, impaired skin integrity.

Epidemic/Pandemic

Foodborne poisonings Acute outbreak, unexpected; local or distant transmission due to travel Risk: Determined by population density, travel, method of transmission Illness: Depends on organism involved.

Nursing diagnosis for people with spinal cord injuries

Ineffective breathing pattern Ineffective airway clearance Impaired physical mobility Disturbed sensory perception Risk for impaired skin integrity Impaired urinary elimination Constipation Acute pain

S/S of shock:

Mental status Delayed capillary refill Cool, clammy moist skin Poor peripheral perfusion Decreased BP Increased HR Decreasing urine volume *Altered mental status and delayed cap refill are common signs of shock.*

Cardinal symptoms of heat stoke include

Muscle cramps, profound diaphoresis, and profound thirst

The carnal manifestations of heat cramps include _______, particularly in the shoulders, abdomen, and lower extremities; _______, and ________

Muscle cramps; profound diaphoresis, profound thirst

Autonomic Dysreflexia (Triggering stimuli):

Obstruction with emptying the bladder (distended bladder most common cause) Distention or contraction of visceral organs (such as constipation, fecal impaction) Stimulation of the skin

Salicylate Poisoning Aspirin (present in compound analgesic tablets) manifestations

Restlessness Tinnitus, deafness Blurring of vision Hyperpnea Hyperpyrexia Sweating Epigastric pain, vomiting Dehydration Respiratory alkalosis and metabolic acidosis Disorientation, coma Cardiovascular collapse Coagulopathy

Autonomic Dysreflexia (Symptoms):

Severe pounding headache Hypertension (up to 300 mm Hg) Profuse diaphoresis above the level of injury Nausea Nasal congestion Bradycardia (30 to 40 bpm) Anxiety

Additional Interventions (SCI)

Strategies to compensate for sensory and perceptual alterations Measures to maintain skin integrity Temporary indwelling catheterization or intermittent catheterization NG tube to alleviate gastric distention High-calorie, high-protein, high-fiber diet Bowel program and use of stool softeners Traction pin care Hygiene and skin care related to traction devices

What are the three signs of brain death?

The three cardinal signs of brain death on clinical examination are coma, the absence of brainstem reflexes, and apnea. - Adjunctive tests, such as cerebral blood flow studies, electroencephalogram (EEG), transcranial Doppler, and brainstem auditory-evoked potential, are often used to confirm brain death

Immediate management to relieve increased ICP requires decreasing cerebral edema, lowering the volume of CSF, or decreasing cerebral blood volume while maintaining cerebral perfusion. How is this accomplished?

These goals are accomplished by administering osmotic diuretics, restricting fluids, draining CSF, controlling fever, maintaining systemic blood pressure and oxygenation, and reducing cellular metabolic demands.

T or F: If life-threatening conditions related to ABCs are identified during primary survey, interventions are started immediately and before proceeding to the next step of survey

True

T or F: Meningitis is an inflammation of the pia mater, the arachnoid, and the cerebrospinal fluid-filled subarachnoid space

True

T or F: The primary responsibility of the nurse in MCI is to be aware of the agency's response plan.

True

T or F: The therapeutic approach is to allow the anger to be expressed and to assist the family members to identify their feelings of frustration.

True

T or F: Trauma involving the central nervous system can be life threatening.

True - Even if not life threatening, brain and spinal cord injury (SCI) may result in major physical and psychological dysfunction and can alter the patient's life completely.

The nurse received a patient from a motor vehicle crash who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage? a. Apply a tourniquet b. Apply firm pressure over the involved area or artery c. Elevate the injured part d. Immobilize the area to control blood loss

b

A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing intervention should be provided? (Select all that apply.) a. Have the patient shower or wash the perineal area before the examination b. Assess and document any bruises and lacerations c. Record a history of the event, using the patient's own words d. Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the policed. e. Ensure that the police are present when the examination is performed

b, c, d

E3. The nurse is assisting with a lumbar puncture and observes that when the physician obtains CSF, it is clear and colorless. What does this indicate? a. A subarachnoid hemorrhage b. An overwhelming infection c. A normal finding; the fluid will be sent for testing to determine other factors d. Local trauma from the insertion of the needle

c

E4While riding a bicycle in a race, a patient fell into a ditch and sustained a head injury. Another cyclist found the patient lying unconscious in the ditch and called 911. What type of concussion does the patient most likely have? A. grade 1 concussion B. grade 2 concussion C. grade 3 concussion D. grade 4 concussion

c

What color category would stable abdominal wound without hemorrhage fall under?

yellow

Temporal Lobe

Auditory center for sound interpretation Complicated memory patterns Wernicke's area for speech

4. A ___ is used to diagnose a skull fracture

CT scan

Only three states and the District of Columbia have locations for national medical response teams for weapons of mass destruction. These states are:

California, Colorado, North Carolina

What is Lyme disease treated with

Doxycycline

Grief

Grief is a complex emotional response to anticipated or actual loss. The key nursing intervention is to help family members work through their grief and to support their coping mechanisms, letting them know that it is normal and acceptable for them to cry, feel pain, and express loss. The hospital chaplain and social services staff serve as invaluable members of the team when assisting families to work through their grief.

What things are not considered resources

- History and physical - Saline lock - PO medication - Tetanus - Prescription refills - Phone call to primary care - Point of care testing - Simple wound care - Crutches - Splint and slings.

The patient in an crushed injury is observed for the following:

- Hypovolemic shock resulting from extravasation of blood and plasma into injured tissues after compression has been released - Spinal cord injury - Erythema and blistering of skin - Fractures (usually an extremity) - Acute kidney injury (acute tubular necrosis [ATN])

Multisystem Assessment Measures for the Patient With Traumatic Brain Injury: Skeletal

Immobility contributes to musculoskeletal changes. Decerebrate or decorticate posturing makes proper positioning difficult. Assessment of range of motion of joints and development of deformities or spasticity

Multisystem Assessment Measures for the Patient With Traumatic Brain Injury: Skin

Immobility secondary to TBI and unconsciousness contributes to the development of pressure areas and skin breakdown. Intubation causes irritation of the mucous membrane and deterioration of oral health. Assessment of skin integrity and character of the skin Assessment of oral mucous membrane and oral health

Why is lactated ringer's solution initially useful as fluid replacement for a patient experiencing hypovolemic shock?

Lactated ringer solution is initially useful because it approximates plasma electrolyte composition and osmolality, allows time for blood typing and screening, restoring circulation, and serves as an adjunct to blood components therapy

Depressed skull fractures

Occur when the bones of the skull are forcefully displaced downward, and can vary from a slight depression to bones of the skull being splintered and embedded within brain tissue. - The bone is pressed inward into the brain tissue to as least the thickness of the skull

Catheterization is performed to achieve the following:

Relieve urinary tract obstruction Assist with postoperative drainage in urologic and other surgeries Provide a means to monitor accurate urine output in patients who are critically ill Promote urinary drainage in patients with neurogenic bladder dysfunction or urine retention Prevent urinary leakage in patients with stage III to IV pressure ulcers

A poison is any substance that, when ingested, inhaled, absorbed, applied to the skin, or produced within the body in relatively small amounts, injures the body by its chemical action. Poisoning from inhalation and ingestion of toxic materials, both intentional and unintentional, constitutes a major health hazard and an emergency situation. Emergency treatment is initiated with the following goals:

Removal or inactivation of the poison before it is absorbed Provision of supportive care in maintaining vital organ function Administration of a specific antidote to neutralize a specific poison Implementation of treatment that hastens the elimination of the absorbed poison - Control airway ventilation, oxygenation, and prevent shock. - Call poison control immediately because they guide you through treatment; they tell you what to do, what to monitor and how long they need to be monitored for. - Important to determine what, when and how substance was ingested, and obtain a health history and weigh the patient.

Name at least four cultural variables that healthcare providers need to consider in any disaster situation in which a large number of diverse religious and ethnic groups of patients need to be treated:

Some cultural considerations include language differences, a variety of religious preferences, rituals of prayer, traditions for burying the dead, and the timing of funeral services

A patient with a foreign body airway obstruction typically demonstrates the inability to _____________? With complete obstruction, permanent brain injury will result in how many minutes?

Speak, breathe, cough; 3 to 5 minutes

What is tentorium?

The dura mater between the cerebral hemispheres and the cerebellum Helps to decrease or prevent transmission of force from one hemisphere to the other Protects the lower brainstem when head trauma occurs

Smallpox:

Virus, Incubation 12 days Extremely contagious; spread by direct contact, by contact with clothing or linens, or by droplets person-to-person Manifestations: High fever, malaise, headache, backache, and prostration; after 1 to 2 days a maculopapular rash appears on the face, mouth, pharynx, and forearms Treatment is supportive care with antibiotics for any additional infection Vaccinate if reintroduced - isolated with the use of transmission precautions

Characteristics of Chemicals: Volatility

Volatility is the tendency for a chemical to become a vapor. The most common volatile agents are phosgene and cyanide. Most chemicals are heavier than air, except for hydrogen cyanide. Therefore, in the presence of most chemicals, people should stand up to avoid heavy exposure (because the chemical will sink toward the floor or ground).

Define TBI

Traumatic brain injury (TBI) or craniocerebral trauma describes an injury that is the result of an external force and is of sufficient magnitude to interfere with daily life and prompts the seeking of treatment.

A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure? a. Give an analgesic as prescribed b. Massage the extremities c. Elevate the legs d. Apply a heat lamp

a

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include: a. pupillary changes. b. diminished responsiveness. c. decreasing blood pressure. d. elevated temperature.

b

A triage patient with a significant injury that can wait several hours for treatment would be a sign of white priority? a. Priority 1 b. Priority 2 c. Priority 3 d. Priority 4

b

A simple (linear) fracture

a break in the continuity of a bone - Simple, clean break - The impacted area of bone bends inward & area around bends outward

An example of a biological weapon of mass destruction is ________; An example of chemical weapon of mass destruction is _______

anthrax; chlorine

E11. A patient has expressive speaking aphasia after having a stroke. Which portion of the brain does the nurse know has been affected? A. Temporal lobe B. Inferior posterior frontal area C. Posterior frontal area D. Partietal-occipital area

b

E11For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? A. so that the patient will not have a respiratory arrest B. because hypoxemia can create or worsen a neurological deficit of the spinal cord C. to increase cerebral perfusion pressure D. to prevent secondary brain injury

b

E12. The nurse is assessing the pupils of a patient who has had a head injury. What does the nurse recognize as a parasympathetic effect? A- Dilated pupils B- Constricted pupils C- One pupil is dilated and the opposite pupil is normal D- Roth's spots

b

Patient was brought into the ED after sustaining injuries due to an explosion while welding. The patient is breathing but has an oxygen saturation of 90%, a respiratory rate of 32, and is coughing. What is the priority action by the nurse? a. Give oxygen at 2 L/min via nasal cannula b. Give oxygen with a nonrebreather mask c. Start an IV of normal saline solution at 125 mL/h d. Obtain a chest x-ray

b

Radiation: Latent phase

(a symptom-free period) After resolution of prodromal phase; can last up to 3 weeks With high-dose radiation, latent period is shorter Decreasing lymphocytes, leukocytes, thrombocytes, red blood cells

A nurse is working as a camp nurse during the summer. A camp counselor comes to the clinic after receiving a snake bite on the arm. What is the first action by the nurse? a. Apply ice to the area b. Apply a tourniquet to the arm above the bite c. Have the patient lie down and place the arm below the level of the heart d. Mark an incision and suck the venom out

c

Radiation: Prodromal phase

(presenting symptoms) 48-72 hours after exposure Nausea, vomiting, loss of appetite, diarrhea, fatigue High-dose radiation—fever, respiratory distress, and increased excitability

Spinal injury: Gastrointestinal and Genitourinary Dysfunction

- Abdominal assessment for internal bleeding, distention, or paralytic ileus - Neurogenic bladder

Ingested (Swallowed) Poisons

- Corrosive poisons include alkaline and acid agents that can cause tissue destruction after coming in contact with mucous membranes. - Alkaline products include lye, drain cleaners, toilet bowl cleaners, bleach, nonphosphate detergents, oven cleaners, and button batteries (batteries used to power watches, calculators, hearing aids, or cameras). - Acid products include toilet bowl cleaners, pool cleaners, metal cleaners, rust removers, and battery acid. - Control of the airway, ventilation, and oxygenation are essential. - ECG, vital signs, and neurologic status are monitored closely for changes. - Shock may result from the cardiodepressant action of the substance ingested, from venous pooling in the lower extremities, or from reduced circulating blood volume resulting from increased capillary permeability - An indwelling urinary catheter is inserted to monitor kidney function. - Blood specimens are obtained to determine the concentration of drug or poison. - Efforts are made to determine what substance was ingested; the amount; the time since ingestion; signs and symptoms, such as pain or burning sensations, any evidence of redness or burn in the mouth or throat, pain on swallowing or an inability to swallow, vomiting, or drooling; age and weight of the patient; and pertinent health history. - The local poison control center should be called if an unknown toxic agent has been taken or if it is necessary to identify an antidote for a known toxic agent. - If there is a specific chemical or physiologic antagonist (antidote), it is given as early as possible to reverse or diminish the effects of the toxin. If this measure is ineffective, procedures may be initiated to remove or dilute the ingested substance. These procedures include administration of multiple doses of activated charcoal, dialysis, or hemoperfusion. - Hemoperfusion involves detoxification of the blood by processing it through an extracorporeal circuit and an adsorbent cartridge containing charcoal or resin, after which the cleansed blood is returned to the patient. - The patient who has ingested a corrosive poison, which can be a strong acid or alkaline substance, is given water or milk to drink for dilution. However, dilution is not attempted if the patient has acute airway edema or obstruction; potential for vomiting; or if there is clinical evidence of esophageal, gastric, or intestinal burn or perforation. - Cathartics, which had traditionally accompanied the use of activated charcoal, are now rarely indicated because they can result in severe electrolyte imbalances, diarrhea, and hypovolemia. - Syrup of ipecac to induce vomiting in the patient who is alert is not recommended due to the risk of aspiration and should never be used with corrosive poisons or with petroleum distillates (e.g., lubricating oil, fuel oil) or further corrosive damage to the upper airway and pharyngeal structures may occur. - Vomiting is never induced after ingestion of caustic substances (acid or alkaline) or petroleum distillates. - Throughout detoxification, the patient's vital signs, CVP, and fluid and electrolyte balance are monitored closely. Hypotension and cardiac dysrhythmias are possible. Seizures are also possible because of CNS stimulation from the poison or from oxygen deprivation. - If the patient complains of pain, analgesic agents are given cautiously. Severe pain causes vasomotor collapse and reflex inhibition of normal physiologic functions.

A nurse is undergoing debriefing with the critical incident stress management team after participating in the response to a disaster. During this process, the nurse will do which of the following? a. Evaluate the care that they provided during the disaster. b. Discuss own emotional responses to the disaster. c. Explore the ethics of the care provided during the disaster. d. Provide suggestions for improving the emergency operations plan.

b. Discuss own emotional responses to the disaster. - In debriefing, participants are asked about their emotional reactions to the incident, what symptoms they may be experiencing (e.g., flashbacks, difficulty sleeping, intrusive thoughts), and other psychological ramifications. The emergency operations plan (EOP) and the care the nurse provided are not evaluated.

Donning COVID 19 PPE

1.Identify and gather the proper PPE to don. 2.Perform hand hygiene using hand sanitizer. 3.Put on isolation gown. Tie all of the ties on the gown. Assistance may be needed by another HCP. 4.Put on NIOSH-approved N95 filtering face piece respirator or higher (use a facemask if a respirator is not available). Nose piece it should be fitted to nose with both hands, not bent or tented; DO NOT PINCH. Extended under the chin. Respirator strap should be on the crown and the other should be on the base of the neck. User seal check every time you put it on. 5.Put on face shield or goggles 6.Perform hand hygiene before putting on gloves. Gloves should cover the cuff (wrist) of gown. 7.HCP may now enter patient room.

Severe head injury GCS

3-8

Antivenin is to treat snake bites must be given within a timeframe of how many hours?

4-12

The nurse is caring for a client with meningitis and implements which transmission-based precautions for this client? A. Private room or cohort client B. Personal respiratory protection device C. Private room with negative airflow pressure D. Mask worn by staff when the client needs to leave the room

A.

Radiation: Recovery

After manifest illness phase Can take weeks to months for full recovery

Two biological agents most likely to be used during a terrorist attack are:

Anthrax, smallpox

A4. Three primary complications of increased ICP are:

Brain stem herniation, diabetes insipidus, SIADH

A client with a C6 SCI is admitted to the ED complaining of a severe pounding HA and has a BP of 180/110. Which intervention should the ED RN implement? A. Keep the client flat in bed B. Dim the lights C. Assess for bladder distention D. Administer narcotics

C. Autonomic dysreflexia.

Hurricanes

Causes flooding and tornadoes (see later discussion) Failure to evacuate Food and water safety Injuries: From recovery activities (e.g., chainsaws), stress-related disorders, and GI and other vector-borne disease; physical injury; bites from traumatized pets

CIWA

Clinical Institute Withdrawal Assessment for Alcohol

Checking cap refill in cold environment?

Cold temperature delays the cap refill.

Intracranial Surgery

Craniotomy Craniectomy Cranioplasty Burr holes

E15A patient has an S5 spinal fracture from a fall. What type of assistive device will this patient require? A. voice or sip-n-puff controlled electric wheelchair B. electric or modified manual wheelchair, needs transfer assistance C. cane D. the patient will be able to ambulate independently

D.

Abrasion:

Denuded skin

What is drowning?

Drowning is the process of experiencing respiratory impairment after being submerged.

Volcanic eruptions

Hazards from lava, openings in ground, gases, ash up to a 20 mile radius Injuries: Acid rain; toxic gases result in inhalation injury; physical injury

Increased ICP causes:

Hypoxia, cerebral edema, hypercapnia, impaired venous return and increase in intrathoracic or abdominal pressure.

Your patient is dx with diffuse axonal injury. Which intervention is appropriate to decrease ICP?

Keep the patient head in a neutral midline position. - Remove cervical collars

Level D PPE

Level D protection is the typical work uniform.

Infectious Neurologic Disorders

Meningitis Brain abscesses Encephalitis Creutzfeldt-Jakob disease and variant Creutzfeldt-Jakob disease

What is ICP?

Normal: 0 -10 Upper limit of normal 15 Greater than 20 can result in herniation

Glasgow Coma Scale

Objectively describe the extent of the impaired consciousness of all types of acute and medical trauma patients.

Human bites are a higher risk for infection

Oral bacterial flora Aerobic and anaerobic bacteria Staph, Strep, Eikenella common Hepatitis B or C, HIV Human jaw has great crushing ability Infection rates as high as 50% with 24-hour delay

People at greatest risk for infections include:

PVD, immunocompromised, infants, elderly, and people on corticosteroids.

Frontal Lobe

Primary motor area Broca's speech center (Dominant side) Voluntary eye movement Access to current sensory data

Occipital Lobe

Primary visual center

What are the most important signs for a Basilar Skull Injury?

Raccoon eyes and battle sign, halo sign, glucose test.

Autonomic dysreflexia occurs among patients with spinal cord lesions above thoracic vertebra __________ after spinal shock has subsided.

T6

Pressure Points for Hemorrhage Control

Temporal, facial, carotid, subclavian, brachial, radial/ulnar, femoral

Glascow Coma Scale (GCS)

The Glasgow Coma Scale is a tool for assessing a patient's response to stimuli. Scores range from 3 (deep coma) to 15 (normal).

Multisystem Assessment Measures for the Patient With Traumatic Brain Injury: Nutritional

The patient receives all fluids IV for the first few days until the GI tract is functioning. A nutritional consultation is initiated within the first 24-48 hours; parenteral or enteral nutrition may be started. Assessment of fluid and electrolyte balance Recording of weight, if possible Hematocrit Electrolyte studies

T or F: Acute upper airway obstruction is a life-threatening medical emergency.

True

Management of wounds

Wound cleansing Closure

A comminuted skull fracture

a splintered or multiple fracture line. - Involves fragmented bone with depression in the brain

Supratentorial

above the tentorium -Incision is made above the area to be operated on; usually located behind the hairline. - Maintain head of bed elevated at 30 degrees, with neck in neutral alignment. - Position patient on either side or back. (Avoid positioning patient on operative side if a large tumor has been removed.)

initial management of non-fatal drowning include:

assess airway, cervical spine, breathing and circulation.

The nurse is triaging people that have been involved in a bus accident. A triage patient with psychological disturbances would be tagged with which color? a. Black b. Green c. Red d. Yellow

b

A patient has experienced blunt abdominal trauma from a motor vehicle crash. The nurse assesses the patient, knowing that which organ is the most frequently injured solid abdominal organ? a. Duodenum b. Large bowel c. Liver d. Pancreas

c

E10. When educating a patient about the use of anticonvulsant medication, what should the nurse inform the patient is a result of long-term use of the medication in women? a. Anemia b. Osteoarthritis c. Osteoporosis d. Obesity

c

9. The three criteria used to assess LOC using the GSC are:

eye opening, verbal response, and motor responses to verbal commands or painful stimuli

The most common causes of traumatic brain injury are ______.

falls

Factors for prolonged recovery from concussion include:

female, less than 18 years old, mental health issues, cervical involvement

5. The most serious brain injury that can develop within the cranial vault is a

hematoma

The three most common localized signs of increased ICP are

hemiparesis, seizures, and mental status changes

A7. The "master gland" is also known as the

pituitary

What color category with third degree burns over 25% total body surface area fall under?

red

Immediate management of spinal cord injury include

stabilize the spine - Cervical Collar - Halo and vest - Back board

Avulsion:

tearing away of tissue from supporting structures

A4. The lobe of the cerebral cortex that is responsible for the understanding of language and music is the

temporal

Includes the auditory center for sound interpretation

temporal

What are meninges?

the protective covering of the brain and spinal cord

Hematoma:

tumorlike mass of blood trapped under the skin

The nurse is administering the IV antiviral medication ganciclovir (Cytovene) to the patient with HSV-1 encephalitis. What is the best way for the nurse to administer the medication to avoid crystallization of the medication in the urine? A. Administer the medication rapidly over 15 minutes with 100 mL of normal saline. B. Dilute the medicine in 500 mL of lactated Ringer's solution C. Administer via slow IV over 1 hour D. Administer in a drip over 4 hours

c

The nurse is assisting in a disaster caused by a massive tornado that has destroyed much of the community. This disaster will require state wide and federal assistance. What classification would this disaster be? a. Level I b. Level II c. Level III d. Level IV

c

The nurse is giving antivenin to a patient who was bitten on the arm by a poisonous snake. What intervention provided by the nurse is required prior to the procedure and every 15 minutes after? a. Give diphenhydramine b. Give cimetidine c. Measure the circumference of the arm d. Assess peripheral pulses

c

Several patients that have been involved in a bombing are unlikely to survive. What priority are these patients given during triage? a. Priority 1 b. Priority 2 c. Priority 3 d. Priority 4

d

6. The four signs of rapidly expanding, acute subdural hematoma that would require immediate surgical intervention include:

coma, hypertension, bradycardia, bradypnea

The second most common cause of unintentional death in children younger than 14 years of age is:

drowning

A3. A person's personality and judgement are controlled by the area of the brain known as

frontal

A5. Voluntary muscle control is governed by a vertical band of "motor cortex" located in the

frontal

What color category would burn to hand fall under?

green

What color category would depression fall under?

green

What color category would fractured humerus fall under?

green

The three most common systemic signs of increased ICP are

headache, N/V, and papilledema

Effective circulatory system consists of the:

heart, blood vessels, and adequate blood volume.

The most common complication of neurogenic bladder is

infection resulting from urinary stasis and catheterization. - Other complications include renal calculi, impaired skin integrity, and urinary incontinence or retention

A2. Three major potential complications in a patient with a depressed level of consciousness are:

pneumonia, aspiration, and respiratory failure.

T or F: types of resources include labs, ekg, xray, ct, mri, iv fluids, iv or im meds, nebs

true

T or F: any kind of traumas places patient at risk for infection

true - tetanus and antibiotics

Minor bleeding is ____ in origin and stops on it own, unless patient is on anticoagulation.

venous

Types of chemicals

vesicants nerve agents blood agents pulmonary agents

Patterned:

wound representing the outline of the object (e.g., steering wheel) causing the wound

What color category would maxillofacial wound without airway compromise fall under?

yellow

What color category would soft tissue injury of lower extremity with adequate collateral circulation fall under?

yellow

Laceration:

skin tear with irregular edges and vein bridging

10. Complications after traumatic head injuries can be classified according to

systemic infections, neurosurgical infections, and heterotrophic ossification

This classification level of PPE includes the typical work uniform 1. A 2. B 3. C 4. D

4. D

Alcohol Withdrawal Syndrome/Delirium Tremens

- Alcohol withdrawal syndrome is an acute toxic state that occurs as a result of sudden cessation of alcohol intake after a bout of heavy drinking or, more typically, after prolonged intake of alcohol. - Delirium tremens may be precipitated by acute injury or infection (pneumonia, pancreatitis, hepatitis) and is the most severe form of alcohol withdrawal syndrome - Delirium tremens is a life-threatening condition and carries a high mortality rate if untreated. - Patients with alcohol withdrawal syndrome show signs of anxiety, uncontrollable fear, tremor, irritability, agitation, insomnia, and incontinence. - They are talkative and preoccupied and experience visual, tactile, olfactory, and auditory hallucinations that often are terrifying. Autonomic overactivity occurs and is evidenced by tachycardia, dilated pupils, and profuse perspiration. - Usually, all vital signs are elevated in the alcoholic toxic state. - The goals of management are to give adequate sedation and support to allow the patient to rest and recover without danger of injury or peripheral vascular collapse. - A physical examination is performed to identify pre-existing or contributing illnesses or injuries (e.g., head injury, pneumonia). A drug history is obtained to elicit information that may facilitate adjustment of any sedative requirements. Baseline blood pressure is determined, because the patient's subsequent treatment may depend on blood pressure changes. - Usually, the patient is sedated as directed with a sufficient dosage of benzodiazepines to establish and maintain sedation, which reduces agitation, prevents exhaustion, prevents seizures, and promotes sleep. The patient should be calm, able to respond, and able to maintain an airway safely on their own. - A variety of medications and combinations of medications are used (e.g., chlordiazepoxide [Librium], lorazepam [Ativan], and clonidine [Catapres]). Haloperidol (Haldol), esmolol (Brevibloc), or midazolam (Versed) may be given for severe acute alcohol withdrawal syndrome. Dosages are adjusted according to the patient's symptoms (agitation, anxiety) and blood pressure response. - The patient is placed in a calm, nonstressful environment (usually a private room) and observed closely. The room remains lighted to minimize the potential for illusions (visual misrepresentations) and hallucinations. - Homicidal or suicidal responses may result from hallucinations. Closet and bathroom doors are closed to eliminate shadows. Someone is designated to stay with the patient as much as possible. The presence of another person has a reassuring and calming effect, which helps the patient maintain contact with reality. To orient the patient to reality, any illusions are explained. - Restraints are used as prescribed, if necessary, if the patient is aggressive or violent, but only when other alternatives have been unsuccessful. Restraints should be used in tandem with verbal intervention to calm the patient and promote adherence. - Fluid losses may result from gastrointestinal losses (vomiting), profuse perspiration, and hyperventilation. In addition, the patient may be dehydrated as a result of alcohol's effect of decreasing antidiuretic hormone. The oral or IV route is used to restore fluid and electrolyte balance. - Temperature, pulse, respiration, and blood pressure are recorded frequently (every 30 minutes in severe forms of delirium) to monitor for peripheral circulatory collapse or hyperthermia (the two most serious complications). - Frequently seen complications include infections (e.g., pneumonia), trauma, hepatic failure, hypoglycemia, and cardiovascular problems. - Hypoglycemia may accompany alcohol withdrawal, because alcohol depletes liver glycogen stores and impairs gluconeogenesis; many patients with alcoholism also are malnourished. Parenteral dextrose may be prescribed if the liver glycogen level is depleted. Orange juice, sports drinks, or other sources of carbohydrates are given to stabilize the blood glucose level and counteract tremulousness. - Supplemental vitamin therapy and a high-protein diet are provided as prescribed to counteract nutritional deficits.

Assessment and diagnostic findings of airway obstruction

- Assessment of the patient who has a foreign object occluding the airway may involve simply asking the person whether he or she is choking and requires help. - If the person is unconscious, inspection of the oropharynx may reveal the offending object. - X-rays, laryngoscopy, or bronchoscopy also may be performed. - Oxygen supplementation should be considered immediately.

Level C PPE

- Level C protection requires the air-purified respirator, which uses filters or sorbent materials to remove harmful substances from the air. - A chemical-resistant coverall with splash hood, chemical-resistant gloves, and boots are included in level C protection.

Categories of Biologic Weapons: Category C

- Low mortality, low morbidity Hantavirus

Osmotic diuretics contraindications

- Renal disease and anuria - Pulmonary congestion - Intracranial bleeding, dehydration - CHF

The nurse recognizes that which interventions are likely to facilitate effective communication between a dying client and family? Select all that apply. 1. The nurse encourages the client and family to identify and discuss feelings openly. 2. The nurse assists the client and family in carrying out spiritually meaningful practices. 3. The nurse removes automony from the client to alleviate any unnecessay stress for the client 4. The nurse makes decisions for the client and family 5. The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger.

1, 2, 5

Doffing COVID 19 PPE

1. Remove gloves. Ensure glove removal does not cause additional contamination of hands. 2. Remove gown. Dispose in trash receptacle. Untie or break it off gently. Remove from shoulders first, pull down away from the body. 3. HCP may now exit patient room. 4. Perform hand hygiene. 5. Remove face shield or goggles . Do not touch the front of the face shield or goggle. 6. Remove and discard respirator (or facemask if used instead of respirator). Bottom strap off first. 7. Perform hand hygiene after removing the respirator/facemask and before putting it on again if your workplace is practicing reuse. - Reuse or extended use of PPE such as respirators is common in practice. - Facilities implementing reuse or extended use of PPE will need to adjust their donning and doffing procedures to accommodate those practices.

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? 1.Blowing the nose 2.Isometric exercises 3.Coughing vigorously 4.Exhaling during repositioning

4

FAST

Abdominal ultrasounds can be used to rapidly assess patients who are hemodynamically unstable to detect intraperitoneal bleeding. This is referred to as the focused assessment with sonography for trauma (FAST) examination (ACS, 2013). During the resuscitation period, pain is managed using administration of small dosages of opioids

Pulse pressure is the difference between SBP and DBP, and is widened in which of the following disorders? A. Early hypovolemic shock B. Increased ICP C. Cardiac tamponade D. Neurogenic shock

B. Increased ICP

EMS transports a patient to the ED with a fragment of machinery in his thigh after a factory explosion. His injury is an example of which type of blast injury type? A. Primary B. Secondary C. Tertiary D. Quaternary

B. Secondary (Fragment wasn't the bomb itself)

B4. If a patient with an altered LOC requires suctioning, what intervention is a priority for the nurse to provide?

Before and after suctioning, the patient is adequately ventilated to prevent hypoxia

opioids manifestations

Pinpoint pupils (may be dilated with severe hypoxia) Decreased blood pressure Marked respiratory depression/arrest Pulmonary edema Stupor → coma Seizures Fresh needle marks along course of any superficial vein Skin abscesses (from "popping")

T or F: Fractures can be classified as either open or closed

True - Open: A tear in the dura, such as from a bullet - Close: Dura is intact.

Acute Alcohol Intoxication

- Alcohol is a psychotropic drug that affects mood, judgment, behavior, concentration, and consciousness. - Many people who drink heavily are young adults or those older than 60 years. - The CDC advocates routine screening for alcohol abuse in all outpatient settings, including EDs. Therefore, screenings, brief interventions, and referral to treatment (SBIRT) for patients presenting with suspected alcohol abuse are recommended. - Alcohol, or ethanol, is a multisystem toxin and CNS depressant that causes drowsiness, impaired coordination, slurring of speech, sudden mood changes, aggression, belligerence, grandiosity, and uninhibited behavior. - In excess, alcohol can cause stupor and eventually coma and death (i.e., alcohol poisoning). - In the ED, the patient who is intoxicated with alcohol or who presents with alcohol poisoning is assessed for head injury, hypoglycemia (which mimics intoxication), and other health problems. - Possible nursing diagnoses include ineffective breathing pattern related to CNS depression and ineffective impulse control related to severe intoxication from alcohol. - Treatment involves detoxification of the acute poisoning, recovery, and rehabilitation. - Commonly, the patient uses mechanisms of denial and defensiveness. The nurse should approach the patient in a nonjudgmental manner, using a firm, consistent, accepting, and reasonable attitude. Speaking in a calm and slow manner is helpful because alcohol interferes with thought processes. - If the patient appears intoxicated, hypoxia, hypovolemia, and neurologic impairment must be ruled out before it is assumed that the patient is intoxicated. - Typically, a blood specimen is obtained for analysis of the blood alcohol level. - If drowsy, the patient should be allowed to sleep off the state of alcoholic intoxication. During this time, maintenance of a patent airway and observation for symptoms of CNS depression are essential. The patient should be undressed and kept warm with blankets. - If the patient is noisy or belligerent, sedation may be necessary. If sedation is used, the patient should be monitored carefully for hypotension and decreased LOC. - The patient is examined for alcohol withdrawal delirium and for injuries and organic disease (such as head injury, seizures, pulmonary infections, hypoglycemia, and nutritional deficiencies) that may be masked by alcoholic intoxication. ] - Acute alcohol intoxication is the cause of trauma for many patients without alcoholism as well. - Pulmonary infections are also more common in patients with alcoholism, resulting from respiratory depression, an impaired defense system, and a tendency toward aspiration of gastric contents. The patient may show little increase in temperature or WBC count. The patient may be hospitalized or admitted to a detoxification center in an effort to examine problems underlying the substance abuse.

The following gastric emptying procedures may be used as prescribed:

- Gastric lavage for the patient who is obtunded is only useful within 1 hour of ingestion, for sustained-release substances, or massive life-threatening amounts of a substance; however, complications of aspiration and stomach or esophageal perforation outweigh its usefulness. If performed, gastric aspirate is saved and sent to the laboratory for testing (toxicology screens).

Encephalitis

- Inflammation of the brain tissue and surrounding meninges - Caused by viral agents, bacteria, fungi, rabies or parasites - Viral infections (herpes simplex [HSV]) most common. Herpes simplex most common - Vector-borne viral infections (West Nile, St. Louis) - Demyelination of axons in involved area and cell death - Hemorrhage, edema, necrosis can lead to increased ICP. Edema in frontal and temporal lobes.

Sarin, Soman

- Nerve Agents - Action: Inhibition of cholinesterase - Signs and symptoms: Increased secretions (salivation, lacrimation, emesis, urination), gastrointestinal motility, diarrhea, bronchospasm - Treatment: Soap and water, supportive care, benzodiazepines, pralidoxime, and atropine

Phases of Blasts and Associated Common Injuries: Secondary

- Results from debris from the scene or shrapnel from the bomb - Common injuries include: Penetrating trunk, skin, and soft tissue injuries Fractures, traumatic amputations

You are a RN in a Mass Casualty Incident (MCI) and are looking at people who have been triaged. You know that if the patient who needs to be seen first is the one with which color tag? 1. black 2. yellow 3. red 4. green

3. red 1 means survival unlikely

Encephalitis Medical Management

Acyclovir for HSV infection Amphotericin or other antifungal agents for fungal infection Anticonvulsants to prevent or control seizures Furosemide or mannitol to reduce cerebral swelling Sedatives for restlessness Aspirin or acetaminophen to reduce fever/swelling - To prevent relapse, treatment should continue for up to 3 weeks. Slow IV administration over 1 hour prevents crystallization of the medication in the urine. - The usual dose of acyclovir is decreased if the patient has a history of renal insufficiency.

The RN is caring for an patient with encephalitis. Which intervention should the RN implement first if the client is experiencing a complication? A. Examine the pupil reaction B. Assess LOC C. Observe of seizure activity D. Monitor VS every shift

B. LOC is the first sign of changes in icp

Infratentorial

Below the tentorium, brainstem - Incision is made at the nape of the neck, around the occipital lobe. - Maintain neck in straight alignment. Avoid flexion of the neck to prevent possible tearing of the suture line. - Position the patient on either side. (Check surgeon's preference for positioning of patient.)

T or F: Contusion is a temporary loss of neurologic function with no apparent structural damage to the brain

False Concussion is a temporary loss of neurologic function with no apparent structural damage to the brain. Contusion is a bruising of the brain surface

Cocaine management

Maintain airway and provide respiratory support. Control seizures. Monitor cardiovascular effects; have antiarrhythmic drugs and defibrillator available. Treat for hyperthermia. If cocaine was ingested, evacuate stomach contents and use activated charcoal to treat. Whole bowel irrigation may be necessary to treat body packers ("mules"). Refer for psychiatric evaluation and treatment in an inpatient unit that eliminates access to the drug. Include drug rehabilitation counseling.

T or F: Sodium retention may occur in the immediate postoperative craniotomy period.

True - Serum and urine electrolytes, BUN, blood glucose, weight, and clinical status are monitored

Cyanide

- Blood agent - Action: Inhibition of aerobic metabolism - Signs and symptoms: Inhalation—tachypnea, tachycardia, coma, seizures; bright red skin; can progress to respiratory arrest, respiratory failure, cardiac arrest, death - Treatment: Soap and water, sodium nitrite, sodium thiocyanate, amyl nitrate, hydroxocobalamin

Who is at an increased risk for airway compromise?

- Seizures - Advanced age - Inhalation/Chemical Burns - Foreign body obstruction - On sedatives - Drowning victims - Cardiopulmonary Arrest - Anaphylaxis

Interventions for Hypercapnia (elevated PaCO2):

- Maintain PaCO2 (normally 35-45) by establishing ventilation.

Active rewarming:

- Active internal (core) rewarming methods are used for moderate to severe hypothermia (less than 28°C to 32.2°C [82.5°F to 90°F]) and include cardiopulmonary bypass, warm fluid administration, warmed humidified oxygen by ventilator, and warmed peritoneal lavage. - Monitoring for ventricular fibrillation as the patient's temperature increases from 31°C to 32°C (88°F to 90°F) is essential. - Make sure they're always on a cardiac monitor and constantly watching vital signs.

The principles of emergency management must be a part of the EOP design and include a comprehensive plan for tackling all potential and actual hazards. The main goal is protection of the community. Predetermined organization is essential to minimize confusion, ensure that all key operations are directed, identify and correct flaws in the plan, and promote a well-coordinated response. Essential components of the EOP include the following (ACS, 2010):

- Activation response: The EOP activation response of a health care facility defines where, how, and when the response is initiated. - Internal/external communication plan: Communication is critical for all parties involved, including communication to and from the prehospital arena. - Plan for coordinated patient care: A response is planned for organized patient care into and out of the facility, including transfers from within the hospital to other facilities. The site of the disaster can determine where the greater number of patients may self-refer. - Security plans: A coordinated security plan involving facility and community agencies is key to the control of an otherwise chaotic situation. - Identification of external resources: Resources outside of the facility are identified, including local, state, and federal resources and information about how to activate these resources. - Plan for people management and traffic flow: "People management" includes strategies to manage the patients, the public, the media, and personnel. Specific areas are assigned and a designated person is delegated to manage each of these groups - Data management strategy: A data management plan for every aspect of the disaster will save time at every step. A backup system for documenting, tracking, and staffing is developed if the facility utilizes an electronic health record. - Demobilization response: Deactivation of the response is as important as activation; resources should not be unnecessarily exhausted. The person who decides when the facility resumes daily activities is clearly identified. Any possible residual effects of a disaster must be considered before this decision is made. - After-action report or corrective plan: Facilities often see increased volumes of patients 3 months or more after an incident. Postincident response must include a critique and a debriefing for all parties involved, immediately and again at a later date. - Plan for practice drills: Practice drills that include community participation allow for troubleshooting any issues before a real-life incident occurs. - Anticipated resources: Food and water must be available for staff, families, and others who may be at the facility for an extended period. - MCI planning: MCI planning includes such issues as planning for mass fatalities and morgue readiness. - Education plan for all of the above: A strong education plan for all personnel regarding each step of the plan allows for improved readiness and additional input for fine-tuning of the EOP. - Hospitals are required to periodically hold disaster drills. Results from these drills can identify flaws within the EOP as well as unanticipated needs prior to any real disaster situation. - Full-scale regional exercises that coordinate responses from both hospitals and emergency medical services (EMS) have been demonstrated as the most effective drills because they clearly identify breakdowns in communication

Administration of Antivenin (Antitoxin)

- An assessment of progressive signs and symptoms is essential before considering administration of antivenin, which is most effective if given within 4 hours and no greater than 12 hours after the snakebite. - The decision to administer antivenin depends on worsening tissue injury and evidence of systemic and coagulopathic symptoms. - Rattlesnakes are more likely to cause coagulation abnormalities as well as more systemic effects. - The most readily available antivenin in the United States is Crotalidae polyvalent immune Fab antivenom (FabAV or CroFab). The dose depends on the type of snake and the estimated severity of the bite. - Indications for antivenin depend on the progression of symptoms, including coagulopathy and systemic reaction. - Crotalidae polyvalent immune Fab antivenom does not require pretesting - If the dose exceeds 10 vials, serum sickness will most likely occur. Serum sickness is a type of hypersensitivity response that results in fever, arthralgias, pruritus, lymphadenopathy, and proteinuria and can progress to neuropathies - FabAV must be given cautiously to patients receiving anticoagulation therapy. Administration of FabAV may result in a recurring coagulopathy. - Before administering antivenin and every 15 minutes thereafter, the circumference of the affected part is measured. Premedication with diphenhydramine (Benadryl) or cimetidine (Tagamet) may be indicated, because these antihistamines may decrease the allergic response to antivenin. - Antivenin is given as an IV infusion whenever possible, although intramuscular administration can be used. - Depending on the severity of the snakebite, the antivenin is diluted in 500 to 1000 mL of normal saline solution. The infusion is started slowly, and the rate is increased after 10 minutes if there is no reaction. - The total dose should be infused during the first 4 to 6 hours after the bite. - The initial dose is repeated until symptoms decrease, after which time the circumference of the affected part should be measured every 30 to 60 minutes for the next 48 hours to detect symptoms of compartment syndrome (swelling, loss of pulse, increased pain, and paresthesias). - There is no limit to the number of antivenin vials that can be given. - Consultation with a snakebite expert is essential at this point; this consultant may be identified and found through contacting the Poison Control Center or a local zoo reptile center. - The most common cause of allergic reaction to the antivenin is too-rapid infusion. Reactions may consist of a feeling of fullness in the face, urticaria, pruritus, malaise, and apprehension. These symptoms may be followed by tachycardia, shortness of breath, hypotension, and shock. In this situation, the infusion should be stopped immediately and IV diphenhydramine given. - Vasopressors are used for patients in shock, and resuscitation equipment must be on standby while antivenin is infusing. - It is important to note that serum sickness (hypersensitivity) can occur within the first few weeks after discharge. The patient and the patient's family members should be educated about the clinical manifestations of serum sickness (i.e., fever; rash starting on the chest and spreading to the back; arthralgia; GI disturbances [e.g., nausea, vomiting, diarrhea, abdominal pain], and headache) and return to the ED if they occur

Anthrax

- Anthrax is recognized as the most likely weaponized biologic agent - Bacillus anthracis is a naturally occurring gram-positive, encapsulated rod that lives in the soil in the spore state throughout the world. - The bacterium sporulates (i.e., is liberated) when exposed to air and is infective only in the spore form. - Contact with infected animal products (raw meat) or inhalation of the spores results in infection. - Cattle and other herbivores are vaccinated against anthrax to prevent transmission through contaminated meat. - As an aerosol, anthrax is odorless and invisible and can travel a great distance before disseminating; hence, the site of release and the site of infection can be miles apart.

Manifestations of brain injurty

- Assess the neurologic system by assessing the LOC using the Glasgow coma scale. The GCS tests eye opening, verbal response and motor response to verbal command, or painful stimuli. Altered LOC: The GCS is used to assess LOC at regular intervals, because changes in the LOC precede all other changes in vital and neurologic signs. A GCS score between 3 and 8 is generally accepted as indicating a severe head injury. Pupillary abnormalities: A unilaterally dilated and poorly responding pupil may indicate a developing hematoma, with subsequent pressure on the third cranial nerve due to shifting of the brain. If both pupils become fixed and dilated, this indicates acute injury and intrinsic damage to the upper brainstem and is a poor prognostic sign. - The patient with a head injury may develop deficits such as anosmia (lack of sense of smell), eye movement abnormalities, aphasia, memory deficits, and posttraumatic seizures or epilepsy. Patients may be left with residual psychological deficits (impulsiveness; emotional lability; or uninhibited, aggressive behaviors) and, as a consequence of the impairment, may lack insight into their emotional responses. Sudden onset of neurologic deficits and neurologic changes; changes in sense, movement, reflexes Changes in vital signs: vital signs also are monitored at frequent intervals to assess the intracranial status. Headache: Symptoms include severe headache, which tends to come and go; alternating focal neurologic signs; personality changes; mental deterioration; and focal seizures Seizures: Because seizures can occur after head injury and can cause secondary brain damage from hypoxia, anticonvulsant agents may be given. * Avoiding opioids as a means of controlling restlessness, because they depress respiration, constrict the pupils, and alter responsiveness *

Encephalitis Nursing Management

- Assessment of neurologic function is key to monitoring the progression of disease. - Comfort measures to reduce headache include dimming the lights, limiting noise and visitors, grouping nursing interventions, and administering analgesic agents. - Opioid analgesic medications may mask neurologic symptoms; therefore, they are used cautiously. - Seizures and altered LOC require care directed at injury prevention and safety. - Nursing care addressing patient and family anxieties is ongoing throughout the illness. - Monitoring of blood chemistry test results and urinary output alert the nurse to the presence of renal complications related to antiviral therapy.

The nurse provides the following advice for the patient treated for heat-induced illness:

- Avoid immediate re-exposure to high temperatures; hypersensitivity to high temperatures may remain for a considerable time. - Maintain adequate fluid intake, wear loose clothing, and reduce activity in hot weather. - Monitor fluid losses and weight loss during workout activities or exercise and replace fluids and electrolytes. - Use a gradual approach to physical conditioning, allowing sufficient time for return to baseline temperature. - Plan outdoor activities to avoid the hottest part of the day (between 10 AM and 2 PM). - For older patients living in urban settings with high environmental temperatures: The nurse directs these patients to places where air conditioning is available (e.g., shopping mall, library, church) and advises them that fans alone are not adequate to prevent heat-induced illness.

Poisonings: Enhance elimination

- Cathartics (sorbitol): used in combination with the first dose of activated charcoal to stimulate intestinal motility and enhance elimination. Can result in severe electrolyte imbalance; rarely used - Emetics: Contraindicated in clients that are not alert & with some poisons - Hemodialysis: Reserved for severe acidosis - Urine alkalization (bicarb): Phenobarbital and salicylate poisoning - Chelating agents: Heavy metal poisoning (lead, iron, copper, mercury, arsenic) -Antidotes - Corrosive agents such as acids and alkalines cause destruction of tissues by contact. Do not induce vomiting with corrosive agents

Multiple trauma

- Caused by a single catastrophic event that causes life-threatening injuries to at least two distinct organs or organ systems. - Patients with single-system trauma still receive full assessment, because even single-system injuries can be life threatening or more severe than they initially appear. - Mortality in patients with multiple trauma is related to the severity of the injuries, the number of systems and organs involved, and the severity of each injury alone and in combination. - Immediately after injury, the body is hypermetabolic, hypercoagulable, and severely stressed. - Care of the patient with multiple injuries requires a team approach, with one person responsible for coordinating the treatment. - The nursing staff assumes responsibility for assessing and monitoring the patient, ensuring/maintaining airway and IV access, administering prescribed medications, collecting laboratory specimens, and documenting activities and the patient's subsequent responses. - External evidence of trauma may be sparse or absent. Patients with multiple trauma should be assumed to have a spinal cord injury until it is proven otherwise. The injury regarded as the least significant in appearance may be the most lethal.

Primary Survey: C is for Circulation

- Circulation Assessment: Assess for external hemorrhage. Check carotid pulse. Peripheral pulses may be absent because of injury or vasoconstriction - Assess quality and rate - Assess skin - Color, temperature, moisture - Assess for signs of shock

Animal and Human Bites: Interprofessional Care

- Clean with copious irrigation, debridement, tetanus prophylaxis, and analgesics - Prophylactic antibiotics for bites at risk for infection, especially wounds over joints, bites on hands or feet, wounds > 6-12 hours old, and puncture wounds - Lacerations loosely sutured; Puncture wounds left open - Clients are admitted for IV antibiotics when infection occurs. ↑ Cellulitis, osteomyelitis, septic arthritis - Report animal and human bites to proper authorities as required - Rabies spread through saliva from effected animal and scratches. - Any exposure to bat, rabies prophylaxis/vaccine is given automatically. - Rabies prophylaxis is also given if the animal not found, wild animal, or if the rabies status is unknown or not up to date. - Rabies is fatal. - Rabies post exposure prophylaxis includes immunoglobin and vaccine and is administered on the first day, then the vaccine itself is given on days 3, 7 and 14 based on weight. If there is a bite mark, the immunoglobin is injected around it, any left over is given IM. - Tetanus shot is also given.

Difference between complete and incomplete spinal cord injury

- Complete: Severed or damaged in a way that eliminates all innervation below the level of the injury - Incomplete: More common. Some function or movement below the level of injury

Potential complications following brain injury

- Decreased Cerebral Perfusion Pressure. - Cerebral Edema and Herniation. - Impaired Oxygenation and Ventilation. - Impaired Fluid, Electrolyte, and Nutritional Balance. - Posttraumatic Seizures.

Emergency & Disaster Nursing: Ethical & Legal Implications

- Ethical Obligation to protect oneself: Competent to provide care in emergency setting and protected, and have the resources to provide care. Nurse should only respond as part of an organized emergency medical response team to ensure safety. Must know your limits. Scarcity of resources Life & death decision-making - Legal Liability standards License verification Scope of practice

Supportive care during rewarming includes the following as directed:

- External cardiac compression (typically performed only as directed in patients with temperatures higher than 31°C [88°F]) - Defibrillation of ventricular fibrillation. A patient whose temperature is less than 32°C [90°F] experiences spontaneous ventricular fibrillation if moved or touched. - Defibrillation is ineffective in patients with temperatures lower than 31°C (88°F); therefore, the patient must be rewarmed first. - Mechanical ventilation with positive end-expiratory pressure (PEEP) and heated humidified oxygen to maintain tissue oxygenation - Administration of warmed IV fluids to correct hypotension and to maintain urine output and core rewarming, as described previously - Administration of sodium bicarbonate to correct metabolic acidosis if necessary - Administration of antiarrhythmic medications - Insertion of an indwelling urinary catheter to monitor urinary output and kidney function - Whirlpool for necrotic tissues, and aids in circulation and debridement

Functions of the lobes of the brain

- Frontal lobe is important for cognitive functioning and control of voluntary movement. - Parietal lobe processes information about taste, touch and movement - Occipital lobe: focuses on vision - Temporal lobe: Contains the auditory cortex and processes of memory with sensations of taste, sound, touch. - Cerebellum: Motor movement, such as posture, balance, coordination speech. - Brain stem: Controls breath, swallowing, heart rate, blood pressure, awake or asleep

Brain Abscess Manifestations

- Headache, usually worse in the morning, is the most prevalent symptom. - Fever is present 50% of the time - Vomiting and focal neurologic deficits occur as well. - Focal deficits include weakness and decreasing vision reflect the area of brain that is involved. - As the abscess expands, symptoms of increased ICP such as decreasing LOC and seizures occur. - Perform a baseline neuro assessment and continue assessing the neurological system.

Categories of Biologic Weapons: Category A

- High mortality Bacillus anthracis (anthrax) Clostridium botulinum (botulism) Francisella tularensis (tularemia) Viral hemorrhagic fevers (e.g., dengue, Ebola) Variola (i.e., smallpox) Yersinia pestis (plague)

Clinical manifestations of increased ICP

- If ICP increases to the point at which the brain's ability to adjust has reached its limits, neural function is impaired; this may be manifested at first by clinical changes in LOC and later by abnormal respiratory and vasomotor responses. - The earliest sign of increasing ICP is a change in LOC. Agitation, slowing of speech, and delay in response to verbal suggestions may be early indicators. - Any sudden change in the patient's condition, such as restlessness (without apparent cause), confusion, or increasing drowsiness, has neurologic significance - As ICP increases, the patient becomes stuporous, reacting only to loud or painful stimuli. - As neurologic function deteriorates further, the patient becomes comatose and exhibits abnormal motor responses in the form of decortication (abnormal flexion of the upper extremities and extension of the lower extremities), decerebration (extreme extension of the upper and lower extremities), or flaccidity. - If the coma is profound and irreversible with no known confounding factors, brainstem reflexes are absent, and respirations are impaired or absent, the patient may be evaluated for brain death

IMPROVING BOWEL FUNCTION (SCI)

- Immediately after SCI, a paralytic ileus usually develops as a result of neurogenic paralysis of the bowel; therefore, a nasogastric tube is often required to relieve distention and to prevent vomiting and aspiration. - Bowel activity usually returns within the first week. - A bowel program can help to control bowel movements by establishing a pattern of planned evacuation - The nurse administers prescribed combinations of stool softeners, stimulant laxatives, bulking laxatives, and rectal laxatives along with rectal stimulation, to counteract the effects of immobility and analgesic agents

MAINTAINING URINARY ELIMINATION (SCI)

- Immediately after SCI, the urinary bladder becomes atonic and cannot contract by reflex activity. Urinary retention is the immediate result. - During the initial acute phase, a Foley catheter is inserted; however, prompt discontinuation is advised due to high risk of catheter-associated UTI. - Once discontinued, the patient has no sensation of bladder distention and overstretching of the bladder and detrusor muscle may occur, delaying the return of bladder function. - The patient is educated to record fluid intake, voiding pattern, amounts of residual urine after voiding, characteristics of urine, and any unusual sensations that may occur.

(ICP) Maintaining Cerebral Perfusion

- Improvements in cardiac output are made using fluid volume and inotropic agents such as dobutamine (Dobutrex) and norepinephrine (Levophed). - The effectiveness of the cardiac output is reflected in the CPP, which is maintained at greater than 70 mm Hg - Decompressive hemicraniectomy may also be considered as a surgical strategy to assist in the management of refractory intracranial hypertension. The removal of a part of the skull allows the brain to expand without the pressure constraints exerted by the cranial vault. Complications of this procedure include infection and increased potential for injury to the unprotected underlying brain structures. - Once the patient is no longer at risk for increased ICP, the bone flap may be surgically replaced

Achieving an adequate breathing pattern in increased ICP

- Increased pressure on the frontal lobes or deep midline structures may result in Cheyne-Stokes respirations, whereas pressure in the midbrain can cause hyperventilation. - If the lower portion of the brainstem (the pons and medulla) is involved, respirations become irregular and eventually cease. - Hyperventilation therapy is a controversial therapy in traumatic brain injury used in some centers to reduce ICP by causing cerebral vasoconstriction and a decrease in cerebral blood volume. The nurse collaborates with the respiratory therapist in monitoring the PaCO2, which is usually maintained at less than 30 mm Hg.

Interventions for impaired venous return:

- Maintain head alignment. - Elevate head of bed 30 degrees.

Management of hypothermia include

- Management consists of removal of wet clothing, continuous monitoring, rewarming, and supportive care. - The CABs of basic life support are a priority. - The patient's vital signs, CVP, urine output, arterial blood gas levels, blood chemistry determinations (blood urea nitrogen, creatinine, glucose, electrolytes), and chest x-rays are evaluated frequently. - Core body temperature is monitored with an esophageal, bladder, or rectal thermistor. - Continuous ECG monitoring is performed, because cold-induced myocardial irritability leads to conduction disturbances, especially ventricular fibrillation. - An arterial line is inserted and maintained to record blood pressure and to facilitate blood sampling. - Cold blood returning from the extremities has high levels of lactic acid and can cause potential cardiac dysrhythmias and electrolyte disturbances

Management of the Client with Sexual Assault

- Management goals: Provide support, reduce emotional trauma, gather available evidence for possible legal proceedings - Nurses may be SANE certified. SANE nurses are forensic nurses with specialized training to conduct sexual assault examinations. - Obtain written and witnessed consent for examination and obtaining of photographs for evidence - Privacy during physical exam and specimen collection - Specimen collection use paper not plastic - Obtain cultures from body - Treating consequences: STIs, pregnancy - Encourage follow-up care - Offer referrals for counseling services

Maintaining Oxygenation and Reducing Metabolic Demands

- Metabolic demands may be reduced through the administration of high doses of barbiturates if the patient is unresponsive to conventional treatment. - Another method of reducing cellular metabolic demand and improving oxygenation is the administration of medications causing sedation. - The most common agents used for sedation are pentobarbital (Nembutal), thiopental (Pentothal), propofol (Diprivan), and dexmedetomidine (Precedex)

Green

- Minimal: Injuries are minor, and treatment can be delayed hours to days. Individuals in this group should be moved away from the main triage area. - Third priority: 3 - Examples include: Upper extremity fractures, minor burns, sprains, small lacerations without significant bleeding, behavioral disorders or psychological disturbances

Nerve Agents Clinical Manifestations

- Signs and symptoms of nerve gas exposure are those of cholinergic crisis and include bilateral miosis, visual disturbances, increased gastrointestinal motility, nausea and vomiting, diarrhea, substernal spasm, indigestion, bradycardia and atrioventricular block, bronchoconstriction, laryngeal spasm, weakness, fasciculations, and incontinence. - The patient must be examined in a dark area to truly identify miosis. - Neurologic responses include insomnia, forgetfulness, impaired judgment, depression, and irritability. - A lethal dose results in loss of consciousness, seizures, copious secretions, fasciculations, flaccid muscles, and apnea.

Primary injury

- The result of direct contact to the head/brain during the instant of initial injury, causing extracranial focal injuries, as well as possible focal brain injuries from sudden movement of the brain within the cranial vault. - Extracranial focal injuries: contusions, lacerations, external hematomas, and skull fractures - Injuries from sudden movement of the brain within the cranial vault: subdural hematomas (SDHs), concussion, diffuse axonal injury [DAI]

Human trafficking

- Use of force, fraud, or coercion for the purpose of subjection into involuntary servitude - May present to ED with injury, accompanied by boyfriend or travel partner - Hx of chronic runaway, homelessness, self-mutilation - Common behaviors: cowering, frightened, agitated, deferring to the person accompanying them - Common complaints: injuries, poor healing, abd pain, dizziness, headaches, rashes or sores - May demonstrate behaviors: addiction, panic attacks, impulse control, hostility, suicide ideations

General signs and symptoms of a subdural hematoma

- s/s include: decreased LOC, drowsiness, unequal/dilated pupils, headache, nausea, vomiting, agitation, confusion and irritability

Cremation is preferred for all deaths due to smallpox because the virus can survive in scabs for up to how many years?

13 years

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? 1.Fluid is clear and tests negative for glucose. 2.Fluid is grossly bloody in appearance and has a pH of 6. 3.Fluid clumps together on the dressing and has a pH of 7. 4.Fluid separates into concentric rings and tests positive for glucose.

4

Depending on the severity of a snakebite, antivenin is diluted in ___________ mL to _________ mL of __________.

500, 1000, normal saline solution

Explain why patients who are most critically ill, with a high mortality rate, would be assigned a low triage priority in a disaster situation:

A critically ill individual with a high mortality rate would be assigned a low triage priority because it would be unethical to use limited resources on those with a low chance of survival. Others who are seriously ill and have a greater chance of survival should be treated.

ESI Algorithm

A indicates ACLS measures B need for hospital bed C resources or no resources D vital signs dangerous reassess

Radiation: Manifest Illness phase

After latent period phase Infection, fluid and electrolyte imbalance, bleeding, diarrhea, shock, and altered level of consciousness

Tsunami

As with flooding (above) but with much more rapid onset resulting in immediate large volume of water on land Injuries: Physical injury from debris; vector-borne disease (see the Flooding section); cholera

A RN is monitoring a client for complications. Which client would be the nurse's lowest priority for monitoring for a brain abscess? A. Endocarditis B. Idiopathic epilepsy C. Liver transplant D. Meningitis

B. Idiopathic epilepsy

Symptoms of heat stroke

Confusion Delirium Seizures Coma Bizarre behaviors Elevated body temp Absence of sweating Tachypnea HTN, and tachycardia Headache Anxiety Syncope Diaphoresis Orthostasis

Treatment of submersion injuries

Correct hypoxia Correct acid-base and fluid imbalances Support basic physiologic functions Rewarm if hypothermia present

Intra-Abdominal Hemorrhage:

Dullness upon percussion, petechiae, bruising.

Types of meninges

Dura mater: the outside layer (tough mother) Subdural space: located between the dura mater and the middle layer, the arachnoid Pia mater: most inner layer Subarachnoid space: located between the arachnoid and pia mater & CSF circulates Epidural space: located between the skull and the outer layer of the dura mater

A patient with a history of SCD taking hydroxyurea complains of chest pain and dyspnea. Which ESI triage level is appropriate for this patient?

ESI triage level 2

Controlling ICP in Patients With Severe Brain Injury

Elevate the head of the bed as prescribed. Maintain the patient's head and neck in neutral alignment (no twisting or flexing the neck). Initiate measures to prevent the Valsalva maneuver (e.g., stool softeners). Maintain body temperature within normal limits. Administer oxygen (O2) to maintain partial pressure of arterial oxygen (PaO2) >90 mm Hg. Maintain fluid balance with normal saline solution. Avoid noxious stimuli (e.g., excessive suctioning, painful procedures). Administer sedation to reduce agitation. Maintain cerebral perfusion pressure of 50-70 mm Hg.

The driver arrives at the site of an MVC and stops to render aid. The driver of the car is unconscious. After stabilizing the client's spine, what should the nurse take next?

Establish an airway

Describe five factors that influence and individuals response to disaster:

Factors that influence a persons response to disaster include the degree and nature of the exposure to the disaster, loss of friends and loved ones, existing coping strategies, available resources and support, and the personal meaning attached to the event.

B2. Name the four most common causes of TBI

Falls, MVAs, being struck by objects, and assaults.

T or F: A grade 2 concussion results in any loss of consciousness lasting from seconds to minutes.

False

T or F: A corrosive poison is an acidic agent that causes tissue destruction after contact

False - A corrosive poison is an alkaline or acidic agent that causes tissue destruction after contact

T or F: A nasogastric tube is used for all severe facial and skull traumas.

False - Nasogastric tubes are contraindicated in basilar skull fractures and severe facial traumas because risk of complications and incorrect insertion. It goes up into the cranial cavity, so OG tubes are performed on these people.

T or F: Evidence is placed in plastic bags

False - Place it in paper bags - Avoid cutting through stains and holes.

Multisystem Assessment Measures for the Patient With Traumatic Brain Injury: GU

Fluid restriction or the use of diuretic agents can alter the amount of urinary output. Urinary incontinence is related to the patient's unconscious state. Intake and output record

Name three of the risk factors of upper airway obstruction in the older adult:

For older adult patients, especially those in extended-care facilities, sedatives and hypnotic medications, diseases affecting motor coordination, and mental dysfunction are risk factors for asphyxiation by food

Risk factors for brain abscess

Infections, and immunosuppression

AD Nursing Interventions

Place client in seated position to lower BP Rapid assessment to identify and eliminate cause Empty the bladder using a urinary catheter or irrigate or change indwelling catheter Examine rectum for fecal mass Examine skin Examine for any other stimulus Administer ganglionic blocking agent such as hydralazine hydrochloride IV Label medical record that client is at risk for autonomic dysreflexia Instruct client in prevention and management The rectum is examined for a fecal mass. If one is present, a topical anesthetic agent is inserted 10 to 15 minutes before the mass is removed, because visceral distention or contraction can cause autonomic dysreflexia. The skin is examined for any areas of pressure, irritation, or broken skin. Any other stimulus that could be the triggering event, such as an object next to the skin or a draft of cold air, must be removed. If these measures do not relieve the hypertension and excruciating headache, antihypertensive medications may be prescribed and given slowly by the IV route. The medical record is labeled with a clearly visible note about the risk of autonomic dysreflexia. The patient is instructed about prevention and management measures. Any patient with a lesion above the T6 segment is informed that such an episode is possible and may occur even many years after the initial injury

A client in a one-car rollover presents to the Emergency Department (ED) with multiple injuries. Using the Emergency Severity Index (ESI), in what priority order should the nurse perform the following actions? a. Remove client's clothing. b. Send blood for laboratory tests. c. Give supplemental oxygen via face mask. d. Perform the jaw-thrust maneuver. e. Insert two large-bore IVs and begin infusion of normal saline.

Primary survey. D. Establish Airway by performing a jaw thrust maneuver. - Rationale: Once airway is open, C. oxygen should be applied to assist with Breathing. E. Insertion of IVs and infusion of IV fluids will support Circulation. A. Clothing is removed during the Exposure portion of the primary survey to complete a physical assessment. B. Laboratory and diagnostic testing is completed during the secondary survey.

Management of Neurogenic Bladder

Self-catherization Increased fluid intake to reduce bacterial count and reduce stasis Bladder retraining program Parasymathomimetic medications: urokoline Surgery

Multisystem Assessment Measures for the Patient With Traumatic Brain Injury: Neuro

Severe TBI results in unconsciousness and alters many neurologic functions. All body functions must be supported. Increased ICP and herniation syndromes are life threatening. Measures are instituted to control elevated ICP. Assessment of neurologic status Assessment for signs and symptoms of ICP elevation Calculation of cerebral perfusion pressure if ICP monitor is in place Monitoring of anticonvulsant medication blood levels

Initiating the Emergency Operations Plan

The disaster activation plan should clearly state how the EOP is to be initiated. If communication is functioning, field incident command will give notice of the approximate number of patients who are arriving, although the number of patients who are self-referring will not be known. -Identify patients & document -Triage -Manage internal problems -Communicate with media & family (usually a designated person) -Nursing roles & responsibilities (important to know your role) -Critical incident stress management (can produce stress for family & staff) *Usually associated with death.

The following measures are carried out in autonomic dysreflexia:

The patient is placed immediately in a sitting position to lower blood pressure. Rapid assessment is performed to identify and alleviate the cause. The bladder is emptied immediately via a urinary catheter. If an indwelling catheter is not patent, it is irrigated or replaced with another catheter. The rectum is examined for a fecal mass. If one is present, a topical anesthetic agent is inserted 10 to 15 minutes before the mass is removed, because visceral distention or contraction can cause autonomic dysreflexia. The skin is examined for any areas of pressure, irritation, or broken skin. Any other stimulus that could be the triggering event, such as an object next to the skin or a draft of cold air, must be removed. If these measures do not relieve the hypertension and excruciating headache, antihypertensive medications may be prescribed and given slowly by the IV route. The medical record is labeled with a clearly visible note about the risk of autonomic dysreflexia. The patient is instructed about prevention and management measures. Any patient with a lesion above the T6 segment is informed that such an episode is possible and may occur even many years after the initial injury

T or F: Airway management is the priority for the patient with injury to the cervical spine.

True

T or F: Basilar skull fractures are suspected when cerebrospinal fluid escapes from the ears and the nose

True

T or F: Hypothermia may be seen with frostbite, and treatment of hypothermia takes precedence

True

T or F: Clear rhinorrhea from the nose is a sign of a basilar fracture

True - Signs of basilar fracture include CSF drainage from the ears or nose, bleeding from the nose or ears, Battle sign (ecchymosis found on the mastoid), and halo sign (ring of fluid around blood stain from drainage)

What color category would C-1 spinal transaction fall under?

black

11. The five vertebrae most commonly involved in a spinal cord injury include:

5th cervical 6th cervical 7th cervical 12th thoracic and 1st lumbar

A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient? A. within 24 hours after exposure B. within 48 hours after exposure C. within 72 hours after exposure D. therapy is not necessary prophylactically and should only be used if the person develops symptoms

A

Name and define the three categories commonly used in triage in the ED:

A basic and widely used triage system that has been in use for many years utilized three categories: emergent, urgent, and non-urgent. In this system, emergent patients have the highest priority, urgent patients are those with serious health problems, but not immediately life-threatening ones, and non-urgent patients are those with episodic illnesses

A5. The primary, lethal complication of increased ICP is:

brain herniation resulting in death

1. The cranial vault contains three main components:

brain, blood, and cerebrospinal fluid

Blast Injury

- A blast may result from terrorism but can also occur anywhere at any time if the right (or wrong) circumstances come together. - The bomb most commonly utilized by terrorists is the pipe bomb, which contains low-velocity explosives and may also contain nails or other implements that cause more damage when the explosive ignites. - Another type of commonly used explosive device is the Molotov cocktail, which uses a common flammable liquid such as gasoline in a glass bottle and a source of ignition, such as a rag. This forms a simple yet effective incendiary device. - Other types of explosive devices include fertilizer bombs and dirty bombs, which include a radioactive source that spreads radiation after the initial blast. - Hazards following a bombing include secondary devices (set to explode at a predetermined time, typically after the arrival of rescue personnel); building collapse; contamination from biologic, chemical, or radiologic weapons; and the presence of terrorists among the patients and bystanders. - Triage of patients involved in a bombing is the same as for all disasters, with a heightened awareness that serious internal injuries from the blast wave may not be immediately evident. - Distance from the blast, whether the blast space was enclosed, composition of the explosive, whether a building collapsed, and the efficiency of medical resources available after the blast all affect patient outcomes after a blast injury. - The majority of injuries are caused by the primary blast wave - A blast wave has four effects. These include spalling, implosion, shearing, and irreversible work. - Spalling refers to the pressure wave itself - Implosion refers to rupture of organs from entrapped gases - Shearing refers to the blast response of different body tissues, dependent on their density - Irreversible work refers to the presence of forces that exceed the tensile strength of an organ or tissue. - If the blast occurs in an enclosed space, the wave has the opportunity to be reflected and thus amplified

Injury prevention

- A component of the emergency nurse's daily role is to provide injury prevention information to every patient with whom there is contact, including patients admitted for reasons other than injury - There are three components of injury prevention. The first is education. Providing information and materials to help prevent violence and to maintain safety at home and in vehicles is important. Involvement in local injury prevention organizations, nursing organizations, and health fairs promotes wellness and safety. In practice, nursing and other health care professionals should avoid using the word accident, because trauma events are preventable and should be viewed as such rather than as "fate" or "happenstance." Responsibility and accountability must be assigned to traumatic incidents, particularly because of the high rate of trauma recidivism (repeated trauma). People who are at risk for trauma and trauma recidivism should be identified and provided with education and counseling directed toward altering risky behaviors and preventing further trauma. - The second component of injury prevention is legislation. Nurses should be actively involved in safety legislation at the local, state, and federal levels. Such legislation is meant to provide universal safety measures, not to infringe on rights. - The third component is automatic protection. Airbags and automotive design are included in this category. These mechanisms provide for safety without requiring personal intervention.

Skull Fractures: Diagnostics & Management

- A computed tomography (CT) scan can be used to diagnose a skull fracture. The ease with which a diagnosis of skull fracture is made depends on the site of the fracture. - If a fracture is found on CT scan, there is always the question of associated brain injury, and a magnetic resonance imaging (MRI) scan provides better resolution and clearer pictures of the injured area - Nondepressed skull fractures generally do not require surgical treatment; however, close observation of the patient is essential. But if no underlying brain injury is present, the patient may be allowed to return home. If the patient is discharged home, specific instructions must be given to the family. - Depressed skull fractures usually require surgery with elevation of the skull and débridement, usually within 24 hours of injury.

Craniotomy

- A craniotomy involves opening the skull surgically to gain access to intracranial structures. - This procedure is performed to remove a tumor, relieve elevated ICP, evacuate a blood clot, or control hemorrhage. - The surgeon cuts the skull to create a bony flap, which can be repositioned after surgery and held in place by periosteal or wire sutures. - One of two approaches through the skull is used: (1) above the tentorium (supratentorial craniotomy) into the supratentorial compartment, or (2) below the tentorium into the infratentorial (posterior fossa) compartment. - A third approach, the transsphenoidal approach (through the mouth and nasal sinuses) is often used to gain access to the pituitary gland

Nuclear Radiation Exposure

- A dirty bomb is a conventional explosive (e.g., dynamite) that is packaged with radioactive material that scatters when the bomb is detonated. It disperses radioactive material and may be called a radiologic weapon, but it is not a nuclear weapon, which uses a complex nuclear fission reaction that is thousands of times more devastating than the dirty bomb. - Sources of radioactive material include not only nuclear weapons but also reactors and simple radioactive samples, such as weapons-grade plutonium or uranium, freshly spent nuclear fuel, or medical supplies (e.g., radium, certain cesium isotopes) used in cancer treatments and radiology. - Any terrorist act or unintentional radiation release can be sizable and may require the entire hospital and prehospital staff to be prepared, recognize signs and symptoms of exposure, and rapidly treat victims without contamination of personnel, visitors, patients, or the facility itself.

B5. What is the optimal way to determine the level of a patient's alertness?

Alertness is measured by the patient's ability to open the eyes spontaneously or in response to a vocal or noxious stimulus (pressure or pain).

Intra-abdominal: Genitourinary Injury

- A focused genitourinary examination, which typically includes a rectal and/or vaginal examination, is performed to determine any injury to the pelvis, bladder, urethra, vagina, or intestinal wall. - In the male patient, a high-riding prostate gland (abnormal position) discovered during a rectal examination indicates a potential urethral injury. - A digital vaginal examination is performed on female patients to determine if there is an open pelvic fracture that has torn the vagina. - To decompress the bladder and monitor urine output in a patient with a genitourinary injury, an indwelling catheter is inserted after a rectal examination has been completed, not before the examination. In addition, urethral catheter insertion when a possible urethral injury is present is contraindicated; a urology consultation and further evaluation of the urethra are required.

Management of Decompression Sickness

- A patent airway and adequate ventilation are established, as described previously, and 100% oxygen is given throughout treatment and transport. - A chest x-ray is obtained to identify aspiration, and at least one IV line is started with lactated Ringer's or normal saline solution. - The cardiopulmonary and neurologic systems are supported as needed. - If an air embolus is suspected, the head of the bed should be lowered. - The patient is kept warm. - Transfer to the closest hyperbaric chamber for treatment is initiated. - If air transport is necessary, low-altitude flight (below 300 m) is required. However, the patient who is awake and alert without central neurologic deficits may be able to travel by ground ambulance or by automobile, depending on the severity of symptoms.

PROVIDING COMFORT MEASURES: THE PATIENT IN TRACTION WITH TONGS OR HALO VEST

- A patient who has had pins, tongs, or calipers placed for cervical stabilization may have a headache or discomfort for several days after the pins are inserted. - Patients initially may be bothered by the rather startling appearance of these devices, but usually they readily adapt to it because the device provides comfort for the unstable neck - The patient may complain of being caged in and of noise created by any object coming in contact with the frame of a halo device, but they can be reassured that adaptation will occur. - The areas around the four pin sites of a halo device are cleaned at least daily and observed for redness, drainage, and pain. The pins are observed for loosening, which may contribute to infection. - If one of the pins becomes detached, the head is stabilized in a neutral position by one person, while another notifies the primary provider. A torque screwdriver should be readily available in case the screws on the frame need tightening. - The skin under the halo vest is inspected for excessive perspiration, redness, and skin blistering, especially on the bony prominences. The vest is opened at the sides to allow the torso to be washed. - The liner of the vest should not become wet, because dampness causes skin excoriation. - Powder is not used inside the vest, because it may contribute to the development of pressure ulcers. - The liner should be changed periodically to promote hygiene and good skin care.

Skull Fractures

- A skull fracture is a break in the continuity of the skull caused by forceful trauma. It may occur with or without damage to the brain. - Skull fractures are classified by type and location. - Types include linear, comminuted, basilar and depressed skull fractures, whereas location fractures include frontal, temporal, and basal skull fractures. - A fracture of the base of the skull is referred to as a basal skull fracture - A fracture may be open, indicating a scalp laceration or tear in the dura (e.g., from a bullet or an ice pick), or closed, in which case the dura is intact.

Concussion

- A temporary loss of consciousness with no apparent structural damage - A shaky movement of the brain - May be mild or more severe - Patient may be admitted for observation or sent home - Report immediately: Observe for any changes in LOC, difficulty in awakening, lethargy, dizziness, confusion, irritability, anxiety, difficulty in speaking or movement, severe headache, vomiting, irritability, slurred speech, and numbness or weakness in the arms or legs - Patient should be aroused and assessed frequently - The mechanism of injury is usually blunt trauma from an acceleration-deceleration force, a direct blow, or a blast injury. If brain tissue in the frontal lobe is affected, the patient may exhibit bizarre irrational behavior, whereas involvement of the temporal lobe can produce temporary amnesia or disorientation. The duration of mental status abnormalities is an indicator of the grade of the concussion. - Repeated concussive incidents can lead to a syndrome known as chronic traumatic encephalopathy. This syndrome has been recognized in those participating in contact sports such as football and boxing. The presentation is similar to Alzheimer disease, characterized by personality changes, memory impairment, and speech and gait disturbances. Imaging findings show gross cerebral, particularly temporal lobe, atrophy - - In the first 1-2 days, they need to rest after the concussion. After that they can start watching a little bit of TV, listening to music, reading, start periods of school work and engage in physical activity. - Normal recovery for people younger than 18 years old is 30 days, and for those older than 18 is 14 days, but may take a lot longer to recovers.

Decontamination of radiation disasters.

- Access restriction is essential to prevent contamination of other areas of the hospital. - Triage outside of the hospital is the best way to prevent it. - Floors are covered to prevent tracking of contaminants throughout the treatment areas. - Strict isolation precautions should be in effect. All air ducts and vents must be sealed to prevent spread. - Waste is controlled through double-bagging and the use of plastic-lined containers outside of the facility. All radiation-contaminated waste must be disposed in appropriate color-coded yellow and magenta canisters. - Staff are required to wear protective clothing, such as water-resistant gowns, two pairs of gloves, masks, caps, goggles, and booties. - Dosimetry devices should be worn by all staff members participating in patient care. The radiation safety officer in the hospital should be notified immediately to assist with surveys (using a radiation survey meter) of the incoming patients and to provide dosimeters to all staff personnel involved in direct care of patients who have been exposed. There is minimal risk to staff if the patients are properly surveyed and decontaminated. - Each patient arriving at the hospital should first be surveyed with the radiation survey meter for external contamination and then directed toward the decontamination area as needed. - Decontamination occurs outside of the ED with a shower, collection pool, tarp, and collection containers for patient belongings, as well as soap, towels, and disposable paper gowns for patients. Water runoff needs to be contained. - After the patient has showered, a resurvey is conducted to determine whether the radioactive contaminants have been removed. - It is important to ensure that during showers, previously clean areas are not contaminated with runoff from the washed contaminated areas (e.g., hair should be washed in a position that protects the body from contamination). - Wounds are irrigated and then covered with a water-resistant dressing prior to total body decontamination. - Internal contamination or incorporation requires decontamination through catharsis, gastric lavage with chelating agents (agents that bind with radioactive substances and are then excreted), or both. - Samples of urine, feces, and vomitus are surveyed to determine internal contamination levels. - Biologic samples are taken through nasal and throat swabs, and a complete blood count with differential is obtained.

Osmotic Diuretics

- Actions: Pull water into the renal tubule without sodium loss - Indications: Increased cranial pressure or acute renal failure due to shock, drug overdose, or trauma - Freely filtered at the renal glomerulus, poorly reabsorbed by the renal tubule - Not secreted by the tubule - Resistant to metabolism

Activated charcoal

- Activated charcoal administration if the poison is one that is absorbed by charcoal; given orally or by nasogastric tube within 60 minutes of poison ingestion - It is effective in small intermittent doses to decrease vomiting. - It should be diluted as a slurry so that it is easier to drink or pass through the nasogastric tube, often mixed with chocolate milk. - Activated charcoal absorbs most commonly ingested poisons except corrosives, heavy metals and hydrocarbons, iron, and lithium. - Works by trapping chemicals and preventing absorption - 50-100g sometimes in multiple doses. - Absorbs cocaine, acetaminophen (monitor liver function), opioids, amphetamines, salicylates, tricyclic antidepressants, SSRIs, phenobarbital, non-barbiturate sedatives - Contraindications: Unprotected airway may aspirate Diminished bowel sounds Paralytic ileus Ingestion of substance poorly absorbed by charcoal such as metal/iron Charcoal can absorb and neutralize antidotes Do not give antidotes immediately before, with or shortly after charcoal

Acute Radiation Syndrome

- Acute radiation syndrome (ARS) can occur after exposure to radiation. - It is the dose, rather than the source, that determines whether ARS develops. - Factors that determine whether the patient's response to exposure will result in ARS include a high dose (minimum 100 rad) and rate of radiation with total body exposure and penetrating-type radiation. - Age, medical history, and genetics also affect the outcome after exposure. - The course is predictable. - Each body system is affected differently in ARS. Systems with cells that rapidly reproduce are most commonly affected. - The hematopoietic system is the first system affected and serves as an indicator of the severity of radiation exposure - A predictor of outcome is the absolute lymphocyte count at 48 hours after exposure. A significant exposure would be indicated by blood lymphocyte counts of 300 to 1200/mm3. - Barrier precautions should be implemented to protect the patient from infection. - Neutrophils decrease within 1 week, platelets decrease within 2 weeks, and red blood cells decrease within 3 weeks. - Hemorrhagic complications including fever and sepsis are common. - Doses of radiation required to produce symptoms are approximately 600 rad or higher. - The gastrointestinal symptoms usually occur at the same time as the changes in the hematopoietic system. Nausea and vomiting occur within 2 hours after exposure. Sepsis, fluid and electrolyte imbalance, and opportunistic infections can occur as complications. - An ominous sign is the presence of high fever and bloody diarrhea; these typically appear on day 10 after exposure. - The central nervous system is affected when the dose exceeds 1000 rad. The symptoms occur when damage to the blood vessels of the brain results in fluid leakage. Signs and symptoms include cerebral edema; nausea; vomiting; headache; and increased intracranial pressure, which heralds a poor outcome and imminent death. Central nervous system injury with this amount of exposure is irreversible and occurs before hematopoietic or gastrointestinal system symptoms appear. Cardiovascular collapse is usually seen in conjunction with these injuries. - Skin effects can also indicate the dose of radiation exposure. With exposure of 600 to 1000 rad, erythema occurs; it can disappear within hours and then reappear. The patient who has been exposed must be evaluated hourly for the presence of erythema. - With exposures greater than 1000 rad, desquamation (radiation dermatitis) of the skin occurs. - Necrosis becomes evident within a few days to months at doses greater than 5000 rad. - Secondary injury can occur when the radiation exposure occurs during a traumatic event such as a blast or burn. Trauma in addition to radiation exposure increases patient mortality. - All definitive treatments must occur within the first 48 hours. Thereafter, all surgical procedures should be delayed for 2 to 3 months because of the potential for delayed wound healing and the possible development of opportunistic infections several weeks

Acute or subacute subdural hematoma

- Acute: symptoms develop over 24 to 48 hours - Subacute: symptoms develop over 48 hours to 2 weeks - Associated with major head injury involving contusion or laceration. Clinical symptoms develop rapidly - Signs and symptoms include changes in the level of consciousness (LOC), pupillary signs, and hemiparesis. There may be minor or even no symptoms with small collections of blood. - Coma, increasing blood pressure, decreasing heart rate, and slowing respiratory rate are all signs of a rapidly expanding mass requiring immediate intervention. - Requires immediate craniotomy and control of ICP - Successful outcome also depends on the control of ICP and careful monitoring of respiratory function

Additional supportive care for heat induced illnesses

- Additional supportive care may include dialysis for AKI, anticonvulsant medications to control seizures, potassium for hypokalemia, and sodium bicarbonate to correct metabolic acidosis. - Benzodiazepines such as diazepam (Valium) may be prescribed to suppress seizure activity, while a phenothiazine such as chlorpromazine (Thorazine) may be prescribed to suppress shivering. - Patients with heat exhaustion or heat cramps may be managed less aggressively. These patients should lie supine in a cool environment. - Patients with heat exhaustion may require IV fluids but may also take oral fluids, if they are tolerated. - Patients with heat cramps are given oral sodium supplements and oral electrolyte solutions

Preventing Head and Spinal Cord Injuries

- Advise drivers to obey traffic laws and to avoid speeding or driving when under the influence of drugs or alcohol. - Advise all drivers and passengers to wear seat belts and shoulder harnesses. Children younger than 12 years should use an age/size-appropriate system in the back seat. - Caution passengers against riding in the back of pickup trucks. - Advise motorcyclists, scooter riders, bicyclists, skateboarders, and roller skaters to wear helmets. - Promote educational programs that are directed toward violence and suicide prevention in the community. - Provide water safety instruction. - Educate patients about steps that can be taken to prevent falls, particularly in older adults. (fall risk is throw rugs) - Advise athletes to use protective devices. Recommend that coaches be educated in proper coaching techniques. - Advise owners of firearms to keep them locked in a secure area where children cannot access them.

Epidural Hematoma

- After a head injury, blood may collect in the epidural (extradural) space between the skull and the dura mater. - This can result from a skull fracture that causes a rupture or laceration of the middle meningeal artery, the artery that runs between the dura and the skull inferior to a thin portion of temporal bone. Hemorrhage from this artery causes rapid pressure on the brain. - Symptoms are caused by the expanding hematoma. - EDHs are often characterized by a brief loss of consciousness, followed by a lucid interval in which the patient is awake and conversant. - During this lucid interval, compensation for the expanding hematoma takes place by rapid absorption of CSF and decreased intravascular volume, both of which help to maintain the ICP within normal limits. - When these mechanisms can no longer compensate, even a small increase in the volume of the blood clot produces a marked elevation in ICP. The patient then becomes increasingly restless, agitated, and confused as the condition progresses to coma. Then, often suddenly, signs of herniation appear (usually deterioration of consciousness and signs of focal neurologic deficits, such as dilation and fixation of a pupil or paralysis of an extremity), and the patient's condition deteriorates rapidly. - The most common type of herniation syndrome associated with an EDH is uncal herniation causing pressure on the midbrain. Uncal herniation makes it an medical emergency. - An EDH is considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes. Treatment consists of making openings through the skull (burr holes) to decrease ICP emergently, remove the clot, and control the bleeding. - A craniotomy may be required to remove the clot and control the bleeding. A drain is usually inserted after creation of burr holes or a craniotomy to prevent reaccumulation of blood. - Client will need monitoring and support of vital body functions; respiratory support

Cricothyroidotomy (Cricothyroid Membrane Puncture)

- Cricothyroidotomy is the opening of the cricothyroid membrane to establish an airway. - This procedure is used in emergency situations in which endotracheal intubation is either not possible or contraindicated, as in airway obstruction from extensive maxillofacial trauma, cervical spine injuries, laryngospasm, laryngeal edema (after an allergic reaction or extubation), hemorrhage into neck tissue, or obstruction of the larynx. - A cricothyroidotomy is replaced with a formal tracheostomy when the patient is able to tolerate this procedure.

Maintaining Ventilation after airway is determined as unobstructed:

- After the airway is determined to be unobstructed, the nurse must ensure that ventilation is adequate by checking for equal bilateral breath sounds. - Satisfactory management of ventilations may prevent hypoxia and hypercapnia. - The nurse must quickly assess for absent or diminished breath sounds, open chest wounds, and difficulty delivering artificial breaths for the patient. - The nurse should monitor pulse oximetry, capnography, and arterial blood gases if the patient requires airway or ventilatory assistance. - A tension pneumothorax can mimic hypovolemia, so ventilatory assessment precedes assessment for hemorrhage. A pneumothorax (both simple and tension) or sucking (open) chest wound is managed with a chest tube and occlusion of the sucking wound; immediate relief of increasing positive intrathoracic pressure and maintenance of adequate ventilation should occur.

Creutzfeldt-Jakob Disease Medical Management \

- After the onset of specific neurologic symptoms, progression of disease occurs quickly. There is no effective treatment for CJD or vCJD. - The care of the patient is supportive and palliative. = Goals of care include prevention of injury related to immobility and dementia, promotion of patient comfort, and provision of support and education for the family. - Institutional protocols are followed for handling of brain, spinal cord, pituitary gland, and eye tissue; and for exposure and decontamination of equipment. In the operating room, it is recommended that disposable instruments be used and then incinerated, because conventional methods of sterilization do not destroy the prion - If disposable instruments cannot be used, stringent sterilization methods such as the use of bleach for cleaning and extended sterilization time for instruments should be used. - CJD can be transmitted by injection or consuming the infected brain or nervous tissue. - Standard precautions. - The nursing care of patients is primarily supportive and palliative. Psychological and emotional support of the patient and family throughout the course of the illness is needed. Care extends to providing for a dignified death and supporting the family through the processes of grief and loss. Hospice services are appropriate either at home or at an inpatient facility.

Autonomic dysreflexia

- Also known as autonomic hyperreflexia - Is an acute life-threatening emergency that occurs as a result of exaggerated autonomic responses to stimuli that are harmless in people without SCI. - It occurs only after spinal shock has resolved. - This syndrome is characterized by a severe, pounding headache with paroxysmal hypertension, profuse diaphoresis above the spinal level of the lesion (most often of the forehead), nausea, nasal congestion, and bradycardia. - It occurs among patients with cord lesions above T6 (the sympathetic visceral outflow level) after spinal shock has subsided - The sudden increase in blood pressure may cause retinal hemorrhage, hemorrhagic stroke, myocardial infarction, or seizures. - A number of stimuli may trigger this reflex: distended bladder (the most common cause); distention or contraction of the visceral organs, especially the bowel (from constipation, impaction); or stimulation of the skin (tactile, pain, thermal stimuli, pressure ulcer). - Massive uncompensated cardiovascular reaction mediated by the SNS. Intact sensory message travels up spinal cord - Untreated can lead to Status Epilepticus, Stroke, MI, & Death

The Monro-Kellie hypothesis

- Also known as the Monro-Kellie doctrine - Explains the dynamic equilibrium of cranial contents. - The cranial vault contains three main components: brain, blood, and cerebrospinal fluid (CSF). - According to the Monro-Kellie hypothesis, the cranial vault is a closed system, and if one of the three components increases in volume, at least one of the other two must decrease in volume or the pressure will increase. - Any bleeding or swelling within the skull increases the volume of contents within the skull and therefore causes increased intracranial pressure (ICP). If the pressure increases enough, it can cause displacement of the brain through or against the rigid structures of the skull. This causes restriction of blood flow to the brain, decreasing oxygen delivery and waste removal. Cells within the brain become anoxic and cannot metabolize properly, producing ischemia, infarction, irreversible brain damage, and eventually brain death - States that the three components, brain tissue, blood, CSF, remains relatively constant in the closed skull structure. The balance among the three components maintains the ICP. If one component increases, the others displace. As mass grows, it results in ischemia and brain death, or the contents of brain can move out the cavity and herniate leading to compression of brainstem and death.

Federal, State, and Local Responses to Emergencies

- An MCI is defined as any incident that causes a large numbers of casualties to the extent that necessary resources become too scarce - When resources to care for casualties become scarce, the greatest good for the greatest number of patients becomes the mode of operation - Local communities must be prepared to act in isolation (i.e., called sustainability planning) and provide competent care for up to 5 days before federal or other state resources may become available. - Disasters are categorized by type based upon anticipated use of resources and incident duration. - A disaster response strategy cannot succeed without appropriate physical assets and a staff trained and prepared to carry out the plan. Assets such as increased security; stockpiles of equipment and medications; and planning, drills, and training are essential - Hazard vulnerability assessments should be performed to identify potential and actual threats that involve a particular facility and community.

What is a spinal cord injury?

- An injury to the spinal cord, vertebral column, supporting soft tissue, or intervertebral discs caused by trauma is a major health disorder. - Risk factors include; young age, male gender, alcohol and drug use - The frequency with which these risk factors are associated with SCI serves to emphasize the importance of primary prevention. - Causes include MVAs, falls, violence (gunshot wounds), and sports-related injuries - The major causes of death are pneumonia, pulmonary embolism (PE), and sepsis - Paraplegia (paralysis of the lower body) and tetraplegia (paralysis of all four extremities; formerly called quadriplegia) can occur, with incomplete tetraplegia being the most frequently occurring injury, followed by complete paraplegia, complete tetraplegia, and incomplete paraplegia.

Cushing's triad

- Cushing's triad is a nervous system response to an acute increase in ICP. - Occurs when there is a significant decrease in CPP - Increase in SBP - Widening pulse pressure (Increased systolic and decreased diastolic) - Bradycardia - Slow irregular respirations - In increased ICP, CPP drops because systolic BP cannot overcome resistance present in the brain. -It is an late sign and requires immediate intervention. - Recovery is possible if caught early and treated. - It is a grave sign. Herniation of the brainstem and occlusion of cerebral blood flow occurs resulting in brain death.

Oropharyngeal/Nasopharyngeal Airway Insertion

- An oropharyngeal airway is a semicircular tube or tubelike plastic device that is inserted over the back of the tongue into the lower posterior pharynx in a patient who is breathing spontaneously but who is unconscious - This type of airway prevents the tongue from falling back against the posterior pharynx and obstructing the airway. - It also allows health care providers to suction secretions. - The nasopharyngeal airway provides the same airway access but is inserted through the nares. With an airway in place the patient may breathe spontaneously. - If breathing is ineffective or absent, bag-valve-mask ventilation is necessary. - In the case of potential facial trauma or basal skull fracture, the nasopharyngeal airway should not be used because it could enter the brain cavity instead of the pharynx.

Nurses should have a heightened awareness of trends that may suggest deliberate dispersal of toxic or infectious agents or pandemic onset that may include the following:

- An unusual increase in the number of people seeking care for fever, respiratory, or gastrointestinal symptoms - Clusters of patients who present with the same unusual illness from a single location. For example, clusters can be from a specific geographic location, such as a city, or from a single sporting or entertainment event. - A large number of fatalities, especially when death occurs within 72 hours after hospital admission - Any increase in disease incidence in a normally healthy population. These cases should be reported to the state health department and to the CDC.

Anthrax Manifestations

- Anthrax is caused by replicating bacteria that release toxin, resulting in hemorrhage, edema, and necrosis. - The incubation period is 1 to 6 days. - There are three main methods of infection: skin contact, gastrointestinal ingestion, and inhalation. - Skin lesions (the most common infection) cause edema with pruritus and macule or papule formation, resulting in ulceration with 1- to 3-mm vesicles. A painless eschar develops, which falls off in 1 to 2 weeks. - Ingestion of anthrax results in fever, nausea and vomiting, abdominal pain, bloody diarrhea, and occasionally ascites. If severe diarrhea develops, decreased intravascular volume becomes the major treatment concern. The bacterium targets the terminal ileum and cecum. Sepsis can occur. - Inhaling anthrax results in severe clinical manifestations. Its symptoms mimic those of the flu, and usually treatment is sought only when the second stage of severe respiratory distress occurs. Antibiotic therapy does not halt the progress of the disease. - Inhaled anthrax can incubate for up to 60 days, making it difficult to identify its source. - Initial signs and symptoms include cough, headache, fever, vomiting, chills, weakness, mild chest discomfort, dyspnea, and syncope, without rhinorrhea or nasal congestion. - Most patients have a brief recovery period followed by the second stage within 1 to 3 days, characterized by fever, severe respiratory distress, stridor, hypoxia, cyanosis, diaphoresis, hypotension, and shock. - These patients require optimization of oxygenation, correction of electrolyte imbalances, and ventilatory and hemodynamic support. - More than 50% of these patients have hemorrhagic mediastinitis on a chest x-ray (a hallmark sign). The disease can also progress to include meningitis with subarachnoid hemorrhage. - Death results approximately 24 to 36 hours after the onset of severe respiratory distress. The mortality rate approaches 100%

Intra-abdominal management

- As indicated by the patient's condition, resuscitation procedures (restoration of airway, breathing, and circulation) are initiated as described previously. - With blunt trauma, the patient is kept on a stretcher to immobilize the spine. - Cervical spine immobilization is maintained until cervical x-rays have been obtained and cervical spine injury has been ruled out. - Likewise, once the backboard is removed, logrolling can be used to protect the spine until x-rays are obtained and confirm that there is no evidence of injuries. - All wounds are located, counted, and documented. - If abdominal viscera protrude, the area is covered with sterile, moist saline dressings to keep the viscera from drying. - Typically, oral fluids are withheld in anticipation of surgery, and the stomach contents are aspirated with an orogastric tube to reduce the risk of aspiration and to decompress the stomach in preparation for diagnostic procedures. - Trauma predisposes the patient to infection by disruption of mechanical barriers, exposure to exogenous bacteria from the environment at the time of injury, aspiration of vomitus, and diagnostic and therapeutic procedures (hospital-acquired infection). - Tetanus prophylaxis and broad-spectrum antibiotics are given as prescribed. - If there is continuing evidence of shock, blood loss, free air under the diaphragm, evisceration, hematuria, severe head injury, musculoskeletal injury, or suspected or known abdominal injury, the patient is rapidly transported to surgery. - In most cases, blunt liver and spleen injuries are managed nonsurgically. - The goal for the management of all patients who have experienced trauma is to minimize the length of stay in the ED. The patient should be moved to the definitive destination quickly so that care and rehabilitation can continue.

Treatment of Increased Intracranial Pressure

- As the damaged brain swells with edema or as blood collects within the brain, an increase in ICP occurs; this requires aggressive treatment - If the ICP remains elevated, it can decrease the CPP. - Initial management is based on preventing secondary injury and maintaining adequate cerebral oxygenation. - Surgery is required for evacuation of blood clots, débridement and elevation of depressed fractures of the skull, and suture of severe scalp lacerations. - ICP is monitored closely; if increased, it is managed by maintaining adequate oxygenation, elevating the head of the bed, and maintaining normal blood volume - Devices to monitor ICP or drain CSF can be inserted during surgery or at the bedside using aseptic technique. The patient is cared for in the intensive care unit (ICU), where expert nursing care and medical treatment are readily available. - Treatment also includes ventilatory support, seizure prevention, fluid and electrolyte maintenance, nutritional support, and management of pain and anxiety. Patients who are comatose are intubated and mechanically ventilated to ensure adequate oxygenation and protect the airway.

Assessment and Diagnostic Findings of intra-abdominal injuries

- As the history of the traumatic event is obtained, the abdomen is inspected as a part of the secondary survey for obvious signs of injury, including penetrating injuries, bruises, and abrasions. - Abdominal assessment continues with auscultation of bowel sounds to provide baseline data from which changes can be noted. - Absence of bowel sounds may be an early sign of intraperitoneal involvement, although stress can also decrease or halt peristalsis and thus bowel sounds. - Further abdominal assessment may reveal progressive abdominal distention, involuntary guarding, tenderness, pain, muscular rigidity, or rebound tenderness along with changes in bowel sounds, all of which are signs of peritoneal irritation. - Hypotension and signs and symptoms of shock may also be noted. - In addition, the chest and other body systems are assessed for injuries that frequently accompany intra-abdominal injuries

Limiting exposure of chemicals

- Evacuation is essential, as is removal of the person's clothing and decontamination as close to the scene as possible and before transport of the person who has been exposed. - Soap and water are effective means of decontamination in most cases. - Staff involved in decontamination efforts must wear PPE and contain and dispose of the runoff after decontamination procedures

Anthrax Treatment

- At present, anthrax is penicillin sensitive; however, strains of penicillin-resistant anthrax are thought to exist. - Recommended treatment includes penicillin (Penicillin V), erythromycin (Erythrocin), gentamicin (Garamycin), or doxycycline (Vibramycin). - If antibiotic treatment begins within 24 hours after exposure, death can be prevented. - In a mass casualty situation, treatment with ciprofloxacin (Cipro) or doxycycline is recommended, because these easily given oral antibiotic agents are stockpiled and there should be sufficient dosages to fully treat many patients who have been anthrax-exposed. - Treatment is continued for 60 days. For patients who have been directly exposed to anthrax but have no signs and symptoms of disease, ciprofloxacin or doxycycline is used for prophylaxis for 60 days. - Standard precautions are the only ones indicated to protect the caregiver exposed to a patient infected with anthrax. - The patient is not contagious, and the disease cannot spread from person to person. - Equipment should be cleaned using standard hospital disinfectant. - After death, cremation is recommended because the spores can survive for decades and represent a threat to morticians and forensic medicine personnel.

Types of Radiation

- Atoms consist of protons, neutrons, and electrons. The protons and neutrons are in balance in the nucleus. - The number of protons is specific for each element in the periodic table. - When an element is radioactive, there is an imbalance in the nucleus, resulting from an excess of neutrons. To achieve stability, a radioactive nuclide can eject particles until the most stable number (an even number) of protons and neutrons exists. - A proton can become a neutron by ejecting a positron; conversely, a neutron can become a proton by ejecting a negative electron. - An alpha particle is released when two protons and two electrons are ejected (beta particles are electrons). - Alpha particles cannot penetrate the skin. A thin layer of paper or clothing is all that is necessary to protect the skin from alpha radiation. However, this low-level radiation can enter the body through inhalation, ingestion, or injection (open wound). Only localized damage occurs. - Beta particles have the ability to moderately penetrate the skin to the layer in which skin cells are being produced. This high-energy radiation can cause skin damage if the skin is exposed for a prolonged period and can cause injury if beta particles penetrate the skin. - Gamma radiation is a short-wavelength electromagnetic energy that is emitted when there is excess core nucleus energy. Gamma particles are penetrating. Therefore, it is difficult to shield against gamma radiation. X-rays are an example of gamma radiation. Gamma radiation often accompanies both alpha particle and beta particle emission.

Biologic Weapons

- Biologic weapons are weapons that spread disease among the general population or the military. They can be used for sabotage, such as food or water contamination with a small target area, or may be used by global terrorists with intentions to enable global objectives. - Biologic weapons are easily obtained and easily disseminated and can result in significant mortality and morbidity - The potential use of biologic weapons calls for continuous increased surveillance by health departments and an increased index of suspicion by clinicians. - Appropriate management of a biologic threat includes rapid recognition of the potential weapon; the use of proper PPE; decontamination, isolation, or quarantine of patients who are infected when appropriate; and the administration of appropriate vaccinations, antidotes, or medications to people at risk. - Biologic weapons are delivered in either a liquid or dry state, applied to foods or water, or vaporized for inhalation or direct contact. - Vaporization may be accomplished through spray or explosives loaded with the weapon. - Because of increases in business and pleasure travel by people in industrialized nations, a biologic weapon could be released in one city and affect people in other cities thousands of miles away. - The vector can be an insect, animal, or person, or there may be direct contact with the weapon itself.

Blast injury: Abdominal and Head Injuries

- Blast abdomen may be evidenced by abdominal hemorrhage and internal organ injury. - The typical signs and symptoms of internal abdominal injury can include pain, guarding, rebound tenderness, rectal bleeding, nausea, and vomiting. - Head injuries are typically minor, but those that are severe result in the majority of postblast deaths. These injuries can occur without a direct blow to the head and may result from the blast itself, building collapse, or flying debris. - Concussions commonly occur postblast, and the usual follow-up evaluation and treatment for postconcussive syndrome is indicated

Blast Lung

- Blast lung results from the blast wave as it passes through air-filled lungs. The result is hemorrhage and tearing of the lung, ventilation-perfusion mismatch, and possible air emboli. - Typical signs and symptoms include dyspnea, hypoxia, tachypnea or apnea (depending on severity), cough, chest pain, and hemodynamic instability. - Management involves providing respiratory support that includes administration of supplemental oxygen with nonrebreathing mask but may also require endotracheal intubation and mechanical ventilation. - If a hemothorax or pneumothorax is present, a chest tube must be inserted to re-expand the lung. - In the event of an air embolus, the patient should be immediately placed in the prone left lateral position to prevent migration of the embolus and will require emergent treatment in a hyperbaric chamber - Complications following blast lung can include respiratory failure as well as acute respiratory distress syndrome.

Blood Agents

- Blood agents such as hydrogen cyanide and cyanogen chloride have a direct effect on cellular metabolism, resulting in asphyxiation through alterations in hemoglobin. - Cyanide is an agent that has profound systemic effects. It is commonly used in the mining of gold and silver and in the plastics and dye industries. - A cyanide release is often associated with the odor of bitter almonds. - In house fires, cyanide is released during the combustion of plastics, rugs, silk, furniture, and other construction materials. - There is a significant correlation between blood cyanide and carbon monoxide levels in patients who survive fires, and in some cases, the cause of death is cyanide poisoning. - Cyanide can be ingested, inhaled, or absorbed through the skin and mucous membranes. - Cyanide is protein bound and inhibits aerobic metabolism, leading to respiratory muscle failure, respiratory arrest, cardiac arrest, and death. - Its inhalation results in flushing, tachypnea, tachycardia, nonspecific neurologic symptoms, stupor, coma, and seizure preceding respiratory arrest. - Its inhalation results in flushing, tachypnea, tachycardia, nonspecific neurologic symptoms, stupor, coma, and seizure preceding respiratory arrest.

Lewisite, sulfur mustard, nitrogen mustard, and phosgene

- Vesicant Agents - Action: Blistering agents - Signs and symptoms: Superficial to partial-thickness burn with vesicles that coalesce; conjunctivitis, nasal irritation - Treatment: Soap and water, Blot; do not rub dry

Managing Behavioral Issues

- Both people and communities suffer immediate and sometimes long-term psychological trauma that most often relates to fear and anxiety - Common responses to disaster include: Anxiety, depression, impaired performance, interpersonal conflicts, posttraumatic stress disorder, somatization (fatigue, general malaise, headaches, gastrointestinal disturbances, skin rashes), and substance abuse - Factors that influence a person's response to disaster include the degree and nature of the exposure to the disaster; loss of friends, family members, and pets; existing coping strategies; available resources and support; and the personal meaning attached to the event. - Other factors, such as loss of home and valued possessions, extended exposure to danger, and exposure to toxic contamination, also influence response and increase the risk of adjustment problems. - Those exposed to the dead and injured, those endangered by the event, older adults, children, emergency first responders, and health care personnel caring for victims are considered to be at higher risk for emotional sequelae. - A bioterrorism attack can have psychological effects, resulting in psychogenic illnesses such as panic, fear, and/or anger - Nurses can assist victims of disaster through active listening and providing emotional support, giving information, and referring patients to therapists or social workers. - Health care workers must refer people to mental health care services because experience has shown that few victims of disaster seek these services, and early intervention minimizes psychological consequences. - Nurses can also discourage victims from subjecting themselves to repeated exposure to the event through media replays and news articles, as well as encourage them to return to normal activities and social roles when appropriate

Complications of increased ICP include brainstem herniation, diabetes insipidus, and syndrome of inappropriate antidiuretic hormone (SIADH).

- Brainstem herniation results from an excessive increase in ICP in which the pressure builds in the cranial vault and the brain tissue presses down on the brainstem. This increasing pressure on the brainstem results in cessation of blood flow to the brain, leading to irreversible brain anoxia and brain death. - Neurogenic diabetes insipidus is the result of decreased secretion of antidiuretic hormone (ADH). The patient has excessive urine output, decreased urine osmolality, and serum hyperosmolarity. Therapy consists of administration of fluids, electrolyte replacement, and administration of a synthetic vasopressin (desmopressin [DDAVP]). - SIADH is the result of increased secretion of ADH. The patient becomes volume overloaded, urine output diminishes, and serum sodium concentration becomes dilute. Treatment of SIADH includes fluid restriction (less than 800 mL/day with no free water), which is usually sufficient to correct the hyponatremia. In severe cases, careful administration of a 3% hypertonic saline solution may be therapeutic. The change in serum sodium concentration should not exceed a correction rate of approximately 1.3 mEq/L/hr.

Burr holes

- Burr holes may be used to determine the presence of cerebral swelling and injury and the size and position of the ventricles. - They are also a means of evacuating an intracranial hematoma or abscess and for making a bone flap in the skull that allows access to the ventricles for decompression, ventriculography, or shunting procedures. - Other cranial procedures include craniectomy (excision of a portion of the skull) and cranioplasty (repair of a cranial defect using a plastic or metal plate).

Critical Incident Stress Management

- CISM is an approach to preventing and treating the emotional trauma that can affect emergency responders as a consequence of their jobs and that can also occur to anyone involved in a disaster or MCI. - CISM is handled by teams, which are available to the OEM. - Components of a management plan include education (preparedness) before an incident occurs about critical incident stress and coping strategies; field support (ensuring that staff get adequate rest, food, and fluids, and rotating workloads) during an incident; and defusings, debriefings, demobilization, supportive services to the family, and follow-up care after the incident. - Defusing is a process by which the person receives education about recognition of stress reactions and management strategies for handling stress. - Debriefing is a more complicated intervention; it involves a 2- to 3-hour process during which participants are asked about their emotional reactions to the incident, what symptoms they may be experiencing (e.g., flashbacks, difficulty sleeping, intrusive thoughts), and other psychological ramifications. Following up and identifying clients that require further assessment and assistance. - In follow-up, members of the CISM team contact the participants of a debriefing and schedule a follow-up meeting if necessary. - People with ongoing stress reactions are referred to mental health specialists.

Reducing Cerebrospinal Fluid and Intracranial Blood Volume

- CSF drainage is frequently performed, because the removal of CSF with a ventriculostomy drain can dramatically reduce ICP and restore CPP. - Caution should be used in draining CSF, however, because excessive drainage may result in collapse of the ventricles and herniation. - The reduction in PaCO2 may result in hypoxia, ischemia, and an increase in cerebral lactate levels. - Maintaining the PaCO2 at greater than 30 mm Hg may prove beneficial

Assessment and diagnosis of the extent of injury are accomplished by the initial physical and neurologic examinations.

- CT and MRI scans are the main neuroimaging diagnostic tools and are useful in evaluating the brain structure. - Positron emission tomography (PET) is available in some trauma centers for assessing brain function. - Any patient with a head injury is presumed to have a cervical spine injury until proven otherwise. The patient is transported from the scene of the injury on a board with the head and neck maintained in alignment with the axis of the body. A cervical collar should be applied and maintained until cervical spine x-rays have been obtained and the absence of cervical SCI documented. - All therapy is directed toward preserving brain homeostasis and preventing secondary brain injury, which is injury to the brain that occurs after the original traumatic event. Common causes of secondary injury are cerebral edema, hypotension, and respiratory depression that may lead to hypoxemia and electrolyte imbalance. Treatments to prevent secondary injury include stabilization of cardiovascular and respiratory function to maintain adequate cerebral perfusion, control of hemorrhage and hypovolemia, and maintenance of optimal blood gas values.

Establishing an airway for airway obstruction

- Establishing an airway may be as simple as repositioning the patient's head to prevent the tongue from obstructing the pharynx. - Other maneuvers, such as the head-tilt/chin-lift maneuver, the jaw-thrust maneuver, or insertion of specialized equipment, may be needed to open the airway, remove a foreign body, or maintain the airway. - In all maneuvers, the cervical spine must be protected from injury. - After these maneuvers are performed, the patient is assessed for breathing by watching for chest movement and listening and feeling for air movement.

Hypothermia

- Can be accompanied with frostbite and leads to physiologic changes in all body organs - Hypothermia is a condition in which the core (internal) temperature is 35°C (95°F) or less as a result of exposure to cold or an inability to maintain body temperature in the absence of low ambient temperatures. - Older adults, infants, people with concurrent illnesses, and those who are homeless are particularly susceptible. - Alcohol ingestion increases susceptibility because it causes systemic vasodilation. - Some medications (e.g., phenothiazines) or medical conditions (e.g., hypothyroidism, spinal cord injury) decrease the ability to shiver, hampering the body's innate ability to generate body heat. - Fatigue and sleep deprivation are also associated with the development of hypothermia. - Heat loss of 2% is normal but increases with exposure. Wet clothing accelerates heat loss, and immersion in cold water increases heat loss by 25% - Victims of trauma are also at risk for hypothermia resulting from treatment with cold fluids, unwarmed oxygen, and exposure during examination. - The patient may also have frostbite, but hypothermia takes precedence in treatment. - Hypothermia leads to physiologic changes in all organ systems. There is progressive deterioration, with apathy, poor judgment, ataxia, dysarthria, drowsiness, pulmonary edema, acid-base abnormalities, coagulopathy, and eventual coma. - Shivering may be suppressed at a temperature of less than 32.2°C (90°F), because the body's self-warming mechanisms become ineffective. - The heartbeat and blood pressure may be so weak that peripheral pulses become undetectable. - Cardiac dysrhythmias may also occur. - Other physiologic abnormalities include hypoxemia and acidosis.

Exposure to carbon monoxide requires immediate treatment. Goals of management are to reverse cerebral and myocardial hypoxia and to hasten elimination of carbon monoxide. Whenever a patient inhales a poison, the following general measures apply:

- Carry the patient to fresh air immediately; open all doors and windows. - Loosen all tight clothing. - Initiate traditional cardiopulmonary resuscitation. - Prevent chilling; wrap the patient in blankets. - Keep the patient as quiet as possible. - Do not give alcohol in any form or permit the patient to smoke. - Carboxyhemoglobin levels are analyzed on arrival at the ED and before treatment with oxygen if possible. - To reverse hypoxia and accelerate the elimination of carbon monoxide, 100% oxygen is given at atmospheric or preferably hyperbaric pressures. Oxygen is given until the carboxyhemoglobin level is less than 5%. - Psychoses, spastic paralysis, ataxia, visual disturbances, and deterioration of mental status and behavior may persist after resuscitation and may be symptoms of permanent brain damage. - When unintentional carbon monoxide poisoning occurs, the health department should be contacted so that the dwelling or building in question can be inspected. A psychiatric consultation is warranted if it has been determined that the poisoning was a suicide attempt.

Increased Intracranial Pressure

- Causes: Increased blood volume Increased brain volume Increased CSF Space occupying lesions - Monroe-Kelli hypothesis: Skull is non compliant box If there is an increase in volume, it must be offset by a decrease of one or both components in order to maintain normal ICP

Skeletal Fracture Reduction and Traction

- Cervical fractures can be reduced, and the cervical spine aligned with some form of skeletal traction, such as with skeletal tongs or with the use of the halo device - Traction is applied to the skeletal traction device by weights (ensuring the weights are unencumbered); the amount depends on the size of the patient and the degree of fracture displacement - The traction force is exerted along the longitudinal axis of the vertebral bodies, with the patient's neck in a neutral position. The traction is then gradually increased by adding more weights. - As the amount of traction is increased, the spaces between the intervertebral discs widen and the vertebrae are given a chance to slip back into position. Reduction usually occurs after correct alignment has been restored. - Once reduction is achieved, as verified by cervical spine x-rays and neurologic examination, the weights are gradually removed until the amount of weight needed to maintain the alignment is identified. - Traction is sometimes supplemented with manual manipulation of the neck by a surgeon, to help achieve realignment of the vertebral bodies. - A halo device may be used initially with traction or may be applied after removal of the tongs. It consists of a titanium or stainless steel halo ring that is fixed to the skull by four pins, which are inserted into the outer table of the skull. The ring is attached to a removable halo vest, a device that suspends the weight of the unit circumferentially around the chest. - Halo devices provide immobilization of the cervical spine while allowing early ambulation for patients with adequate function. - Thoracic and lumbar injuries are usually treated with surgical intervention, followed by immobilization with a fitted brace. Traction is often not indicated either before or after surgery, due to the relative stability of the spine in these regions. - The patient's vital organ functions and body defenses must be supported and maintained until spinal and neurogenic shock abates and the neurologic system have recovered from the traumatic insult; this can take up to 4 months.

Signs of Increased ICP: Early

- Change in LOC is the earliest sign. Often agitation, slowing of speech and a delayed response may also be an early indication of increased ICP. - Disorientation, restlessness, increased respiratory effort, purposeless movements, and mental confusion. - Pupillary changes and impaired extraocular movements. - Weakness in one extremity or on one side of the body. - Headache that is constant, increasing in intensity, and aggravated by movement or straining.

Preparedness and Response: Personal Protective Equipment

- Chemical or biologic agents and radiation are silent killers and are generally colorless and odorless. - The purpose of PPE is to shield health care workers from the chemical, physical, biologic, and radiologic hazards that may exist when caring for patients who have been contaminated. - The U.S. Environmental Protection Agency (EPA) has divided protective clothing and respiratory protection into the following four categories, levels A through D - Levels C and D PPE are the levels most often used in hospital facilities. - Protective equipment must be donned before contact with a patient who has been contaminated. - The acute care facility's standard precaution PPE (level D) generally is not adequate for protection from a patient who has been chemically, biologically, or radiologically contaminated. - Level C PPE is adequate for the average patient exposure. - The health care provider must use equipment that is capable of providing protection against the agent involved. This may mean using a splash suit along with a full-face positive- or negative-pressure respirator (a filter-type gas mask) or even an SCBA for medical personnel in the field. - No single PPE is capable of protecting against all hazards. - Under no circumstances should responders wear any PPE without proper training, practice, and fit testing of respirator masks as necessary

Neurogenic Bladder

- Dysfunction that results from disorder or dysfunction of the nervous system & leads to urinary incontinence. - Causes: SCI Spinal tumor Herniated vertebral disc Multiple Sclerosis, Spina Bifida Congenital disorders Infection and/or Complications of diabetes - Two types: Spastic (Reflex): Spastic is more common, and is a result of a spinal cord lesion above the voiding reflex arch so its an upper motor neuron lesion. It results in loss of conscious sensation and cerebral motor control. It empties on reflex with minimal or no controlling influence. Flaccid: Lower motor neuron lesion. It is caused from trauma. The bladder continues to fill and becomes distended and overflow incontinence occurs.

Patients are at high risk for VTE after SCI.

- Chest pain, shortness of breath, and changes in arterial blood gas values must be reported promptly to the primary provider. - The circumferences of the thighs and calves are measured and recorded daily; further diagnostic studies are performed if a significant increase is noted - Anticoagulation should be initiated within 72 hours of injury and continued for at least 3 months - The use of low-molecular-weight heparin or low-dose unfractionated heparin may be followed by long-term oral anticoagulation (i.e., warfarin [Coumadin]). - Additional measures such as range-of-motion exercises, antiembolism stockings, and adequate hydration are important preventive measures. - SCDs may also be used to reduce venous pooling and promote venous return. - It is also important to avoid external pressure on the lower extremities that may result from flexion of the knees while the patient is in bed.

Snakebites

- Children between 1 and 9 years of age are the most likely victims. - The greatest number of bites occurs during the daylight hours and early evening of the summer months. - The most frequent poisonous snakebite in the United States occurs from Crotalidae, otherwise called pit vipers, such as water moccasins, copperheads, and rattlesnakes. - The most common site is the upper extremity - Of pit viper bites, 75% to 80% result in envenomation (injection of a poisonous material by sting, spine, bite, or other means); the rest result in what are called dry bites. - Venomous snakebites are medical emergencies. - Snake venom consists primarily of proteins and has a broad range of physiologic effects. - Snake venom may affect multiple organ systems, especially the neurologic, cardiovascular, and respiratory systems. - Classic clinical signs of envenomation are edema, ecchymosis, and hemorrhagic bullae, leading to necrosis at the site of envenomation. - Symptoms include lymph node tenderness, nausea, vomiting, numbness, and a metallic taste in the mouth. - Without decisive treatment, these clinical manifestations may progress to include fasciculations, hypotension, paresthesias, seizures, and coma

Subdural Hematoma

- Collection of blood between the dura and the brain - Occurs most often from a tearing of the bridging veins within the cerebral hemispheres or from a laceration of brain tissue, but it can also occur as a result of coagulopathies or rupture of an aneurysm. - Bleeding occurs more slowly than a epidural hematoma - An SDH is more frequently venous in origin and is caused by the rupture of small vessels that bridge the subdural space - Highest mortality rate because they often are unrecognized until the patient presents with severe neurologic compromise - SDHs may be acute or chronic depending on the size of the involved vessel and the amount of bleeding on CT scan.

Impaired Fluid, Electrolyte, and Nutritional Balance.

- Common imbalances include hyponatremia, which is often associated with SIADH, hypokalemia, and hyperglycemia. - Modifications in fluid intake with tube feedings or IV fluids, including hypertonic saline, may be necessary to treat these imbalances - Insulin administration may be prescribed to treat hyperglycemia; blood glucose levels are maintained between 80 and 160 mg/dL - Undernutrition is also a common problem in response to the increased metabolic needs associated with severe head injury. Decisions about early feeding should be individualized; options include IV hyperalimentation or placement of a feeding tube - Caloric expenditure can increase up to 120% to 140% with TBI, requiring close monitoring of nutritional status, with a higher concentration of protein if tolerated

Documentation of Consent and Privacy

- Consent to examine and treat the patient is part of the ED record. - If the patient is unconscious and brought to the ED without family or friends, this fact must be documented. Monitoring of the patient's condition, as well as all instituted treatments and the times at which they were performed, must be documented. After treatment, a notation is made on the record about the patient's condition, response to the treatment, and condition at discharge or transfer and about instructions given to the patient and family for follow-up care. - The patient is also provided with a statement of the privacy policy of the health care agency, according to federal law. Patients involved in violent events can be provided with an alias, and access to the electronic health record is limited to protect the privacy of the patient. A patient may also request extra privacy by limiting access to their room and by choosing not to receive phone calls, mail, flowers, other gifts, or certain visitors. These practices relate to the federally mandated privacy policy stipulated in the Health Insurance Portability and Accountability Act (HIPAA). - According to the Emergency Medical Treatment and Active Labor Act (EMTALA), every ED with a Medicare provider agreement must perform a medical screening examination on all patients arriving with an emergency medical complaint if their acute signs and symptoms could result in serious injury or death if left untreated. EDs are also required to provide treatment aimed at stabilizing each patient's condition. If the patient must be transferred to another facility, the patient's consent for transfer should be obtained, if possible. In addition, acceptance by the receiving facility and physician must be obtained, and an appropriate method of transfer for the patient should be secured. Documentation of assessment and treatment must be sent with the patient upon transfer

Frostbite Management

- Constrictive clothing and jewelry that could impair circulation are removed. - Wet clothing is removed as rapidly as possible. - If the lower extremities are involved, the patient should not be allowed to ambulate. - Controlled yet rapid rewarming is instituted. - Frozen extremities are usually placed in a 37°C to 40°C (98.6°F to 104°F) circulating bath for 30- to 40-minute spans. This treatment is repeated until circulation is effectively restored. - During rewarming, an analgesic for pain is given as prescribed, because the rewarming process may be very painful. - To avoid further mechanical injury, the body part is not handled. Massage is contraindicated. - Once rewarmed, the part is protected from further injury and is elevated to help control swelling. - Sterile gauze or cotton is placed between affected fingers or toes to prevent maceration, and a bulky dressing is placed on the extremity. - A foot cradle may be used to prevent contact with bedclothes if the feet are involved. - Hemorrhagic blebs, which may develop 1 hour to a few days after rewarming, are left intact and not ruptured. Nonhemorrhagic blisters are débrided to decrease the inflammatory mediators found in the blister fluid. - A physical assessment is conducted with rewarming to observe for concomitant injury, such as soft tissue injury, dehydration, alcohol intoxication, or fat embolism. Problems such as hyperkalemia (e.g., from release of potassium in the damaged cells) and hypovolemia, which occur frequently in people with frostbite, are corrected. - Risk of infection is also great; therefore, aseptic technique is used during dressing changes, and tetanus prophylaxis is given as indicated. - Nonsteroidal anti-inflammatory drugs (NSAIDs) are prescribed for their anti-inflammatory effects and to control pain. - Whirlpool bath for the affected body parts to aid circulation and débridement of necrotic tissue to help prevent infection - Escharotomy (incision through the eschar) to prevent further tissue damage, to allow for normal circulation, and to permit joint motion - Fasciotomy to treat compartment syndrome - After rewarming, hourly active motion of any affected digits is encouraged to promote maximal restoration of function and to prevent contractures. Discharge instructions also include encouraging the patient to avoid tobacco, alcohol, and caffeine because of their vasoconstrictive effects, which further reduce the already deficient blood supply to injured tissues.

SCI

- Damage in SCI ranges from transient concussion (from which the patient fully recovers) to contusion, laceration, and compression of the spinal cord tissue (either alone or in combination), to complete transection (severing) of the spinal cord (which renders the patient paralyzed below the level of the injury). - The vertebrae most frequently involved are the 5th, 6th, and 7th cervical vertebrae (C5-C7), the 12th thoracic vertebra (T12), and the 1st lumbar vertebra (L1). These vertebrae are most susceptible because there is a greater range of mobility in the vertebral column in these areas - SCIs can be separated into two categories: primary injuries and secondary injuries. - Primary injuries are the result of the initial insult or trauma and are usually permanent. - Secondary injuries resulting from SCI include edema and hemorrhage. The secondary injury is a major concern for critical care nurses. Early treatment is essential to prevent partial damage from becoming total and permanent.

Decompression Sickness

- Decompression sickness, also known as "the bends," occurs in patients who have engaged in diving (lake/ocean diving), high-altitude flying, or flying in commercial aircraft within 24 hours after diving. - Decompression sickness results from formation of nitrogen bubbles that occur with rapid changes in atmospheric pressure. They may occur in joint or muscle spaces, resulting in musculoskeletal pain, numbness, or hypesthesia. - More significantly, nitrogen bubbles can become air emboli in the bloodstream and thereby produce stroke, paralysis, or death. - To identify decompression sickness, a detailed history is obtained from the patient or diving partner. - Evidence of rapid ascent, loss of air in the tank, buddy breathing, recent alcohol intake or lack of sleep, or a flight within 24 hours after diving suggests possible decompression sickness. - Some patients describe a perfect dive yet still have the signs and symptoms of decompression sickness, in which case they must receive treatment for the condition. - Signs and symptoms include joint or extremity pain, numbness, hypesthesia, and loss of range of motion. - Neurologic symptoms mimicking those of a stroke or spinal cord injury can indicate an air embolus. - Cardiopulmonary arrest can also occur in severe cases and is usually fatal. - All patients with decompression sickness need rapid transfer to a hyperbaric chamber.

Nerve Agents Treatment

- Decontamination with copious amounts of soap and water or saline solution for 8 to 20 minutes is essential. - The water is blotted off, not wiped off, the skin. Wiping may have the unintended effect of rubbing more of the agent into the skin. - Fresh 0.5% hypochlorite solution (bleach) can also be used. - The airway is maintained, and suctioning is frequently required. Plastic airway equipment should not be used, because plastic will absorb sarin gas and may result in continued exposure to the agent. - Atropine 2 to 4 mg is administered by IV, followed by 2 mg every 3 to 8 minutes for up to 24 hours of treatment. - Alternatively, IV atropine 1 to 2 mg per hour may be given until clear signs of anticholinergic activity have returned (decreased secretions, tachycardia, and decreased gastrointestinal motility). - Another medication that may serve as an antidote is pralidoxime (Protopam), which allows cholinesterase to become active against acetylcholine. - Pralidoxime 1 to 2 g in 100 to 150 mL of normal saline solution is given over 15 to 30 minutes. - Pralidoxime has no effect on secretions and may have any of the following side effects: hypertension, tachycardia, weakness, dizziness, blurred vision, and diplopia. - Diazepam (Valium) or other benzodiazepines are used to control seizures, to decrease fasciculations, and to alleviate apprehension and agitation.

Preparedness and Response: Decontamination

- Decontamination, the process of removing accumulated contaminants or rendering them harmless, is critical to the health and safety of health care providers by preventing secondary contamination. - The decontamination plan should establish procedures and educate employees about decontamination procedures, identify the equipment needed and methods to be used, and establish methods for disposal of contaminated materials. - Authorities agree that to be effective, decontamination must include a minimum of two steps. - The first step is removal of the patient's clothing and jewelry and then rinsing the patient with water. Depending on the type of exposure, this step alone can remove a large amount of the contamination and decrease secondary contamination. - The second step consists of a thorough soap-and-water wash and rinse. The hospital must be prepared to perform additional decontamination prior to entry into the facility. - The hospital personnel may also treat "walking wounded" who did not receive any decontamination at the scene. - When patients arrive at the facility after being assessed and treated by a prehospital provider, it should not be assumed that they have been thoroughly decontaminated.

Management of the Client with Increased ICP

- Decrease cerebral edema: Give Mannitol (osmotic diuretic, it sends fluid from the cerebral space to the intravascular space). Monitor s/s of heart failure and pulmonary edema. Hypertonic (3%) saline, to dehydrate brain tissues and decrease cerebral edema. Steroids if edema is not caused by trauma. - Maintain cerebral perfusion - Reduce CSF and intracranial blood volume: Using a drain, and if that is used, prevent infection. - Control fever: Fever increases metabolic demand, and temperature regulation may be impaired due to damaged hypothalamus. - Maintain O2 & CO2 levels - Reduce metabolic demand: This is done by reducing stimulation, and initiating a barbiturates' coma - Optimize tissue perfusion: Elevate HOB 30-45 degrees, maintain head and neck at neutral alignment, no twisting or flexing - Maintain negative fluid balance - Monitor for secondary complications - Elevate the HOB 45 degrees - Neutral alignment facilitate venous drainage - Stool softeners: To prevent Valsalva maneuvers - Avoid excessive suctioning, and painful procedures. If suctioning, ICP should not go above 25 and should return to baseline within 5 minutes. - High PEEP should be used cautiously - Seizure prevention: Seizure prophylaxis

Issues in emergency nursing care

- Emergency nursing is demanding because of the diversity of conditions and situations that present unique challenges. - Challenges include legal issues, occupational health and safety risks for ED staff, and the challenge of providing holistic care in the context of a fast-paced, technology-driven environment in which serious illness and death are encountered on a daily basis. Another dimension of emergency nursing is nursing in disasters. - With the increasing use of weapons of terror and mass destruction, both internationally and at home, the emergency nurse must recognize and treat patients exposed to biologic and other weapons, anticipating nursing care in the event of a mass casualty incident from natural causes or a terrorist event - Documentation of Consent and Privacy: - Limiting Exposure to Health Risks: - Violence in the Emergency Department - Providing Holistic Care

Delayed Primary Closure

- Delayed primary closure may be indicated if tissue has been lost or there is a high potential for infection. - A thin layer of gauze (to ensure drainage and prevent pooling of exudate), covered by an occlusive dressing, may be used. The wound is splinted in a functional position to prevent motion and decrease the possibility of contracture. - If there are no signs of suppuration (formation of purulent drainage), the wound may be sutured (with the patient receiving a local anesthetic). - The use of antibiotic agents to prevent infection depends on factors such as how the injury occurred, the age of the wound, and the risk of contamination. - The site is immobilized and elevated to limit accumulation of fluid in the interstitial spaces of the wound. - Tetanus prophylaxis is given as prescribed, based on the condition of the wound and the patient's immunization status. If the patient's last tetanus booster was given more than 5 years ago, or if the patient's immunization status is unknown, a tetanus booster must be given - The patient is instructed about signs and symptoms of infection and is instructed to contact the primary provider or clinic if there is sudden or persistent pain, fever or chills, bleeding, rapid swelling, foul odor, drainage, or redness surrounding the wound.

Clinical manifestations of spinal cord injury

- Dermatomes show connection between the vertebrae and other parts of the body. - Symptoms of spinal cord injury depend on the type and level of the injury. Type refers to the extend of injury to the spinal cord. - A complete spinal cord lesion signifies loss of both sensory and voluntary motor communication from the brain to the periphery, resulting in paraplegia or tetraplegia - Incomplete spinal cord lesion denotes that the ability of the spinal cord to relay messages to and from the brain is not completely absent. Sensory and/or motor fibers are preserved below the lesion. - Injuries are classified according to the area of spinal cord damage: central, lateral, anterior, or peripheral - The neurologic level refers to the lowest level at which sensory and motor functions are intact. Below the neurologic level, there may be total or partial, sensory and/or motor paralysis (dependent upon affected tracts), loss of bladder and bowel control (usually with urinary retention and bladder distention), loss of sweating and vasomotor tone, and marked reduction of blood pressure from loss of peripheral vascular resistance. - If conscious, the patient usually complains of acute pain in the back or neck, which may radiate along the involved nerve. However, absence of pain does not rule out spinal injury, and a careful assessment of the spine should be conducted if there has been a significant force and mechanism of injury (i.e., concomitant head injury). - Respiratory dysfunction is related to the level of injury. The muscles contributing to respiration are the diaphragm (C4), intercostals (T1-T6), and abdominals (T6-T12). Injuries at C4 or above (causing paralysis of the diaphragm) often will require ventilator support, since acute respiratory failure is a leading cause of death. - Injuries of T12 and above will have impact on respiratory function.

Chronic subdural hematoma

- Develops over weeks to months - Develop from seemingly minor head injuries and is seen most frequently in older adults who are prone to this type of head injury due to brain atrophy, which is a consequence of the aging process - Due to prolonged time prior to the onset of symptoms, the actual causative injury may be minor and forgotten - A chronic SDH can resemble other conditions, such as stroke. The bleeding is less profuse, but compression of the intracranial contents still occurs. The blood within the brain changes in character in 2 to 4 days, becoming thicker and darker. In a few weeks, the clot breaks down and has the color and consistency of motor oil. - The brain adapts to this foreign body invasion, and the clinical signs and symptoms fluctuate. Symptoms include severe headache, which tends to come and go; alternating focal neurologic signs; personality changes; mental deterioration; and focal seizures - The treatment for a chronic SDH consists of surgical evaluation for evacuation of the clot. The operative procedure may be carried out through multiple burr holes, or a craniotomy may be performed for a sizable subdural mass that cannot be suctioned or drained through burr holes.

Primary Survey: D is for Disability

- Disability: Assessment measured by client's LOC - LOC assesses the client response to verbal and/or painful stimuli - AVPU. Alertness can be important to selecting appropriate airway interventions. - Glasgow Coma Scale: Score ranges from 3 to 15. Standardized for consistent communication among care team members - GCS is not accurate for intubated/sedated patients, it is a standardized tool used for communication among care team members. GCS less than 8, anticipate intubation.

Spinal injury: Cardiovascular and Respiratory Dysfunction

- Disruption of autonomic nervous system - Pay attention to T6 or above - Bradycardia, hypotension, hypothermia - Systolic blood pressure below 90 mm Hg provides poor perfusion to the spinal cord - Interruption of spinal innervation to the respiratory muscles - Assess for atelectasis and pneumonia

Animal and Human Bites

- Dog bites are responsible for the majority of deaths from bites by a nonvenomous animal - Cat bites have a high risk of infection because of the presence of Pasteurella in their saliva. - All animal bites must be reported to public health authorities, which must provide follow-up screening of the offending animal for rabies. - If the animal cannot be located and rabies vaccination verified, rabies prophylaxis for the person who has been bitten must be instituted. - The human mouth contains more bacteria than that of most other animals, so a high risk of bite-related infection exists. - The ED nurse should inspect any bitten tissue for pus, erythema, or necrosis. - A health care provider should take photographs, which can be used as evidence in criminal and legal proceedings. - Guidelines for collecting forensic evidence for photographing with and without a measuring device should be followed. - Cleansing with soap and water is then necessary, followed by the administration of antibiotics and tetanus toxoid as prescribed.

Emergency & Disaster Nursing: State & Federal Regulations

- Duty to Rescue: : Concept in tort law. A party can be held liable for failing to come to recuse of another party who could face potential danger or death without being rescued. Should not leave individual until EMS arrives. - Maryland Good Samaritan Law: Protect reasonable behavior of HCP when initiating interventions to protect the life of injured person until emergency care provider is available. Cannot charge fee and anyone can sue you. - Catastrophic Heath Emergency (CHE) Act (Maryland): The HCP is immune from civil and criminal law liability if he/she acts in good faith. - Emergency Care Providers - General Immunity: Not liable for any act or medical care unless he or she acts in gross negligence or misconduct.

Secondary injury

- Evolves over the ensuing hours and days after the initial injury and results from inadequate delivery of nutrients and oxygen to the cells. - Identification, prevention, and treatment of secondary injury are the main foci of early management of severe TBI. - Contributors to this process include intracranial pathologic processes such as intracranial hemorrhage, cerebral edema, intracranial hypertension, hyperemia, seizures, and vasospasm - Ischemia or chemical changes can also result in secondary injury - Systemic effects from hypotension, hyperthermia, hypoxia, hypercarbia, infection, electrolyte imbalances, and anemia can also be factors which add to the complex biochemical, metabolic, and inflammatory changes that further compromise an injured brain

Black

- Expectant: Injuries are extensive, and chances of survival are unlikely even with definitive care. Persons in this group should be separated from other casualties, but not abandoned. Comfort measures should be provided when possible. - Examples include: Patients who are unresponsive with penetrating head wounds, high spinal cord injuries, wounds involving multiple anatomic sites and organs, 2nd/3rd-degree burns in excess of 60% of body surface area, seizures or vomiting within 24 hours after radiation exposure, profound shock with multiple injuries, agonal respirations; no pulse, no blood pressure, pupils fixed and dilated

Monro-Kellie doctrine

- Explains the dynamic equilibrium of cranial contents. - The hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the components causes a change in the volume of the others. - Because brain tissue has limited space to expand, compensation typically is accomplished by displacing or shifting CSF, increasing the absorption or diminishing the production of CSF, or decreasing cerebral blood volume. Without such changes, ICP begins to rise. - Under normal circumstances, minor changes in blood volume and CSF volume occur constantly as a result of alterations in intrathoracic pressure (coughing, sneezing, straining), posture, blood pressure, and systemic oxygen and carbon dioxide levels

Three types of radiation-induced injury can occur: external irradiation, contamination with radioactive materials, and incorporation of radioactive material into body cells, tissues, or organs:

- External irradiation exposure occurs when all or part of the body is exposed to radiation that penetrates or passes completely through the body. In this type of exposure, the person is not radioactive and does not require special isolation or decontamination measures. Irradiation does not necessarily constitute a medical emergency. - Contamination occurs when the body is exposed to radioactive gases, liquids, or solids either externally or internally. If internal, the contaminant can be deposited within the body. Contamination requires immediate medical management to prevent incorporation. - Incorporation is the actual uptake of radioactive material into the cells, tissues, and susceptible organs. The organs involved are usually the kidneys, bones, liver, and thyroid.

Primary survery

- Focuses on stabilizing life-threatening conditions. - The ED staff work collaboratively and follow the ABCDE (airway, breathing, circulation, disability, exposure) method - Establish a patent airway. - Provide adequate ventilation, employing resuscitation measures when necessary. Patients who have experienced trauma must have the cervical spine protected and chest injuries assessed first, immediately after the airway is established. - Evaluate and restore cardiac output by controlling hemorrhage, preventing and treating shock, and maintaining or restoring effective circulation. This includes the prevention and management of hypothermia. In addition, peripheral pulses are examined, and any immediate closed reductions of fractures or dislocations are performed if an extremity is pulseless. - Determine neurologic disability by assessing neurologic function using the Glasgow Coma Scale (GCS) and a motor and sensory evaluation of the spine. A quick neurologic assessment may be performed using the AVPU mnemonic - Undress the patient quickly but gently so that any wounds or areas of injury are identified; this may entail cutting away articles of clothing

Food Poisoning

- Food poisoning is a sudden illness that occurs after ingestion of contaminated food or drink. - Botulism is a serious form of food poisoning that requires continual surveillance and can lead to death. - If possible, the suspected food should be brought to the medical facility and a history obtained from the patient or family. - Food, gastric contents, vomitus, serum, and feces are collected for examination. - The patient's respirations, blood pressure, level of consciousness (LOC), CVP (if indicated), and muscular activity are monitored closely. - Death from respiratory paralysis can occur with botulism, fish poisoning, and some other food poisonings. - Because large volumes of electrolytes and water are lost by vomiting and diarrhea, fluid and electrolyte status should be assessed. Severe vomiting produces alkalosis, and severe diarrhea produces acidosis. - The patient is assessed for signs and symptoms of fluid and electrolyte imbalances, including lethargy, rapid pulse rate, fever, oliguria, anuria, hypotension, and delirium. - Baseline weight and serum electrolyte levels are obtained for future comparisons. - Measures to control nausea are also important to prevent vomiting, which could exacerbate fluid and electrolyte imbalances. An antiemetic medication is given parenterally as prescribed if the patient cannot tolerate fluids or medications by mouth - For mild nausea, the patient is encouraged to take sips of weak tea, carbonated drinks, or tap water. - After nausea and vomiting subside, clear liquids are usually prescribed for 12 to 24 hours, and the diet is gradually progressed to a low-residue, bland diet.

Precautions to be taken to avoid injury include the following situations:

- For prisoners, the hand or ankle restraint (handcuff) is never released, and a guard is always present in the room. - A mask can be placed on the patient to prevent spitting or biting. - Nonrestraint techniques should be tried when possible—e.g., talking with the patient, minimizing environmental stimulation. - Physical restraints are used on any patient who is violent only as needed and, if used, should be humanely and professionally given; nonetheless, the staff should be cognizant that the patient could head-butt, even if restrained. - Distance should be maintained from the patient to avoid grabbing; staff should not wear items that can be grabbed by the patient, such as dangling jewelry and stethoscopes. Furthermore, distance should be maintained between the patient and the door so that an escape route for the staff member is preserved. - Objects should not be left within patient reach; even an intravenous (IV) line spike can become a tool of violence if the patient is determined. - Courses on safety (de-escalation and physical restraint techniques) assist the staff with preparing for various violent situations. - In the case of gunfire in the ED, self-protection is a priority.

Orthostatic Hypotension.

- For the first 2 weeks after SCI, the blood pressure tends to be unstable and can be quite low. It gradually returns to preinjury levels, but periodic episodes of severe orthostatic hypotension frequently interfere with efforts to mobilize the patient. - Interruption in the reflex arcs that normally produce vasoconstriction in the upright position, coupled with vasodilation and pooling in abdominal and lower extremity vessels, can result in hypotension. - Orthostatic hypotension is a particularly common problem for patients with lesions above T7. In some patients with tetraplegia, even slight elevations of the head can result in blood pressure dysregulation. - Close monitoring of vital signs before and during position changes is essential. - Optimization of fluid status and vasopressor medication can be used to treat the profound vasodilation. - Antiembolism stockings should be applied to improve venous return from the lower extremities. - Abdominal binders may also be used to encourage venous return and provide diaphragmatic support when the patient is upright - Activity should be planned in advance, and adequate time should be allowed for a slow progression of position changes from recumbent to sitting and upright. Tilt tables frequently are helpful in assisting patients to make this transition.

Heat-Induced Illnesses Management

- For the patient with heat stroke, simultaneous treatment focuses on stabilizing oxygenation using the CABs (circulation, airway, and breathing) (formerly referred to as the ABCs) of basic life support. This includes establishing IV access for fluid administration. - After the patient's clothing is removed, the core (internal) temperature is reduced to 39°C (102°F) as rapidly as possible, preferably within 1 hour - The patient's temperature is constantly monitored with a thermistor placed in the rectum, bladder, or esophagus to evaluate core temperature. - Caution is used to avoid hypothermia and to prevent hyperthermia, which may recur spontaneously within 3 to 4 hours. - The cooling process should stop at 38°C (100.4°F) in order to avoid iatrogenic hypothermia\ - Throughout treatment, the patient's status is monitored carefully, including vital signs, ECG findings (for possible myocardial ischemia, myocardial infarction, and dysrhythmias), central venous pressure (CVP), and level of responsiveness, all of which may change with rapid alterations in body temperature. - A seizure may be followed by recurrence of hyperthermia. - To meet tissue needs exaggerated by the hypermetabolic condition, 100% oxygen is given. - IV infusion therapy of normal saline or lactated Ringer solution is initiated as directed to replace fluid losses and maintain adequate circulation. - Cooling redistributes fluid volume from the periphery to the core. - Urine output is also measured frequently, because ATN may occur as a complication of heat stroke from rhabdomyolysis (see previous discussion). - Blood specimens are obtained for serial testing to detect bleeding disorders, such as disseminated intravascular coagulation, and for serial enzyme studies to estimate thermal hypoxic injury to the liver, heart, and muscle tissue. - Permanent liver, cardiac, and CNS damage may occur.

Frostbite

- Frostbite is trauma from exposure to freezing temperatures and freezing of the intracellular fluid and fluids in the intercellular spaces. It results in cellular and vascular damage. - Frostbite can result in venous stasis and thrombosis. - Body parts most frequently affected by frostbite include the feet, hands, nose, and ears. - Frostbite ranges from first degree (redness and erythema) to fourth degree (full-depth tissue destruction). - A frozen extremity may be hard, cold, and insensitive to touch and may appear white or mottled blue-white, or red and painful. - The patient history should include environmental temperature, duration of exposure, clothing worn, humidity, and the presence of wet conditions. - Protective clothing may partially prevent exposure to cold environments; however, wearing wet socks and exercise/movement may diminish the protective effects of insulation by 45% - When the lower extremities are involved, the client should not walk. - Controlled but rapid rewarming should take place.

Signs of Increased ICP: Late

- GCW 8 or less - The level of consciousness continues to deteriorate until the patient is comatose - The pulse rate and respiratory rate decrease or become erratic, and the blood pressure and temperature increase (Cushing's triad) - Altered respiratory patterns develop, including Cheyne-Stokes breathing - Projectile vomiting may occur - Hemiplegia or decorticate or decerebrate posturing; bilateral flaccidity occurs before death. - Loss of brainstem reflexes: pupil, gag, corneal, and swallowing

Wound cleansing

- Hair around the wound may be clipped (only as directed) if it is anticipated that the hair will interfere with wound closure. - Typically, the area around the wound is cleansed with normal saline solution or a polymer agent (e.g., Shur-Clens). - The antibacterial agent povidone-iodine (Betadine) should not be allowed to get deep into the wound without thorough rinsing. - Povidone-iodine is used only for the initial cleansing because it injures exposed and healthy tissue, resulting in further tissue damage - If indicated, the area is infiltrated with a local intradermal anesthetic through the wound margins or by regional block. - The nurse then assists with cleaning and débriding the wound. The wound is irrigated gently and copiously with sterile isotonic saline solution to remove surface dirt. - Devitalized tissue and foreign matter are removed because they impede healing and may promote infection. - Any small bleeding vessels are clamped, tied, or cauterized. - After wound treatment, a nonadherent dressing is applied to protect the wound and to serve as a splint and as a reminder to the patient that the area is injured.

Promoting nutrition in clients with head injuries

- Head injury results in metabolic changes that increase calorie consumption and nitrogen excretion. - Protein demand increases. - Early initiation of nutritional therapy has been shown to improve outcomes in patients with head injury. Patients with brain injury are assumed to be catabolic, and nutritional support consultation should be considered as soon as the patient is admitted. - Parenteral nutrition via a central line or enteral feedings given via a nasogastric or nasojejunal feeding tube should be considered, though enteral is the preferred route. - If CSF rhinorrhea occurs or if there is any suspicion of disruption to the skull base, an oral feeding tube should be inserted instead of a nasal tube. - Laboratory values should be monitored closely in patients receiving parenteral nutrition. Elevating the head of the bed can help prevent distention, regurgitation, and aspiration. A continuous-drip infusion or pump may be used to regulate the feeding. Enteral or parenteral feedings are usually continued until the swallowing reflex returns and the patient can meet caloric requirements orally

A mother calls a neighborhood nurse and tells the nurse that her 3 year old child has just ingested liquid furniture polish. Which action should the nurse instruct the mother to take first? 1. induce vomiting 2. call an ambulance 3. call the poison control center 4. bring the child to the emergency department

4

Meningitis Manifestations

- Headache and fever are frequently the initial symptoms. Fever tends to remain high throughout the course of the illness. The headache is usually either steady or throbbing and very severe as a result of meningeal irritation. - Neck immobility: A stiff and painful neck (nuchal rigidity) can be an early sign, and any attempts at flexion of the head are difficult because of spasms in the muscles of the neck. Usually, the neck is supple, and the patient can easily bend the head and neck forward. - Positive Brudzinski sign: When the patient's neck is flexed (after ruling out cervical trauma or injury), flexion of the knees and hips is produced; when the lower extremity of one side is passively flexed, a similar movement is seen in the opposite extremity. - Photophobia (extreme sensitivity to light): This finding is common due to irritation of the meninges, especially around the diaphragm sellae. - A rash can be a striking feature of N. meningitidis infection, occurring in about half of patients with this type of meningitis. Skin lesions develop, ranging from a petechial rash with purpuric lesions to large areas of ecchymosis. - Disorientation and memory impairment: The changes depend on the severity of the infection as well as the individual response to the physiologic processes. Behavioral manifestations are also common. As the illness progresses, lethargy, unresponsiveness, and coma may develop. - Seizures can occur and are the result of areas of irritability in the brain. ICP increases secondary to diffuse brain swelling or hydrocephalus. The initial signs of increased ICP include decreased level of consciousness (LOC) and focal motor deficits. - If ICP is not controlled, the uncus of the temporal lobe may herniate through the tentorium, causing pressure on the brainstem. - An acute fulminant infection occurs in about 10% of patients with meningococcal meningitis, producing signs of sepsis: an abrupt onset of high fever, extensive purpuric lesions (over the face and extremities), shock, and signs of disseminated intravascular coagulation - Death may occur within a few hours after onset of the infection.

Hospital Emergency Preparedness Plans

- Health care facilities are required by the Joint Commission to create a plan for emergency preparedness and to practice this plan at least twice a year - These plans are developed by the facility's safety/disaster management committee and are overseen by an administrative liaison. - Before the basic emergency operations plan (EOP) can be developed, the planning committee of the health care facility first evaluates characteristics of the community to identify the likely types of natural and man-made disasters that might occur. - This hazard vulnerability analysis process is the responsibility of the local health care facility and its safety committee, safety officer, or emergency department (ED) manager. This information can be gathered by questioning local law enforcement, fire departments, and emergency medical systems and assessing the patterns of local train traffic, automobile traffic, and flood, earthquake, tornado, or hurricane activity. - Consideration is also given to possible mass casualties that could arise because of the community's proximity to chemical plants, nuclear facilities, or military bases. Federal, judicial, or financial buildings, schools, and any places where large groups of people gather can be considered high-risk areas. - The emergency preparedness planning committee must have a realistic understanding of its resources. It must determine, for example, whether the facility has or needs a pharmaceutical stockpile (e.g., vaccinations, antibiotics) available to treat specific chemical or biologic agents - Another scenario that might be anticipated may include the dispersal of a pulmonary intoxicant or choking agent, which would require that emergency operations planners determine how many ventilators are available within the facility and throughout the greater community. - The committee might also outline how staff would triage and assign priority to patients when the number of ventilators is limited. - Multiple factors influence a facility's ability to respond effectively to a sudden influx of injured patients, and the committee must anticipate various scenarios to improve its preparedness.

Heat-Induced Illnesses

- Heat stroke is an acute medical emergency caused by failure of the heat-regulating mechanisms of the body. It is the inability to maintain cardiac output in the face of moderately high body temperatures and is associated with dehydration. - The most common cause of heat stroke is nonexertional, prolonged exposure to an environmental temperature of greater than 39.2°C (102.5°F), although a heat index of greater than 35°C (95°F) is associated with increased mortality. - Heat stroke usually occurs during extended heat waves, especially when they are accompanied by high humidity. - Exertional heat stroke is caused by strenuous physical activity that occurs in a hot environment. - People at risk for nonexertional heat stroke are those not acclimatized to heat, those who are older or very young, those unable to care for themselves, those with chronic and debilitating diseases, and those taking certain medications (e.g., major tranquilizers, anticholinergics, diuretics, beta blockers) - Heat-related events occurred most often in rural areas - Exertional heat stroke occurs in healthy individuals during sports or work activities (e.g., exercising in extreme heat and humidity). Hyperthermia results because of inadequate heat loss. - Less severe forms of heat-induced illnesses include heat exhaustion and heat cramps or heat illness. - Heat illness is caused by a loss of electrolytes, typically during strenuous physical activity in a hot environment

Heat-Induced Illnesses Assessment and diagnosis

- Heat stroke, whether the cause is exertional or nonexertional, causes thermal injury at the cellular level, resulting in coagulopathies and widespread damage to the heart, liver, and kidneys. - When assessing the patient, the nurse notes the following symptoms: profound central nervous system (CNS) dysfunction (manifested by confusion, delirium, bizarre behavior, coma, seizures); elevated body temperature (40.6°C [105°F] or higher); hot, dry skin; and usually anhidrosis (absence of sweating), tachypnea, hypotension, and tachycardia. - The patient with heat exhaustion, on the other hand, may exhibit similarly high body temperatures accompanied by headaches, anxiety, syncope, profuse diaphoresis, gooseflesh, and orthostasis. - The cardinal manifestations of heat cramps include muscle cramps, particularly in the shoulders, abdomen, and lower extremities; profound diaphoresis; and profound thirst

ESI Algorithm

- Help to assign the patient triage level. - A the nurse asks does the nurse requires immediate life-saving. If the answer is yes, then the patient is automatically triaged as ESI level 1. If no, then the patient moves on to the next category. - B asks whether or not the patient needs a bed, such as pain, confusion, lethargy or high risk. - C. asks resources or no resources. - D vital signs (vital signs in danger zone places the patient back to level B). - For the patient assigned to an urgent or higher triage category, stabilization, provision of critical treatments, and prompt transfer to the appropriate setting (intensive care unit, operating room, general care unit) are the priorities of emergency care. Although treatment is initiated in the ED, ongoing definitive treatment of the underlying problem is provided in other settings, and the sooner the patient is stabilized and moved to that area, the better the outcome.

Intracranial Hemorrhage

- Hematomas are collections of blood in the brain that may be epidural (above the dura), subdural (below the dura), or intracerebral (within the brain) - Major symptoms are frequently delayed until the hematoma is large enough to cause distortion of the brain and increased ICP. - The signs and symptoms of cerebral ischemia resulting from compression by a hematoma are variable and depend on the speed with which vital areas are affected and the area that is injured. - A rapidly developing hematoma, even if small, may be fatal, whereas a larger but slowly developing one may allow compensation for increases in ICP.

You are caring for a patient who has been exposed to anthrax. What kind of precautions are you going to take? 1. Droplet 2. contact 3. airborne 4. standard

4. standard

Intra-abdominal Internal Bleeding

- Hemorrhage frequently accompanies abdominal injury, especially if the liver or spleen has been traumatized. Therefore, the patient is assessed continuously for signs and symptoms of external and internal bleeding. - The front of the body, flanks, and back are inspected for bluish discoloration, asymmetry, abrasion, and contusion. - Abdominal CT scans permit detailed evaluation of abdominal contents and retroperitoneal examination. - Abdominal ultrasounds can be used to rapidly assess patients who are hemodynamically unstable to detect intraperitoneal bleeding. This is referred to as the focused assessment with sonography for trauma (FAST) examination - During the resuscitation period, pain is managed using administration of small dosages of opioids. - The location of pain can indicate certain types of intra-abdominal injuries. Pain in the left shoulder is common in a patient with bleeding from a ruptured spleen, whereas pain in the right shoulder can result from laceration of the liver.

What is hemorrhage?

- Hemorrhage that results in the reduction of circulating blood volume is a main cause of shock. - Minor bleeding, which is usually venous, generally stops spontaneously unless the patient has a bleeding disorder or has been taking anticoagulant agents. - Internal hemorrhage can hide in many anatomic spaces and compartments, resulting in shock without external evidence of hemorrhage. The internal spaces and compartments that are capable of housing large amounts of blood include the retroperitoneum, pelvis, chest, and thighs. - The patient is assessed for signs and symptoms of shock: cool, moist skin (resulting from poor peripheral perfusion), decreasing blood pressure, increasing heart rate, delayed capillary refill, and decreasing urine volume - The goals of emergency management are to control the bleeding, maintain adequate circulating blood volume for tissue oxygenation, and prevent shock. - Patients who hemorrhage are at risk for cardiac arrest caused by hypovolemia with secondary anoxia.

Control of External Hemorrhage

- If a patient is hemorrhaging externally (e.g., from a wound), a rapid physical assessment is performed as the patient's clothing is cut away in an attempt to identify the area of hemorrhage. - Direct, firm pressure is applied over the bleeding area or the involved artery at a site that is proximal to the wound - A firm pressure dressing is applied, and the injured part is elevated to stop venous and capillary bleeding, if possible. If the injured area is an extremity, the extremity is immobilized to control blood loss. - A tourniquet is applied to an extremity when the external hemorrhage cannot be controlled in any other way and until surgery can be performed. - The tourniquet is applied just proximal to the wound and tied tightly enough to control arterial blood flow. - The patient is tagged with a skin-marking pencil or on adhesive tape on the forehead with a "T," stating the location of the tourniquet and the time applied. - If the patient has suffered a traumatic amputation with uncontrollable hemorrhage, the tourniquet remains in place until the patient is in the operating room - Time of tourniquet application and removal should be documented.

Management of airway obstruction

- If the patient can breathe and cough spontaneously, a partial obstruction should be suspected. The victim is encouraged to cough forcefully and to persist with spontaneous coughing and breathing efforts as long as good air exchange exists. - If the patient demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis, the patient should be managed as if there were complete airway obstruction. - After the obstruction is removed, rescue breathing is initiated. If the patient has no pulse, cardiac compressions are instituted.

Intubation With a King Tube or Laryngeal Mask Airway

- If the patient is not hospitalized and cannot be intubated in the field, emergency medical personnel may insert a King Tube, which rapidly provides pharyngeal ventilation. - When the tube is inserted into the trachea, it functions like an endotracheal tube. - The two balloons that surround the tube are inflated after the tube is inserted. - One balloon is large and occludes the oropharynx. This permits ventilation by forcing air through the larynx. - The smaller balloon is inflated with air and occludes the esophagus at a site distal to the glottis. - Breath sounds are auscultated after balloon inflation to make sure that the oropharyngeal balloon (or cuff) does not obstruct the glottis. - One variant type of King Tube is designed so that a gastric tube may also be passed for suction. - If it is difficult to establish an airway, a laryngeal mask airway (LMA) may be inserted as an interim airway device. The design of the LMA provides a "mask" in the subglottic airway with a cuff inflated within the esophagus. It allows easy insertion for rapid airway control until a more definitive airway can be placed. Some LMAs also permit removal of secretions from the esophagus

Control of Internal Bleeding

- If the patient shows no external signs of bleeding but exhibits tachycardia, falling blood pressure, thirst, apprehension, cool and moist skin, or delayed capillary refill, internal hemorrhage is suspected. - Typically, packed red blood cells, plasma, and platelets are given at a rapid rate, and the patient is prepared for more definitive treatment (e.g., surgery, pharmacologic therapy) - Arterial blood gas specimens are obtained to evaluate pulmonary function and tissue perfusion and to establish baseline hemodynamic parameters, which are then used as an index for determining the amount of fluid replacement the patient can tolerate and the response to therapy. - The patient is maintained in the supine position and monitored closely until hemodynamic or circulatory parameters improve, or until he or she is transported to the operating room or intensive care unit.

Management of snake bites

- Initial first aid at the site of the snakebite includes having the person lie down, removing constrictive items such as rings, providing warmth, cleansing the wound, covering the wound with a light sterile dressing, and immobilizing the injured body part below the level of the heart. - Airway, breathing, and circulation are the priorities of care. - Ice, incision and suction, or a tourniquet is not applied. - Tetanus and analgesia should be given as necessary. - There is no one specific protocol for treatment of snakebites. - In general, ice, tourniquets, heparin, and corticosteroids are not used during the acute stage. - Corticosteroids are contraindicated in the first 6 to 8 hours after the bite because they may depress antibody production and hinder the action of antivenin (antitoxin manufactured from the snake venom and used to treat snakebites). - Parenteral fluids may be used to treat hypotension. - If vasopressors are used to treat hypotension, their use should be short term. - Surgical exploration of the bite is rarely indicated. - Typically, the patient is observed closely for at least 6 hours. The patient is never left unattended.

Management of fractures

- Immediate attention is given to the patient's general condition. Assessment of airway, breathing, and circulation (which includes pulses in the extremities) is conducted. The patient is also evaluated for neurologic or abdominal injuries before the extremity is treated, unless a pulseless extremity is detected. - If a pulseless extremity is identified, repositioning of the extremity to proper alignment is required. - If the pulseless extremity involves a fractured femur, Hare traction (a portable in-line traction device) may be applied to assist with alignment. - If repositioning is ineffective in restoring the pulse, a rapid total-body assessment must be completed, followed by transfer of the patient to the operating room for arteriography and possible arterial repair versus amputation. - After the initial evaluation has been completed, all injuries identified are evaluated and treated. - Using a systematic head-to-toe approach, the nurse inspects the entire body, observing for lacerations, swelling, and deformities, including angulation (bending), shortening, rotation, and asymmetry. - All peripheral pulses, especially those distal to the fractured extremity, are palpated. The extremity is also assessed for coolness, blanching, and decreased sensation and motor function, which are indicative of injury to the extremity's neurovascular supply. - A splint is applied before the patient is moved. Splinting immobilizes the joint at a site distal and proximal to the fracture, relieves pain, restores or improves circulation, prevents further tissue injury, and prevents a closed fracture from becoming an open one. - If the fracture is open, a moist, sterile dressing is applied. - After splinting, the vascular status of the extremity is checked by assessing color, temperature, pulse, and blanching of the nail bed.

Red

- Immediate: Injuries are life threatening but survivable with minimal intervention. Individuals in this group can progress rapidly to expectant if treatment is delayed. - First Priority: 1 - Examples include: Sucking chest wound, airway obstruction secondary to mechanical cause, shock, hemothorax, tension pneumothorax, asphyxia, unstable chest and abdominal wounds, incomplete amputations, open fractures of long bones, and 2nd/3rd-degree burns of 15-40% total body surface area

Maintaining body temperature in clients with brain injury

- In a patient with a head injury, a rapid increase in body temperature is regarded as unfavorable because hyperthermia increases the metabolic demands of the brain and may indicate brainstem damage—a poor prognostic sign. - Fever in the patient with a TBI can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection. - The nurse monitors the patient's temperature every 2 to 4 hours. If the temperature increases, efforts are made to identify the cause and to control it using acetaminophen and cooling devices to maintain normothermia - Cooling devices should be used with caution so as not to induce shivering, which increases ICP. - If infection is suspected, potential sites of infection are cultured and antibiotic agents are prescribed and given.

Contusion

- In cerebral contusion the brain is bruised and damaged in a specific area because of severe acceleration-deceleration force or blunt trauma. The impact of the brain against the skull leads to a contusion. - More severe injury with possible surface hemorrhage: Coup injury (Occurs at site of impact; by forehead) or Contrecoup (in a line opposite the site of impact; behind the head) - Longer period of unconsciousness with more symptoms of neurologic deficits and changes in vital signs - Clinical manifestations of a contusion are dependent upon size, location, and the extent of surrounding cerebral edema. - Although a contusion may occur in any area of the brain, most are usually located in the anterior portions of the frontal and temporal lobes, around the sylvian fissure, and at the orbital areas. - Contusions can be characterized by loss of consciousness associated with stupor and confusion. - The effects of injury, particularly hemorrhage and edema, peak after about 18 to 36 hours. These effects, which can cause secondary effects resulting in increased ICP and possible herniation syndromes, are most pronounced in temporal lobe contusions. - Deep contusions are more often associated with hemorrhage and destruction of the reticular activating fibers, altering arousal *Important to prevent further trauma in these patients*

Management of crush injuries

- In conjunction with maintaining the airway, breathing, and circulation, the patient is observed for acute kidney injury (AKI). - Severe muscular damage may cause rhabdomyolysis, a toxic syndrome caused by a release of myoglobin from ischemic skeletal muscle, resulting in ATN. - The classic triad of clinical manifestations suggestive of rhabdomyolysis includes myalgias (muscle cramps), generalized muscle weakness, and darkened urine. - The serum creatine kinase (CK) is monitored as the most sensitive indicator of rhabdomyolyis; levels in excess of 6000 IU/L are considered diagnostic - In addition to treatment aimed at preventing or treating ATN, major soft tissue injuries are splinted promptly to control bleeding and pain. - The serum lactic acid level is monitored; a decrease to less than 2.5 mmol/L is an indication of successful resuscitation. - If an extremity is injured, it is elevated to relieve swelling and pressure. - If compartment syndrome develops, the physician may perform a fasciotomy (i.e., surgical incision to the level of the fascia) to restore neurovascular function - Medications for pain and anxiety are then given as prescribed, and the patient is quickly transported to the operating suite for wound débridement and fracture repair. - A hyperbaric oxygen chamber (if available) may be used to hyperoxygenate crushed tissue, if indicated.

Meningitis

- Inflammation of the membranes and the fluid space surrounding the brain and spinal cord - Septic caused by bacteria (Streptococcus pneumoniae, Neisseria meningitidis). It is deadly - Aseptic caused by viral infection secondary to cancer or a weak immune system. It is self-limiting, and feels like the flu. - Fungal infections - N. meningitidis is transmitted by secretions or aerosol contamination, and infection is most likely in dense community groups such as college campuses. High mortality within 24 hours. - Predisposing conditions: Pneumonia, sinusitis, and sickle cell. - Once the causative organism enters the bloodstream, it crosses the blood-brain barrier and proliferates in the cerebrospinal fluid (CSF). The host immune response stimulates the release of cell wall fragments and lipopolysaccharides, facilitating inflammation of the subarachnoid and pia mater. Because the cranial vault contains little room for expansion, the inflammation may cause increased intracranial pressure (ICP). CSF circulates through the subarachnoid space, where inflammatory cellular materials from the affected meningeal tissue enter and accumulate. - Pus forms and spreads to cranial and spinal nerves common with bacterial. Increased ICP.

You are treating people in a disaster. You see a patient with a black tag. You understand that this color means? 1. needs immediate intervention 2. treatment can be delayed 3. minor injuries, move away from main triage area 4. survival unlikely

4. survival unlikely

Primary Survey: C is for Circulation (Interventions)

- Insert 2 large bore IVs, of at least 18 gauge or bigger - If unable to get an IV, an IO or central line is inserted - Aggressive fluid resuscitation using normal saline or lactated ringer's solution - Obtain and blood type and screen - In emergency situations, O- blood can be given to any patient - Apply pressure to external bleeding - Do not remove object if impaled or knife wound - Tourniquet above injury (proximal) Do not apply to joint

Intra-Abdominal Injuries

- Intra-abdominal injuries are categorized as penetrating or blunt trauma. - Penetrating abdominal injuries (i.e., gunshot wounds, stab wounds) are serious and usually require surgery. - The liver is the most frequently injured solid organ due to its size and anterior placement in the right upper quadrant of the abdomen. - In gunshot wounds, the most important prognostic factor is the velocity at which the missile enters the body. - All abdominal gunshot wounds that cross the peritoneum or are associated with peritoneal signs require surgical exploration. On the other hand, some stab wounds may be managed nonoperatively due to low velocity and less penetration of the implement. - Blunt trauma to the abdomen may result from motor vehicle crashes, falls, blows, or explosions. - Blunt trauma is commonly associated with extra-abdominal injuries to the chest, head, or extremities. - The incidence of delayed and trauma-related complications is greater than for penetrating injuries. This is especially true of blunt injuries involving the liver, kidneys, spleen, or blood vessels, which can lead to massive blood loss into the peritoneal cavity

Gastric lavage

- Intubate before lavage if altered LOC or diminished gag reflex - Perform lavage within 1 hour of ingestion of most poisons - Contraindicated: Caustic agents b/c possibility of re-exposure to esophagus Co-ingested sharp objects b/c can cause perforation Ingested nontoxic substances

Scalp Injury

- Isolated scalp trauma is generally classified as a minor injury. - Trauma may result in an abrasion (brush wound), contusion, laceration, or hematoma beneath the layers of tissue of the scalp (subgaleal hematoma). - A large avulsion (tearing away) of the scalp may be potentially life threatening and is a true emergency. - Diagnosis of a scalp injury is based on physical examination, inspection, and palpation. - Scalp wounds are potential portals of entry for organisms that cause intracranial infections. So irrigate before suturing or stapling. - Subgaleal hematomas (hematomas below the outer covering of the skull) usually reabsorb and do not require any specific treatment.

Creutzfeldt-Jakob Disease (CJD) & Variant CJD

- It is an infectious neurologic disorders called transmissible spongiform encephalopathies (TSE). - CJD is very rare and has no identifiable cause. - vCJD, the human variation of bovine spongiform encephalopathy (BSE) (commonly known as mad cow disease), results from the ingestion by humans of prions in infected meat. - One characteristic they share is a lack of CNS inflammation. - The disease is not spread by casual contact; vCJD may be contracted through ingestion of infected beef - CJD may lie dormant for decades before causing neurologic degeneration. The incubation period of vCJD seems to be shorter (less than 10 years). - In both diseases, the symptoms are progressive, there is no definitive treatment, and the outcome is fatal

Carbon Monoxide Poisoning

- It is the most common cause of fatality from poisoning and is frequently under-reported to poison control centers or misdiagnosed - Carbon monoxide exerts its toxic effect by binding to circulating hemoglobin and thereby reducing the oxygen-carrying capacity of the blood. - Hemoglobin absorbs carbon monoxide 200 times more readily than it absorbs oxygen. - Carbon monoxide-bound hemoglobin, called carboxyhemoglobin, does not transport oxygen. - A person with carbon monoxide poisoning may appear intoxicated (from cerebral hypoxia). - Other signs and symptoms include headache, muscular weakness, palpitation, dizziness, and confusion, which can progress rapidly to coma. - Skin color, which can range from pink or cherry-red to cyanotic and pale, is not a reliable sign. - Pulse oximetry may reveal a high hemoglobin saturation, which may be deceiving, since the hemoglobin molecule is saturated with carbon monoxide rather than oxygen

Level A PPE

- Level A protection is worn when the highest level of respiratory, skin, eye, and mucous membrane protection is required. - This includes a self-contained breathing apparatus (SCBA) and a fully encapsulating, vapor-tight, chemical-resistant suit with chemical-resistant gloves and boots.

Level B PPE

- Level B protection requires the highest level of respiratory protection but a lesser level of skin and eye protection than with level A situations. - This level of protection includes the SCBA and a chemical-resistant suit, but the suit is not vapor tight.

Categories of Biologic Weapons: Category B

- Low mortality, moderate morbidity Brucella species (brucellosis) Coxiella burnetii (Q fever) Staphylococcus aureus, Vibrio species (food poisoning) Rickettsia typhi (typhus) Arboviruses (viral encephalitis) Cryptosporidium parvum (Cryptosporidiosis)

Interventions For The Patient With a Traumatic Brain Injury

- Maintain Airway: The brain is extremely sensitive to hypoxia, and a neurologic deficit can worsen if the patient is hypoxic. The patient who is intubated is at high risk for ventilator-associated pneumonia, and providing good oral hygiene can help prevent this complication - Monitoring neurologic function including GCS, vitals, motor function, and pupils - The GCS is considered the most sensitive indicator of a lapse in neurologic functioning in patients with TBI and is often the earliest sign of acute change in ICP. - Vital signs are monitored at frequent intervals to assess the intracranial status. Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic blood pressure, and widening pulse pressure (Cushing reflex). As brain compression increases, respirations become rapid, the blood pressure may decrease, and the pulse slows further. In a patient with a head injury, a rapid increase in body temperature is regarded as unfavorable because hyperthermia increases the metabolic demands of the brain and may indicate brainstem damage—a poor prognostic sign. - Fluid and Electrolyte: They are at risk for developing Diabetes insipidus (DI) or Syndrome of inappropriate antidiuretic hormone (SIADH). Fluid Management is optimal but minimize edema. - Preventing and detecting increased ICP: Get vital signs every 1-2 hours, administer meds to prevent hyper/hypotension, cardiac monitoring, monitor for fever, prophylaxis, hyperventilation to promote oxygenation which is reduced related to cerebral vasoconstriction and decreased cerebral blood volume and ICP within the first 20 hours, mechanical ventilations. - Use caution when removing or suctioning pulmonary secretions, which are thick, due to increased ICP, Suctioning can increase ICP. Don't aggressively ventilate them because it can also increase ICP. - Keep HOB elevated in patient with TBI, with exception to those who are hypotensive. - Determining brain death: Done by an EEG or CTA (done by neurologist) - Drug therapy: Glucocorticoids, mannitol, sedatives, antileptic drugs, Tylenol, - Nutritional Status: evaluate swallowing, Level of Consciousness - Managing Sensory, Cognitive, and Behavioral Changes (specific to the injury & area of the brain)

Interventions for hypoxia:

- Maintain PaO2 >60 mmHg. - Maintain oxygen therapy. - Monitor arterial blood gas values. - Suction when needed. - Maintain a patent airway.

Decreased Cerebral Perfusion Pressure.

- Maintenance of adequate CPP is important to prevent serious complications of head injury due to decreased cerebral perfusion. - Adequate CPP is greater than 50 mm Hg. If CPP falls below a patient's threshold, a vasodilating cascade occurs, causing the volume of blood to increase inside the brain, which causes ICP to increase. - Measures to maintain adequate CPP are essential because a decrease in CPP can impair cerebral perfusion and cause brain hypoxia and ischemia, leading to permanent brain damage. - Once the threshold CPP is reached, vasoconstriction of the cerebral blood vessels occurs, causing ICP to decrease. - Therapy (e.g., elevation of the head of the bed, increased IV fluids, CSF drainage) is directed toward decreasing cerebral edema and increasing venous outflow from the brain. Systemic hypotension, which causes vasoconstriction and a significant decrease in CPP, is treated with increased IV fluids or vasopressors

Inserting an Oropharyngeal Airway

- Measure the oral airway alongside the head. The airway should reach from lip to ear. - Extend the patient's head by placing one hand under the bony chin (only if the cervical spine is uninjured). With the other hand, tilt the head backward by applying pressure to the forehead while simultaneously lifting the chin forward. - Open the patient's mouth. - A. Insert the oropharyngeal airway with the tip facing up toward the roof of the mouth until it passes the uvula. B. Rotate the tip 180 degrees so that the tip is pointed down toward the pharynx. This displaces the tongue anteriorly, and the patient then breathes through and around the airway. An alternate method is to use a tongue blade to hold the tongue and insert the oropharyngeal airway directly without rotation. - The distal end of the oropharyngeal airway is in the hypopharynx, and the flange is approximately at the patient's lips. Make sure that the tongue has not been pushed into the airway.

Collection of Forensic Evidence

- Meticulous documentation includes descriptions of all wounds, mechanism of injury, time of events, and collection of evidence. - The basics of care management for patients with traumatic injury include an understanding that trauma in any patient (living or dead) has potential legal or forensic science implications if criminal activity is suspected. - When clothing is removed from the patient who has experienced trauma, the nurse must be careful not to cut through or disrupt any tears, holes, blood stains, or dirt present on the clothing if criminal activity is suspected. - Each piece of clothing should be placed in an individual paper bag. Plastic bags are not used because they retain moisture; moisture may promote mold and mildew formation, which can destroy evidence. If the clothing is wet, it should be hung to dry. - Clothing should not be given to families. - Valuables should be inventoried and either placed in the hospital safe or clearly documented to which family member they were given. - If a police officer is present to collect clothing or any other items from the patient, each item is labeled and the transfer of custody to the officer, the officer's name, the date, and the time are documented. - Evidence cannot be left unattended in the room; a formal chain of custody must be maintained for the evidence to be valid and useful for legal purposes. - All deaths of patients who experienced trauma are reported to the medical examiner. - If suicide or homicide is suspected in a patient who experienced trauma, the medical examiner examines the body on site or has the body moved to the coroner's office for autopsy. All tubes and lines must remain in place. - The patient's hands must be covered with paper bags to protect evidence on the hands or under the fingernails. - In the patient who has survived trauma, tissue specimens may be swabbed from the hands and nails as potential evidence. - Photographs of wounds or clothing are essential and should include a reference ruler in one photo and another without the ruler. - Documentation should also include any statements made by the patient in the patient's own words and surrounded by quotation marks. A chain of evidence is essential. If the patient's case is reviewed in a court of law in the future, clear documentation assists the judicial process and helps to identify the activities that occurred in the ED.

The Patient Who Has Undergone Intracranial Surgery: Regulating temperature

- Moderate temperature elevation can be expected after intracranial surgery because of the reaction to blood at the operative site or in the subarachnoid space. - Injury to the hypothalamic centers that regulate body temperature can occur during surgery. - Fever is treated vigorously to combat the effect of an elevated temperature on brain metabolism and function. - Nursing interventions include monitoring the patient's temperature and using the following measures to reduce body temperature: removing blankets, placing ice packs, and administering prescribed antipyretics to reduce fever

Interventions for increase in intrathoracic or abdominal pressure:

- Monitor ABG values, and keep PEEP as low as possible. - Provide humidified oxygen. - Administer stool softeners.

Heat-Induced Illnesses Gerontologic Considerations

- Most heat-related deaths occur in older adults because their circulatory systems are unable to compensate for stress imposed by heat. - Older adults have a decreased ability to perspire as well as a decreased ability to vasodilate and vasoconstrict. - They have less subcutaneous tissue, a decreased thirst mechanism, and a diminished ability to concentrate urine to compensate for heat. - Many older adults do not drink adequate amounts of fluid, partly because of fear of incontinence, and thus have a greater risk of heat stroke. - Many older adults fear being victims of crime, so even if their residence lacks air conditioning, they tend to keep windows closed despite high temperatures and humidity levels.

Natural Disasters

- Natural disasters may result in mass casualties. - In the event of a natural disaster, loss of communications, potable water, and electricity is usually the greatest obstacle to a well-coordinated emergency response, and preparatory planning is essential. - Wireless technology (e.g., cellular phones, computers, other communication devices) may not be functional. - The majority of the immediate casualties are trauma related. These mass casualties tax the trauma system to provide triage, transport of patients (in poor weather and road conditions), and management within the trauma centers. Most patients usually begin arriving within an hour of the event. - The "walking wounded" may not seek care for 5 days to 2 weeks after the event or may seek care for injuries received during cleanup activities. - Casualties arrive at hospitals in three waves. The first wave consists of people who are minimally (generally) injured who arrive of their own accord. The second wave consists of patients who are severely injured. The third wave consists of patients who are injured and who arrive after they are discovered by rescuers. - Excessive exposure to the natural elements and the need for food and water (by both patients and emergency responders) are critical issues. - Safety equipment that protects rescue workers from injury, exposure, and potentially dangerous animals (e.g., snakes, alligators, spiders) must be readily available. Rescue workers may also injure themselves in the process of extrication or cleanup (e.g., chain saws, building collapse). - Hypothermia can occur rapidly in workers who are exposed to water at temperatures of 23.9°C (75°F) or less. - As is true during all disasters, mental health workers and shelters are needed throughout the community. Veterinary assistance is also essential because pets are frequently abandoned and injured. - Pulmonary problems peak with earthquakes and volcanic eruptions because of the increased particulate matter in the air. Most volcano-related deaths are from suffocation and exposure to noxious gases. - After floods or water disasters, waterborne transmission of agents such as Escherichia coli, salmonella, shigella, typhoid, leptospirosis, malaria, and tularemia are common and cause widespread disease. - Larger-scale issues that can cause significant later morbidity and mortality include the absence of water purification, waste removal, removal of human and animal remains, and vector control. - Removal or disposal of biologic, chemical, and nuclear agents must also be considered.

Encephalitis Diagnosis

- Neuroimaging studies, such as EEG, and CSF examination are used to diagnose encephalitis. - MRI is used to detect early changes caused by herpes simplex; scans usually show edema in the frontal and temporal lobes. - The EEG shows diffuse slowing or focal changes in the temporal lobe in the majority of patients. - Lumbar puncture often reveals a high opening pressure, glucose within normal limits, and high protein levels in CSF samples - Viral cultures are almost always negative. The polymerase chain reaction (PCR) is the standard test for early diagnosis of herpes simplex encephalitis. PCR identifies the deoxyribonucleic acid (DNA) bands of HSV-1 in the CSF. The validity of PCR is very high between the 3rd and 10th days after symptom onset.

Gerontologic Considerations: Skull fractures

- Neurologic assessment can be challenging, as the older adult patient with a TBI can have hearing and/or visual deficits or pre-existing dementia or cognitive issues, making establishment of a neurologic baseline difficult. - The most common causes of injury in older adult patients are falls and motor vehicle crashes - Physiologic changes related to aging may place the older adult at increased risk for injury, alter the type and severity of injury that occurs, or lead to complications. - Two major factors place older adults at increased risk for hematomas. First, brain weight decreases, the dura becomes more adherent to the skull, and reaction times slow with increasing age. Second, many older adults take aspirin and anticoagulant agents as part of routine management of chronic conditions.

Nonfatal Drowning

- Nonfatal drowning is defined as survival for at least 24 hours after submersion that caused a respiratory arrest. - The most common consequence is hypoxemia, hypercapnia, bradycardia, and dysrhythmias. - Children under 5 years of age and those over the age of 85 have the highest risk of drowning - Factors associated with drowning and nonfatal drowning include alcohol ingestion, inability to swim, diving injuries, hypothermia, and exhaustion. - Successful resuscitation with full neurologic recovery has occurred in patients who have experienced nonfatal drowning after prolonged submersion in cold water. This is possible because of a decrease in metabolic demands and/or the diving reflex. - The nonfatal drowning process involves the onset of hypoxia, hypercapnia, bradycardia, and dysrhythmias. - If there is a violent struggle associated with the nonfatal drowning episode, exercise-induced acidosis and tachypnea can result in aspiration. - Hypoxia and acidosis cause eventual apnea and loss of consciousness. When the victim loses consciousness and makes a final effort to breathe, the terminal gasp occurs. Water then moves passively into the airways prior to death. - After resuscitation, hypoxia and acidosis are the major complications experienced by a person who has experienced nonfatal drowning - Resultant pathophysiologic changes and pulmonary injury depend on the type of fluid (fresh or salt water) and the volume aspirated. - Freshwater aspiration results in a loss of surfactant and, therefore, an inability to expand the lungs. - Salt-water aspiration leads to pulmonary edema from the osmotic effects of the salt within the lungs. - If a person survives submersion, acute respiratory distress syndrome (ARDS), resulting in hypoxia, hypercarbia, and respiratory or metabolic acidosis, can occur.

Brain Abscess: Nursing Management

- Nursing care focuses on continuing to assess the neurologic status, administering medications, assessing the response to treatment, and providing supportive care. - Blood laboratory test results, specifically blood glucose and serum potassium levels, need to be closely monitored when corticosteroids are prescribed. Administration of insulin or electrolyte replacement may be required to return these values to within normal limits. - Patient safety is another key nursing responsibility. Injury may result from decreased LOC or falls related to motor weakness or seizures. - The nurse must assess the family's ability to express distress at the patient's condition, cope with the patient's illness and deficits, and obtain support.

A traumatic brain injury: open (penetrating)

- Occurs when an object penetrates the skull, enters the brain, and damages the soft brain tissue in its path or when blunt trauma to the head is so severe that it opens the scalp, skull, and dura to expose the brain. - The integrity of the brain and the dura is violated - There is exposure to environmental contaminants - Damage may occur to underlying vessels, dural sinus brain and the cranial nerves

A traumatic brain injury: closed (blunt)

- Occurs when the head accelerates and then rapidly decelerates or collides with another object (e.g., a wall, the dashboard of a car) and brain tissue is damaged but there is no opening through the skull and dura. - Acceleration/deceleration injury occurs when the head accelerates and then rapidly decelerates, damaging brain tissue - The integrity of the skull in not violated - More serious of the two types of injury - The damage to brain tissue depends on the degree and mechanisms of injury

Nursing Role and Interventions for Victims of Human Trafficking

- Offer opportunity for client to speak alone, without companion - Use targeted, appropriate questions: Are you in control of your own money? Are you able to come and go as you please? Who is the person(s) accompanying you? - May decline assistance - Resource: The National Human Trafficking Hotline

Special populations may have different blast-associated risks. These include:

- Older adults are particularly susceptible to bone fractures because they tend to have decreased bone density. - Older adults tend to have more pre-existing morbid conditions that may be exacerbated by the explosion. - Patients who are pregnant are particularly susceptible to placental shear forces that may result in abruptio placentae. - People with mobility disabilities may have difficulty extricating themselves from the site of the blast

Primary Survey: Airway Interventions

- Open airway using jaw-thrust maneuver. Avoid hyperextending neck - Suction and/or remove foreign body - Insert nasopharyngeal or oropharyngeal airway (In unconscious clients only) - Endotracheal intubation: Rapid-sequence intubation is the referred procedure for unprotected airway. Medications used to facilitate rapid sequence intubation include a sedative, an analgesic, and a neuromuscular blockade agent; these are usually given by the practitioner performing the intubation. These drugs aid in intubation and reduce the risk of aspiration and airway trauma. - If intubation is impossible due to obstruction, an emergency Cricothyroidotomy or tracheotomy is performed. - Ventilate with 100% oxygen using an ambu-bag. The key to ventilating is using the C-Clamp technique; pull chin up the mask. - Cervical spine must be protected from injury during all techniques - After intervention assess patient for breathing: Watch for chest movement & listen for air movement

Decreasing Cerebral Edema (ICP)

- Osmotic diuretics such as mannitol and hypertonic saline (3%) may be given to dehydrate the brain tissue and reduce cerebral edema - An indwelling urinary catheter is usually inserted to monitor urinary output and to manage the resulting diuresis. If the patient is receiving osmotic diuretics, serum osmolality and electrolytes should be determined to assess hydration status. If a brain tumor is the cause of the increased ICP, corticosteroids (e.g., dexamethasone) help reduce the edema surrounding the tumor. - Another method for decreasing cerebral edema is fluid restriction. Limiting overall fluid intake leads to dehydration and hemoconcentration, which draws fluid across the osmotic gradient and decreases cerebral edema. Conversely, overhydration of the patient with increased ICP is avoided, because it increases cerebral edema. - Researchers have long hypothesized that lowering body temperature would decrease cerebral edema by reducing the oxygen and metabolic requirements of the brain, thus protecting the brain from continued ischemia. If body metabolism can be reduced by lowering the body temperature, the collateral circulation in the brain may be able to provide an adequate blood supply to the brain.

Difference between partial and complete airway obstruction

- Partial obstruction of the airway can lead to progressive hypoxia, hypercarbia, and respiratory and cardiac arrest. - If the airway is completely obstructed, permanent brain injury or death will occur within 3 to 5 minutes secondary to hypoxia. Air movement is absent in the presence of complete airway obstruction. Oxygen saturation of the blood decreases rapidly because obstruction of the airway prevents entry of air into the lungs. Oxygen deficit occurs in the brain, resulting in unconsciousness, with death following rapidly.

Passive rewarming

- Passive or active external rewarming is used for mild hypothermia (32.2°C to 35°C [90°F to 95°F]). - Passive external rewarming uses over-the-bed heaters to the extremities and increases blood flow to the acidotic, anaerobic extremities. - The cold blood from peripheral tissues has high lactic acid levels. As this blood returns to the core, it causes a significant drop in the core temperature (i.e., core temperature afterdrop) and can potentially cause cardiac dysrhythmias and electrolyte disturbances. - Active external rewarming uses forced-air warming blankets. - Care must be taken to prevent extremity burn from these devices, because the patient may not have effective sensation to feel the burn.

Identifying Patients and Documenting Patient Information

- Patient tracking is a critical component of casualty management. - Disaster tags, which are numbered and include triage priority, name, address, age, location and description of injuries, and treatments or medications given, are used to communicate patient information. - The tag should be securely placed on the patient and remain with the patient at all times. The tag number and the patient's name, if known, are recorded in a disaster log. The log is used by the command center to track patients, assign beds, and provide families with information.

Posttraumatic Seizures.

- Patients with head injury are at an increased risk for posttraumatic seizures. - Posttraumatic seizures are classified as immediate (within 24 hours after injury), early (within 1 to 7 days after injury), or late (more than 7 days after injury) - Seizure prophylaxis is the practice of administering anticonvulsant medications to patients with head injury to prevent seizures. - It is important to prevent posttraumatic seizures, especially in the immediate and early phases of recovery, because seizures may increase ICP and decrease oxygenation - However, many anticonvulsant medications impair cognitive performance and can prolong the duration of rehabilitation. Therefore, the overall benefits of these medications must be weighed against their side effects.

Family and Intimate Partner Violence (IPV)

- Pattern of coercive behavior in a relationship - Most victims are women, children, older adults - Have multiple injuries in various stages of healing - Injury does not fit the explanation - Involves fear, humiliation, intimidation, neglect, and/or intentional physical, emotional, financial, or sexual injury - Screening for domestic violence required in ED: Ask if they feel safe at home - Make referrals - Notify appropriate agencies - Provide emotional support - Inform victims about options - Abuser may be present, so get them away from the abuser when asking questions.

The Patient Who Has Undergone Intracranial Surgery: Coping with sensory deprivation

- Periorbital edema is a common consequence of intracranial surgery, because fluid drains into the dependent periorbital areas when the patient has been positioned in a prone position during surgery. A hematoma may form under the scalp and spread down to the orbit, producing an area of ecchymosis (black eye). - Before surgery, the patient and family should be informed that one or both eyes may be edematous temporarily after surgery. After surgery, elevating the head of the bed (if not contraindicated) and applying cold compresses over the eyes will help reduce the edema. The surgeon is notified if periorbital edema increases significantly, because this may indicate that a postoperative clot is developing or that there is increasing ICP and poor venous drainage. Health care personnel should announce their presence when entering the room to avoid startling the patient whose vision is impaired due to periorbital edema or neurologic deficits. - Additional factors that can affect sensation include a bulky head dressing, the presence of an endotracheal tube, and effects of increased ICP. - In the absence of bleeding or a CSF leak, every effort is made to minimize the size of the head dressing.

Supratentorial and Infratentorial Approaches: Post-Op management

- Postoperatively, an arterial line and a central venous pressure line may be in place to monitor and manage blood pressure and central venous pressure. The patient may be intubated and may receive supplemental oxygen therapy. Ongoing postoperative management is aimed at detecting and reducing cerebral edema, relieving pain and preventing seizures, and monitoring ICP and neurologic status. - Medications to reduce cerebral edema include mannitol, which increases serum osmolality and draws free water from areas of the brain (with an intact blood-brain barrier). The fluid is then excreted by osmotic diuresis. Dexamethasone may be administered IV every 6 hours for 24 to 72 hours; the route is changed to oral as soon as possible, and the dosage is tapered over 5 to 7 days - Acetaminophen is usually prescribed for temperatures exceeding 37.5°C (99.6°F) and for mild pain. The patient usually has a headache after a craniotomy as a result of stretching and irritation of nerves in the scalp during surgery. Codeine, administered IV or orally, is often sufficient to relieve headache. Morphine sulfate may also be used in the management of postoperative pain in patients who have undergone a craniotomy with the goal of a patient reporting acceptable pain level - Serum levels are monitored to check that the medication levels are within the therapeutic range. - A patient undergoing intracranial surgery may have an ICP or cerebral oxygenation monitor inserted during surgery.

Supratentorial and Infratentorial Approaches: Pre-Op Medical Management

- Preoperative diagnostic procedures may include a CT scan to demonstrate the lesion and show the degree of surrounding brain edema, the ventricular size, and the displacement. - An MRI scan provides information similar to that of a CT scan with improved tissue contrast, resolution, and anatomic definition. - Cerebral angiography may be used to study a tumor's blood supply or obtain information about vascular lesions. - Transcranial Doppler flow studies are used to evaluate the blood flow within intracranial blood vessels. - Most patients are prescribed an anticonvulsant medication such as phenytoin (Dilantin), levetiracetam (Keppra), or a phenytoin metabolite fosphenytoin sodium (Cerebyx) before surgery to reduce the risk of postoperative seizures. - Before surgery, corticosteroids such as dexamethasone may be given to reduce cerebral edema if the patient has a brain tumor. - Fluids may be restricted. - A hyperosmotic agent (mannitol) and a diuretic agent such as furosemide (Lasix) may be administered IV immediately before and sometimes during surgery if the patient tends to retain fluid, as do many who have intracranial dysfunction. - Antibiotic agents may be given if there is a chance of cerebral contamination; diazepam (Valium) or lorazepam (Ativan) may be prescribed before surgery to allay anxiety.

Death in the Emergency Department

- Prepare for the times when sudden death occurs - Anticipate your own reaction/feelings - Help caregivers grieve Collecting personal belongings Viewing the body Making mortuary arrangements Provide comfort Ensure privacy Offer chaplain visit - May need to contact medical examiner or coroner - Autopsies Upon family request In cases of death within 24 hours of ED admission When suspected trauma or violence has occurred

Preparedness and Response: Recognition and Awareness

- Preparedness for natural disasters and acts of terrorism includes devising specific community contingency plans that prepare residents, particularly those who are vulnerable (e.g., older adults, people with disabilities) for access to necessary life-sustaining resources and for evacuation, as necessary - Preparedness includes an awareness of the potential for covert use of WMD, self-protection, and early detection, containment, or decontamination of substances and agents that may affect others by secondary exposure. - The strength of many toxins, mobility of many members of society, and long incubation periods for some organisms and diseases can result in an epidemic that can quickly and silently spread across the entire country. For example, a formerly healthy person with a rapid onset of flulike symptoms can have an ominous illness, such as anthrax. - If any of these trends are noted, an extensive patient history is taken in an attempt to identify the possible agent involved. This history includes an occupational, work, and environmental assessment, in addition to the regular admission history. - An exposure history contains, at a minimum, information about current and past exposures to possible hazards and an assessment of the patient's typical day and any deviations in routines. - The work history includes, at a minimum, a description of all previous jobs, including short-term, seasonal, and part-time employment and any military service. - The environmental history includes assessment of present and previous home locations, water supply, and any hobbies, to name a few factors. - The admission history should include such information as recent travel and contact with others who have been ill or have recently died of a fatal illness. - Suspicions or findings are reported to the appropriate resources in the facility and to proper authorities in the community. Resources can include the infection control department, the state health department, the CDC, the local poison control center, various internet sites, and material safety data sheets (MSDS) or the Chemtrac database - The MSDS provides information to employees and health care providers regarding specific chemical agents; it includes the chemical name, physical data, chemical ingredients, fire and explosive hazard data, health and reactive data, spill or leak procedures, special protection information, and special precautions.

Mannitol

- Prevention and treatment of oliguric phase of renal failure; reduction of ICP and treatment of cerebral edema; reduction of elevated IOP; promotion of urinary excretion of toxic substances; diagnostic use for measurement of glomerular filtration rate; also available as an irrigant in transurethral prostatic resection and other transurethral procedures. - Actions: Elevates the osmolarity of the glomerular filtrate, leading to a loss of water, sodium, and chloride; creates an osmotic gradient in the eye, reducing IOP; creates as osmotic effect that decreases swelling after transurethral surgery. - As an irrigant has a rapid onset and short duration. - Adverse effects include dizziness, headache, hypotension, rash, nausea, anorexia, dry mouth, thirst, diuresis, and fluid and electrolyte imbalances.

Difference between primary and delayed primary closure

- Primary closure Suture Derma bond Sterile strips - Delayed primary closure Gauze w/occlusive dressing Splint wound

There are three categories of predicted survival after radiation exposure: probable, possible, and improbable.

- Probable survivors have either no initial symptoms or only minimal symptoms (e.g., nausea and vomiting), or these symptoms resolve within a few hours. These patients should have a complete blood count drawn and may be discharged with instructions to return if any symptoms recur. - Possible survivors present with nausea and vomiting that persist for 24 to 48 hours. They experience a latent period, during which leukopenia, thrombocytopenia, and lymphocytopenia occur. Barrier precautions and protective isolation are implemented if the patient's lymphocyte count is less than 1200/mm3. Supportive treatment includes administration of blood products, prevention of infection, and provision of enhanced nutrition. - Improbable survivors have received more than 800 rad of total-body penetrating irradiation. People in this group demonstrate an acute onset of vomiting, bloody diarrhea, and shock. Any neurologic symptoms suggest a lethal dose of radiation. These patients still require decontamination to prevent further contamination of the area and of others. Personal protection is essential, because it is virtually impossible to fully decontaminate these patients; all of their internal organs have been irradiated. The survival time is variable; however, death usually occurs swiftly due to shock. If there are no neurologic symptoms, patients may be alert and oriented, similar to a patient with extensive burns. In a mass casualty situation, these patients would be triaged into the black category, where they will receive comfort measures and emotional support. If it is not a mass casualty situation, aggressive fluid and electrolyte therapies are essential.

Increased ICP may reduce cerebral blood flow

- Reduced cerebral blood flow results in ischemia and cell death. - In the early stages of cerebral ischemia, the vasomotor centers are stimulated and the systemic pressure rises to maintain cerebral blood flow. Usually, this is accompanied by a slow bounding pulse and respiratory irregularities. These changes in blood pressure, pulse, and respiration are important clinically because they suggest increased ICP. - The concentration of carbon dioxide in the blood and in the brain tissue also plays a role in the regulation of cerebral blood flow. - An increase in the partial pressure of arterial carbon dioxide (PaCO2) causes cerebral vasodilation, leading to increased cerebral blood flow and increased ICP. - A decrease in PaCO2 has a vasoconstrictive effect, limiting blood flow to the brain. Decreased venous outflow may also increase cerebral blood volume, thus raising ICP.

Triage

- Process of assessing patients to determine management priorities - The word triage comes from the French word trier, meaning "to sort." - In the daily routine of the ED, triage is used to sort patients into groups based on the severity of their health problems and the immediacy with which these problems must be treated. - A basic and widely used triage system that had been in use for many years utilized three categories: emergent, urgent, and nonurgent. - Systems that meet these criteria for validity and reliability that are commonly used in the United States are the Emergency Severity Index (ESI) and the Canadian Triage and Acuity Scale (CTAS). The ESI assigns patients into five levels, from level 1 (most urgent) to level 5 (least urgent). - With the ESI, patients are assigned to triage levels based on both their acuity and their anticipated resource needs - The goal of all triage is rapid assessment and decision-making, preferably under 5 minutes. - Nurses in the triage area collect additional crucial baseline data: full vital signs including pain assessment, history of the current event and past medical history, neurologic assessment findings, weight, allergies (especially to latex and medications), domestic violence screening, and necessary diagnostic data. - In addition to the collection of initial vital signs and medical history, triage consists of providing basic first aid, which may include application of ice, bleeding control, and basic wound care, as well as initiating protocol-based prescriptions (e.g., x-rays, administering antipyretic or mild analgesic agents, obtaining an electrocardiogram [ECG] or urinalysis, removing sutures). The triage nurse also is responsible for and monitors the waiting area, maintains a safe environment, reassesses patients who are waiting, and is the initial liaison to the families of patients.

Creutzfeldt-Jakob Disease Manifestations

- Psychiatric symptoms occur early in vCJD, whereas they are a late symptom in CJD. - The mean age at onset of vCJD is 27 years, whereas the mean age for CJD onset is 65 years. - The presenting symptoms of vCJD include affective symptoms (i.e., behavioral changes), sensory disturbance, and limb pain. Muscle spasms and rigidity, dysarthria, incoordination, cognitive impairment, and sleep disturbances follow. - Patients with sporadic CJD present with mental deterioration, ataxia, and visual disturbance. Memory loss, involuntary movement, paralysis, and mutism occur as the disease progresses. - After clinical presentation, people with vCJD survive an average of 22 months; those with CJD survive for less than 1 year

Phosgene, chlorine

- Pulmonary agent - Action: Separation of alveoli from capillary bed - Signs and symptoms: Pulmonary edema, bronchospasm, chest tightness, burning sensation, blurry vision; Phosgene can result in pain then blisters followed by partial to full-thickness burn - Treatment: Copious flushing, move to fresh air—away from gases, airway management, ventilatory support, and bronchoscopy

Pulmonary Agents

- Pulmonary agents such as phosgene and chlorine destroy the pulmonary membrane that separates the alveolus from the capillary bed, disrupting alveolar-capillary oxygen transport mechanisms. - Capillary leakage results in fluid-filled alveoli. - Phosgene and chlorine both vaporize, rapidly causing this pulmonary injury. Phosgene has the odor of freshly mown hay. - Signs and symptoms include pulmonary edema with shortness of breath, especially during exertion. - An initial hacking cough is followed by frothy sputum production. - A particulate air filter mask is the only protection required to protect health care personnel. - Phosgene does not injure the eyes.

Measurement and Detection

- Radiation is measured in several different units. - The rad is the basic unit of measurement. A rad is equivalent to 0.01 J of energy per kilogram of tissue. To determine the damaging effect of the rad, a conversion to the rem (roentgen equivalents man) is necessary. The rem reflects the type of radiation absorbed and the potential for damage. For example, 200,000 mrem results in mild radiation sickness (1 rem = 1000 mrem). - Typical natural yearly exposure for a person is 360 mrem. - Another important concept is half-life. The half-life of a radioactive product is the time it takes to lose half of its radioactivity. - The only way to detect radiation is through a device that determines the exposure per minute. The Geiger counter (or Geiger-Mueller survey meter) can measure background radiation quickly through detection of gamma radiation and some beta radiation. With high-level radiation, the Geiger counter may underestimate exposure. - Other devices include the ionization chamber survey meter, alpha monitors, and dose rate meters. - Personal dosimeters are simple tools that identify radiation exposure and are worn by radiology personnel every day.

Treatment of blood agents

- Rapid administration of amyl nitrate, sodium nitrite, and sodium thiosulfate is essential to the successful management of cyanide exposure. - First, the patient is intubated and placed on a ventilator. - Next, amyl nitrate pearls are crushed and placed in the ventilator reservoir to induce methemoglobinemia. Cyanide has a 20% to 25% higher affinity for methemoglobin than it does for hemoglobin; it binds methemoglobin to form either cyanomethemoglobin or sulfmethemoglobin. The cyanomethemoglobin is then detoxified in the liver by the enzyme rhodanese. - Next, IV sodium nitrite is given to induce the rapid formation of methemoglobin. - IV sodium thiosulfate is then given; it has a higher affinity for cyanide than methemoglobin and stimulates the conversion of cyanide to sodium thiocyanate, which can be excreted by the kidneys - Sodium nitrite can result in severe hypotension, and thiocyanate can cause vomiting, psychosis, arthralgia, and myalgia. - The production of methemoglobin is contraindicated in patients with smoke inhalation, because they already have decreased oxygen-carrying capacity secondary to the carboxyhemoglobin produced by smoke inhalation. - In facilities where a hyperbaric chamber is available, it may be used to provide oxygenation while the previously discussed therapies are initiated. - An alternative suggested treatment for cyanide poisoning is hydroxocobalamin (vitamin B12a). Hydroxocobalamin binds cyanide to form cyanocobalamin (vitamin B12). It must be administered IV in large doses. Administration of vitamin B12 can result in a transient pink discoloration of mucous membranes, skin, and urine. In high doses, tachycardia and hypertension can occur, but they usually resolve within 48 hours.

Management of the Client With Heat Stroke

- Reduce temperature to 39°C as quickly as possible - Circulation, airway, breathing - Cool sheets, towels, or sponging with cool water - Ice to neck, groin, chest, and axillae - Cooling blankets stop cooling at 38 C - Immersion in cold water bath - During cooling have fan blow on patient - Stop cooling at 38°C - Monitor temperature, VS, ECG, CVP, LOC, I&O - IVs to replace fluid losses - Medications: anticonvulsant, potassium, sodium bicarbonate, benzodiazepines - 100% Oxygen

Osmotic diuretics adverse effects

- Related to sudden drop in fluid levels - Causes electrolyte disturbances - Nausea, vomiting, hypotension, light-headedness, confusion, and headache

Methods to bring down body temperature

- Removal of clothes - Cool sheets and towels or continuous sponging with cool water - Ice applied to the neck, groin, chest, and axillae while spraying with tepid water - Cooling blankets - Immersion of the patient in a cold water bath is the optimal method for cooling (if available) - During cooling procedures, an electric fan is positioned so that it blows on the patient to augment heat dissipation by convection and evaporation.

Determining Resources

- Resources needed are determined after the patient is stabilized or if the patient is already stable without threat to life. - Resources include: Labs, blood, urine, ECG, X-rays, CT, MRI, IV, IM, nebulized medications - Simple procedures: Lac repair, Foley catheter - Complex procedure: Conscious sedation

Supportive Measures for Head Injury

- Respiratory support: The patient must be monitored for a patent airway, altered breathing patterns, and hypoxemia and pneumonia. Interventions may include endotracheal intubation, mechanical ventilation, and positive end-expiratory pressure. - Seizure precautions and prevention: Posttraumatic seizures are classified as immediate (within 24 hours after injury), early (within 1 to 7 days after injury), or late (more than 7 days after injury). Seizure prophylaxis is the practice of administering anticonvulsant medications to patients with head injury to prevent seizures. It is important to prevent posttraumatic seizures, especially in the immediate and early phases of recovery, because seizures may increase ICP and decrease oxygenation. Benzodiazepines (lorazepam, midazolam) are often used, but can cause difficulty when assessing the neurological system due to prolonged sedation. Propofol is a sedative and drug of choice because it has a shorter half-life, rapid onset and elimination of less than an hour. - NG or OG tube: A nasogastric tube may be inserted, because reduced gastric motility and reverse peristalsis are associated with head injury, making regurgitation and aspiration common in the first few hours. - Fluid and electrolyte maintenance: Common imbalances include hyponatremia, which is often associated with SIADH, hypokalemia, and hyperglycemia. Modifications in fluid intake with tube feedings or IV fluids, including hypertonic saline, may be necessary to treat these imbalances. Insulin administration may be prescribed to treat hyperglycemia; blood glucose levels are maintained between 80 and 160 mg/dL. Pain and anxiety management - Nutrition: Decisions about early feeding should be individualized; options include IV hyperalimentation or placement of a feeding tube (jejunal or gastric). Caloric expenditure can increase up to 120% to 140% with TBI, requiring close monitoring of nutritional status, with a higher concentration of protein if tolerated

Phases of Blasts and Associated Common Injuries: Quaternary

- Results from pre-existing conditions exacerbated by the force of the blast or by postblast injury complications - Severe injuries with complex injury patterns—burns, crush injuries, head injuries - Common pre-existing conditions that become exacerbated—COPD, asthma, cardiac conditions, diabetes, and hypertension

Phases of Blasts and Associated Common Injuries: Primary

- Results from pressure wave - Common injuries include: Pulmonary barotraumas, including pulmonary contusions Head injuries, including concussion, other severe brain injuries Tympanic membrane rupture, middle ear injury Abdominal hollow organ perforation, hemorrhage

Phases of Blasts and Associated Common Injuries: Tertiary

- Results from pressure wave that causes the victim to be thrown - Common injuries include: Head injuries Fractures, including skull

Diffused Axonal Injury

- Results from widespread shearing and rotational forces that produce damage throughout the brain—to axons in the cerebral hemispheres, corpus callosum, and brainstem. - The injured area may be diffuse with no identifiable focal lesion. -DAI is associated with prolonged traumatic coma; it is more serious and is associated with a poorer prognosis than a focal lesion. - The patient with DAI in severe head trauma experiences no lucid interval, immediate coma, decorticate (lesions in the cerebral hemispheres) and decerebrate (lesions in the mid brain, brain stem or pons) posturing, and global cerebral edema. - Significant damage to axons in the white matter - Depends on severity, small areas of hemorrhage and enlargement of lateral ventricles may be seen by CT scan - Severe DAI may be present with immediate coma - Seen in MVA - Diagnosis is made by clinical signs in conjunction with a CT or MRI scan. - Recovery depends on the severity of the axonal injury.

Routine ED triage protocols differ significantly from the triage protocols used in disasters and mass casualty incidents (field triage).

- Routine triage directs all available resources to the patients who are most critically ill, regardless of potential outcome. - In field triage (or hospital triage during a disaster), scarce resources must be used to benefit the most people possible.

Organ procurement organizations (OPOs) assist in

- Screening potential donors - Counseling donor families - Obtaining informed consent - Harvesting organs - Can be distressing - May be 1st positive step in grieving

Maintaining a patent airway in increased ICP

- Secretions that are obstructing the airway must be suctioned with care, because transient elevations of ICP occur with suctioning - Hypoxia caused by poor oxygenation leads to cerebral ischemia and edema. - Coughing is discouraged because it increases ICP. - The lung fields are auscultated at least every 8 hours to determine the presence of adventitious sounds or any areas of congestion. - Elevating the head of the bed may aid in clearing secretions and improve venous drainage of the brain.

Transsphenoidal

- Sella turcica and pituitary region - Incision is made beneath the upper lip to gain access into the nasal cavity. - Maintain nasal packing in place and reinforce as needed. - Instruct patient to avoid blowing the nose. - Provide oral care according to institutional procedure. - Keep head of bed elevated to promote venous drainage and drainage from the surgical site.

Assess the sensation and motor function below the level of injury:

- Sensation: (Absence of tactile sensation) Have patient close eyes Touch skin and check light touch and pin prick Compare bilateral responses along dermatomes - Motor: (Flaccid paralysis of all voluntary muscles) Flex/extend of joints (e.g., elbow, wrist, fingers) Test deep tendon reflexes. Done by advanced practice nurse or health care provider

Assessment and Diagnostic Findings of increased ICP

- The most common diagnostic tests are CT scanning and MRI. - The patient may also undergo cerebral angiography, PET, or SPECT. - Transcranial Doppler studies provide information about cerebral blood flow. - The patient with increased ICP may also undergo electrophysiologic monitoring to observe cerebral blood flow indirectly. Evoked potential monitoring measures the electrical potentials produced by nerve tissue in response to external stimulation (auditory, visual, or sensory). - Lumbar puncture is avoided in patients with increased ICP, because the sudden release of pressure in the lumbar area can cause the brain to herniate

The problems resulting from neurogenic bladder disorders vary considerably from patient to patient and are a major challenge to the health care team.

- Several long-term objectives appropriate for all types of neurogenic bladders include preventing overdistention of the bladder, emptying the bladder regularly and completely, maintaining urine sterility with no stone formation, and maintaining adequate bladder capacity with no reflux. - Specific interventions include continuous, intermittent, or self-catheterization; the use of an external condom-type catheter; a diet low in calcium (to prevent calculi); and encouragement of mobility and ambulation. - A liberal fluid intake is encouraged to reduce the urinary bacterial count, reduce stasis, decrease the concentration of calcium in the urine, and minimize the precipitation of urinary crystals and subsequent stone formation. - A bladder retraining program may be effective in treating a spastic bladder or urine retention. The use of a timed, or habit, voiding schedule may be established. To further enhance emptying of a flaccid bladder, the patient may be taught to "double void." After each voiding, the patient is instructed to remain on the toilet, relax for 1 to 2 minutes, and then attempt to void again in an effort to further empty the bladder. - Parasympathomimetic medications, such as bethanechol (Urecholine), may help to increase the contraction of the detrusor muscle. - Surgery may be carried out to correct bladder neck contractures or vesicoureteral reflux, or to perform a urinary diversion procedure.

Small Pox Manifestations

- Signs and symptoms of smallpox infection include high fever, malaise, headache, backache, and prostration. - After 1 to 2 days, a maculopapular rash appears, evolving at the same rate, beginning on the face, mouth, pharynx, and forearms. Only then does the rash progress to the trunk and also become vesicular to pustular - There is a large amount of the virus in the saliva and pustules. - Smallpox is contagious only after the appearance of the rash. - There are two forms of smallpox: variola major and variola minor. - Variola major is more common, results in a higher fever and more extensive rash, and has a 30% case fatality rate (i.e., the likelihood of fatality per case diagnosed). - Hemorrhagic smallpox, a subtype of variola major, includes all of the above signs and symptoms plus a dusky erythema and petechiae leading to frank hemorrhage of the skin and mucous membranes, and it results in death by day 5 or 6

Signs of increasing ICP include

- Slowing of the heart rate (bradycardia) - Increasing systolic blood pressure - Widening pulse pressure (Cushing reflex). - As brain compression increases, respirations become rapid, the blood pressure may decrease, and the pulse slows further. The temperature is maintained at less than 38°C (100.4°F). - Tachycardia and arterial hypotension may indicate that bleeding is occurring elsewhere in the body. - In a patient with a head injury, a rapid increase in body temperature is regarded as unfavorable because hyperthermia increases the metabolic demands of the brain and may indicate brainstem damage—a poor prognostic sign.

Smallpox

- Smallpox (variola) is classified as a deoxyribonucleic acid (DNA) virus. - It has an incubation period of approximately 12 days. - It is extremely contagious and is spread by direct contact, by contact with clothing or linens, or by droplets from person to person only after the fever has decreased and the rash phase has begun. - Aerosolization of the virus would result in widespread dissemination. - The World Health Organization (WHO) declared smallpox eradicated in 1977 and stopped worldwide vaccination in 1980. In the United States, the last child was vaccinated in 1972. Therefore, a large portion of the current population has no immunity to the virus. - A smallpox vaccination plan introduced in 2003 proposed that a designated number of ED staff receive the first vaccinations to ensure that ED staff would be immunized in the event of a smallpox outbreak. - Currently, only people with a high likelihood of exposure to smallpox are encouraged to receive the vaccination

Spinal and Neurogenic Shock

- Spinal shock Loss of all sensation below the level of injury. A sudden absence of reflex activity below level of spinal injury Blood pressure may be decreased and the patient may be bradycardic. The reflexes that initiate bladder and bowel function are affected. Bowel distention and paralytic ileus can be caused by depression of the reflexes and are treated with intestinal decompression by insertion of a nasogastric tube. A paralytic ileus most often occurs within the first 2 to 3 days after SCI and resolves within 3 to 7 days. Muscular flaccidity, lack of sensation and reflexes below level of injury - Neurogenic shock Caused by the loss of function of the autonomic nervous system Blood pressure, heart rate, and cardiac output decrease Venous pooling occurs because of peripheral vasodilation Paralyzed portions of the body do not perspire Body takes on temperature of environment **With injuries to the cervical and upper thoracic spinal cord, innervation to the major accessory muscles of respiration is lost and respiratory problems develop. These include decreased vital capacity, retention of secretions, increased partial pressure of arterial carbon dioxide (PaCO2) levels and decreased oxygen levels, respiratory failure, and pulmonary edema.**

Assessment of the Client With A Brain Injury

- Start with a history: Ask when, where and how the injury occurred, whether or not the client lost consciousness and for how long, if there's been a change in LOC, or used drug/alcohol. - Ask if there was seizure activity afterwards, and any other diseases they may have. - It is important to get as much information about event right away after injury. - Physical Assessment: No two injuries are the same, so each client may present with a variety of symptoms which may be influenced based on severity and increase in ICP - If client have consumed drugs or alcohol, be aware that their neuro problems can be masked - Assess for signs of increased ICP - Assess neuro status frequently, and compare it to the baseline you need a baseline. - Rule out cervical/spinal cord injury before anything. - Vital signs often accompanied by brain injury include: hyper/hypotension, Cushing's triad, cardiac dysrhythmias, low GCS, signs of CFS leakage, halo sign, ecchymosis. - Hypertension and tachycardia suggest hypovolemic shock - Psychosocial assessment: Mild TBI symptom of disability 1 year or longer after injury is not uncommon. Moderate to severe, they are never the same after the injury. They can have personality changes. - Assess family dynamics, and how they're coping. - There's no test to diagnose the brain injury, but labs are done to prevent secondary insults. - Multisystem assessment

Suprapubic Catheters

- Suprapubic catheterization allows bladder drainage by inserting a catheter or tube into the bladder through a suprapubic (above the pubis) incision or puncture - This may be a temporary measure to divert the flow of urine from the urethra when the urethral route is impassable (because of injuries, strictures, prostatic obstruction), after gynecologic or other abdominal surgery when bladder dysfunction is likely to occur, and occasionally after pelvic fractures. - Suprapubic bladder drainage may be maintained continuously for several weeks. When the patient's ability to void is to be tested, the catheter is clamped for 4 hours, during which time the patient attempts to void. After the patient voids, the catheter is unclamped, and the residual urine is measured. If the amount of residual urine is less than 100 mL on two separate occasions (morning and evening), the catheter is usually removed. However, if the patient complains of pain or discomfort, the suprapubic catheter is usually left in place until the patient can void successfully. - Patients can usually void sooner after surgery than those with urethral catheters, and they may be more comfortable. The catheter allows greater mobility, permits measurement of residual urine without urethral instrumentation, and presents less risk of bladder infection. - The patient requires liberal amounts of fluid to prevent encrustation around the catheter. Other potential problems include the formation of bladder stones, acute and chronic infections, and problems collecting urine

Invasive interventions for brain injuries

- Surgical Management ICP monitoring device: (Minimally invasive) Burr hole (Keyhole Craniotomy) Craniotomy: Extreme cases in which ICP cannot be controlled. Incision into cranium to remove ischemic tissue or tips of the temporal lobes. Removal of epidural or subdural hematomas

Skull fractures manifestations.

- Symptoms, apart from those of the local injury, depend on the severity and the anatomic location of the underlying brain injury. - Usually have localized, persistent pain - Fractures of the cranial vault may or may not produce swelling in the region of the fracture.

Blast injury: Tympanic Membrane Rupture

- TM rupture is the most frequent injury after subjection to a pressure wave because the TM is the body's most sensitive organ to pressure. - There is an increased incidence of TM rupture when a blast occurs in close proximity to the patient and when it occurs in an enclosed space. - Signs and symptoms include hearing loss, tinnitus, pain, dizziness, and otorrhea - The majority of TM ruptures heal spontaneously. - Approximately 5% of patients with TM rupture from a blast will require hearing aids, whereas the majority will suffer only mild high-frequency hearing loss - Other ear injuries may include ossicular disruption and impaction of foreign bodies.

Terrorism

- Terrorism involves the systematic use of violence to create feelings of fear. - Terrorists have become increasingly sophisticated, organized, and therefore effective. - The U.S. Department of Homeland Security was created after the attacks of September 11, 2001, to coordinate federal and state efforts to combat terrorist activity. - A plan that adheres to guidelines devised by the National Incident Management System (NIMS), which is directed by the Federal Emergency Management Agency (FEMA), is essential for every community and facility. - The preparation based on the NIMS guidelines is effective for terrorist events, as well as any disaster situation, including natural disasters. Natural disasters are caused by environmental forces, including storms, floods, fires, earthquakes, and similar forces of nature. - Warfare, terrorism, and natural disasters are just some of the reasons nurses must plan for mass casualties. Airplane crashes, train crashes, toxic substance spills, and infectious disease outbreaks are other disasters that can result in mass casualties and tax the resources of health care facilities and their communities. Acute care facilities must be prepared for any and all of these disasters.

CTAS system

- The CTAS system's five levels include time parameters that guide how frequently patients must be reassessed by either a nurse or provider. - Patients assigned to the resuscitation category must receive continuous nursing surveillance, those in the emergent category must be reassessed at least every 15 minutes, patients in the urgent category must be reassessed at least every 30 minutes, patients in the less urgent category must be reassessed at least every 60 minutes, and those in the nonurgent category must be reassessed at least every 120 minutes

The Incident Command System

- The Incident Command System (ICS) is a federally mandated command structure that coordinates personnel, facilities, equipment, and communication in any emergency situation. - The ICS is the center of operations for organization, planning, and transport of patients in the event of a specific local MCI. - Successful incident management requires equipment compatibility, effective communication, adequate distribution of resources, and clear differentiation of members' roles. - The ICS ensures that any hazardous substances used during an MCI are identified promptly and that appropriate personal protection equipment is distributed. In addition to all of these responsibilities, the ICS is also responsible for determining when an MCI has ended. - The Hospital Incident Command System (HICS) is a modification of the ICS that is used by both hospitals and law enforcement agencies. - The HICS incident commander is the hospital emergency preparedness coordinator who oversees and coordinates all efforts surrounding the event. - The HICS team includes a safety officer, public information officer, liaison officer, operations chief, logistics chief, planning chief, and finance chief. Each team member has a specific responsibility and communicates directly back to the incident commander

Managing Internal Problems

- The Red Cross has developed a basic survival/shelter resource kit; however, each facility must determine its supply lists based on its own needs assessment. - The EOP committee should determine the top 10 critical medications used during normal day-to-day operations and then anticipate which other medications may be required in a disaster or an MCI. For example, the health care facility might plan to have available a stockpile of antidotes (e.g., cyanide kits) or antibiotics used in treating biologic agents. - Information should be available about stocking or restocking any of the basic and special supplies, how those supplies are requested, and the time required to receive those supplies.

Intra-abdominal: Intraperitoneal Injury

- The abdomen is assessed for tenderness, rebound tenderness, guarding, rigidity, spasm, increasing distention, and pain. - Referred pain is a significant finding because it suggests intraperitoneal injury. - To determine if there is intraperitoneal injury and bleeding, the patient is usually prepared for diagnostic procedures, such as peritoneal lavage, abdominal ultrasonography, or abdominal CT scanning. - Diagnostic peritoneal lavage (DPL), although no longer the standard diagnostic study used to evaluate a traumatized abdomen, remains a backup procedure that is easily performed and is very useful during mass casualty situations when CT scanners may not be readily available. - DPL involves the instillation of 1 L of warmed lactated Ringer's or normal saline solution into the abdominal cavity. After a minimum of 400 mL has been returned, a fluid specimen is sent to the laboratory for analysis. - Positive laboratory findings include a red blood cell count greater than 100,000/mm3; a WBC count greater than 500/mm3; or the presence of bile, feces, or food. - In patients with stab wounds, sinography may be performed to detect peritoneal penetration; a purse-string suture is placed around the wound and a small catheter is introduced through the wound. A contrast agent is then introduced through the catheter, and x-rays are taken to identify any peritoneal penetration.

Intracerebral Hemorrhage and Hematoma

- The accumulation of blood within the brain tissue caused by the tearing of small arteries and veins in the subcortical white matter - Acts as a space-occupying lesion - May also produce significant brain edema and ICP elevations - Brainstem hemorrhage occurs as a result of direct trauma, fractures, or torsion or twisting injuries to the brainstem (Poor prognosis) - Intracerebral hemorrhage is bleeding into the parenchyma of the brain. - It is commonly seen in head injuries when force is exerted to the head over a small area (e.g., missile injuries, bullet wounds, stab injuries). - Other causes: Systemic hypertension, which causes degeneration and rupture of a vessel, Rupture of an aneurysm, Vascular anomalies, Intracranial tumors, Bleeding disorders such as leukemia, hemophilia, aplastic anemia, and thrombocytopenia, and Complications of anticoagulant therapy - The onset may be insidious, beginning with the development of neurologic deficits, followed by headache. - Management includes supportive care; control of ICP; and careful administration of fluids, electrolytes, and antihypertensive medications. - Surgical intervention by craniotomy or craniectomy permits removal of the blood clot and control of hemorrhage, but may not be possible because of the inaccessible location of the bleeding or the lack of a clearly circumscribed area of blood that can be removed.

Maryland Good Samaritan Law

- The act or omission is not one of gross negligence - The assistance or medical care is provided without fee or other compensation - The assistance or medical care is provided: At the scene of an emergency In transit to a medical facility Through communications with personnel providing emergency assistance. - The assistance or aid is provided within prudent manner - No procedures outside scope of practice - The individual relinquishes care of the victim when someone who is licensed or certified by this State to provide medical care or services becomes available to take responsibility. - Good Samaritan Law and Overdoses. No repercussions if ask for help

Maintaining negative fluid balance in increased ICP

- The administration of osmotic and loop diuretics is part of the treatment protocol to reduce ICP. - Corticosteroids may be used to reduce cerebral edema (except when it results from trauma), and fluids may be restricted. - Skin turgor, mucous membranes, urine output, and serum and urine osmolality are monitored to assess fluid status. - If IV fluids are prescribed, the nurse ensures that they are given at a slow to moderate rate with an IV infusion pump, to prevent too-rapid administration and avoid overhydration. - For the patient receiving mannitol, the nurse observes for the possible development of heart failure and pulmonary edema. The intent of treatment is to promote a shift of fluid from the intracellular to the intravascular compartment and to control cerebral edema. However, this shift of fluid volume to the intravascular compartment may overwhelm the ability of the myocardium to increase workload sufficient to meet these demands, which may cause failure and pulmonary edema. - For patients undergoing dehydrating procedures, vital signs, including blood pressure, must be monitored to assess fluid volume status. An indwelling urinary catheter is inserted to permit assessment of renal function and fluid status. During the acute phase, urine output is monitored hourly. An output greater than 200 mL per hour for 2 consecutive hours may indicate the onset of diabetes insipidus

Cerebral Response to Increased Intracranial Pressure

- The brain can maintain a steady perfusion pressure if the arterial systolic blood pressure is 50 to 150 mm Hg and the ICP is less than 40 mm Hg. - As ICP rises and the autoregulatory mechanism of the brain is overwhelmed, the CPP can increase to greater than 100 mm Hg or decrease to less than 50 mm Hg. - Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage. Therefore, the CPP must be maintained at 70 to 80 mm Hg to ensure adequate blood flow to the brain. - If ICP is equal to MAP, cerebral circulation ceases. - A clinical phenomenon known as the Cushing's response (or Cushing's reflex) is seen when cerebral blood flow decreases significantly. This response is seen clinically as an increase in systolic blood pressure, widening of the pulse pressure, and reflex slowing of the heart rate. It is a late sign requiring immediate intervention; however, perfusion may be recoverable if the Cushing's response is treated rapidly. - At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. When this occurs, the patient exhibits significant changes in mental status and vital signs. The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad, which is a grave sign. At this point, herniation of the brainstem and occlusion of the cerebral blood flow occur if therapeutic intervention is not initiated.

Primary Closure

- The decision to suture a wound depends on the nature of the wound, the time since the injury was sustained, the degree of contamination, and the vascularity of tissues. - If primary closure is indicated, the wound is sutured or stapled, usually by the physician, with the patient receiving either local anesthesia or moderate sedation - Wound closure begins when subcutaneous fat is brought together loosely with a few sutures to close off the dead space. The subcuticular layer is then closed, and finally the epidermis is closed. - Sutures are placed near the wound edge, with the skin edges leveled carefully to promote optimal healing. - Instead of sutures, sterile strips of reinforced microporous tape or a bonding agent (skin glue) may be used to close clean, superficial wounds.

The Patient Who Has Undergone Intracranial Surgery: Maintaining cerebral tissue perfusion

- The endotracheal tube is left in place until the patient shows signs of awakening and has adequate spontaneous ventilation, as evaluated clinically and by arterial blood gas analysis. - Some degree of cerebral edema occurs after brain surgery; it tends to peak 24 to 36 hours after surgery, potentially producing decreased responsiveness on the second postoperative day - Intraventricular drainage is carefully monitored, using strict asepsis when any part of the system is handled. - Vital signs and neurologic status (LOC and responsiveness, pupillary and motor responses) are assessed every 15 to 60 minutes. - Extreme head rotation is avoided, because this raises ICP. - After supratentorial surgery, the patient is placed on their back or side (on the unoperated side if a large lesion was removed) with one pillow under the head. The head of the bed may be elevated 30 degrees, depending on the level of the ICP and the neurosurgeon's preference. - After posterior fossa (infratentorial) surgery, the patient is kept flat on one side (off the back) with the head on a small, firm pillow. The patient may be turned on either side, keeping the neck in a neutral position. When the patient is being turned, the body should be turned as a unit to prevent placing strain on the incision and possibly tearing the sutures. The head of the bed may be elevated slowly as tolerated by the patient.

Management of multiple traumas

- The goals of treatment are to determine the extent of injuries and to establish priorities of treatment. - Any injury interfering with a vital physiologic function (e.g., airway, breathing, circulation) is an immediate threat to life and has the highest priority for immediate treatment. - Essential lifesaving procedures are performed simultaneously by the emergency team. - As soon as the patient is resuscitated, clothes are removed or cut off and a rapid physical assessment is performed. - Transfer from field management to the ED must be orderly and controlled, with attention and silence given to listen to the verbal report from EMS personnel.

Emergency Management of spinal cord injury

- The immediate management at the scene of the injury is critical, because improper handling of the patient can cause further damage and loss of neurologic function. - Any patient who is involved in a motor vehicle crash, a diving or contact sports injury, a fall, or any direct trauma to the head and neck must be considered to have SCI until such an injury is ruled out. - Initial care must include a rapid assessment, immobilization, extrication, and stabilization or control of life-threatening injuries, and transportation to the most appropriate medical facility. - At the scene of the injury, the patient must be immobilized on a spinal (back) board, with the head and neck maintained in a neutral position, to prevent an incomplete injury from becoming complete. - One member of the team must assume control of the patient's head to prevent flexion, rotation, or extension; this is done by placing the hands on both sides of the patient's head at about ear level to limit movement and maintain alignment while a spinal board and/or cervical immobilizing device is applied. - If possible, at least four people should slide the patient carefully onto a board for transfer to the hospital. Head blocks should also be considered, as they will further limit any neck movement. - Any twisting movement may irreversibly damage the spinal cord by causing bony fragment or disc movement or exacerbating ligamentous injury, causing further instability. - The patient is referred to a regional spinal injury or trauma center because of the multidisciplinary personnel and support services required to counteract the destructive changes that occur in the first 24 hours after injury. - During treatment in the emergency and x-ray departments, the patient is kept on the transfer board. - The patient must always be maintained in an extended position. No part of the body should be twisted or turned, and the patient is not allowed to sit up. - Once the extent of the injury has been determined, the patient may be placed on a rotating specialty bed or in a cervical collar - Later, if SCI and bone instability have been ruled out, the patient may be moved to a conventional bed or the collar may be removed without harm. - If a specialty bed is needed but not available, the patient should be placed in a cervical collar and on a firm mattress.

Exposure to radiation is affected by time, distance, and shielding.

- The longer a person is within the radiation area, the higher the exposure. - The larger the amount of radioactive material in the area, the greater the exposure. - The farther away the person is from the radiation source, the lower the exposure. - Shielding from the radiation source also decreases exposure. - Three types of radiation-induced injury can occur: external irradiation, contamination with radioactive materials, and incorporation of radioactive material into body cells, tissues, or organs - Sequelae of contamination and incorporation can occur days to years later. - The thyroid gland can be largely protected from radiation exposure by administration of stable iodine (potassium iodide, or KI) before or promptly after the intake of radioactive iodine. - Priorities in the treatment of any type of radiation exposure are always treatment for life-threatening injuries and illnesses first, followed by measures to limit exposure, contamination control, and finally decontamination.

Wounds

- The main goal of treatment is to restore the physical integrity and function of the injured tissue while minimizing scarring and preventing infection. - Proper documentation of the characteristics of the wound, using precise descriptions and correct terminology, is essential. - Photographs are helpful because they provide an accurate, visible depiction of the wound. Photographs also become important for exigent wounds (i.e., wounds that will eventually heal). - Determining when and how the wound occurred is important because a treatment delay increases infection risk. - Using aseptic technique, the clinician inspects the wound to determine the extent of damage to underlying structures or the presence of a foreign body. - Sensory, motor, and vascular function is evaluated for changes that might indicate complications.

Monitoring fluids and electrolytes in patients with head injuries

- The monitoring of serum electrolyte levels is important, especially in patients receiving osmotic diuretics, those with syndrome of inappropriate antidiuretic hormone (SIADH) secretion, and those with posttraumatic diabetes insipidus. - Serial studies of blood and urine electrolytes and osmolality are carried out because head injuries may be accompanied by disorders of sodium regulation. - Hyponatremia is common after head injury due to shifts in extracellular fluid, electrolytes, and volume. Hyperglycemia, for example, can cause an increase in extracellular fluid that lowers sodium. Hypernatremia may also occur as a result of sodium retention that may last several days, followed by sodium diuresis. Increasing lethargy, confusion, and seizures may be the result of electrolyte imbalance. - Endocrine function is evaluated by monitoring serum electrolytes, blood glucose values, and intake and output. Urine is tested regularly for acetone. - A record of daily weights is maintained, especially if the patient has hypothalamic involvement and is at risk for the development of diabetes insipidus.

Risk factors/Causes of TBI

- The most common causes of TBIs are falls (35.2%), motor vehicle crashes (17.3%), being struck by objects (16.5%), and assaults (10%). - Children 0 to 4 years, adolescents 15 to 19 years, and adults 65 years and older are most likely to sustain a TBI. - In every age group, TBI rates are higher for males than for females

Nerve Agents

- The most toxic agents in existence are the nerve agents such as sarin, soman, tabun, and VX. They are inexpensive, effective in small quantities, and easily dispersed. - In the liquid form, nerve agents evaporate into a colorless, odorless vapor. - Organophosphates (pesticides) are similar in nature to the nerve agents used in warfare and are readily available in the farming industry. - Nerve agents can be inhaled or absorbed percutaneously or subcutaneously. - These agents bond with acetylcholinesterase so that acetylcholine is not inactivated; the adverse result is continuous stimulation (hyperstimulation) of the nerve endings. - Carbamates, which are insecticides originally extracted from the Calabar bean, are derivatives of carbamic acid; they are nerve agents that specifically inhibit acetylcholinesterase for several hours and then spontaneously become unbound from the acetylcholinesterase. However, organophosphates require the formation of new enzyme (acetylcholinesterase) before nervous system function can be restored. - A very small drop of a nerve agent is enough to result in sweating and twitching at the site of exposure. A larger amount results in more systemic symptoms. - Effects can begin anywhere from 30 minutes up to 18 hours after exposure. - The more common organophosphates and carbamates (e.g., Sevin and malathion) that are used in agriculture result in less severe symptoms than do those used in warfare or in terrorist attacks. - In an ordinary situation (e.g., nonwarfare, nonterrorist attack situation), a patient could arrive at the ED having been unintentionally exposed to organophosphates or intentionally exposed to these agents in a suicidal attempt.

Managing Media Requests for Information

- The number of reporters and newscasters and their support teams can be acute, possibly compromising operations and patient confidentiality. - The disaster plan should include a clearly defined process for managing media requests, including a designated spokesperson, the public information officer, a site for the dissemination of information (away from patient care areas), and a regular schedule for providing updates. - The EOP helps prevent the release of contradictory or inaccurate information. - Initial statements should focus on current efforts and what is being done to better understand the scope and impact of the situation. - Information about casualties should not be released. - Security staff should not allow media personnel access to patient care areas. However, media resources may be mobilized to notify the general population when disease containment is needed in case of an epidemic or the potential for one, including the location of shelters, necessity of quarantines, and point of dispensing units in the case of bioterrorism

The Patient Who Has Undergone Intracranial Surgery: Improving gas exchange

- The patient undergoing neurosurgery is at risk for impaired gas exchange and pulmonary infections due to immobility, immunosuppression, decreased LOC, and fluid restriction. - Immobility compromises the respiratory system by causing pooling and stasis of secretions in dependent areas and the development of atelectasis. - The patient whose fluid intake is restricted may be more vulnerable to atelectasis as a result of inability to expectorate thickened secretions. - Pneumonia can develop due to aspiration and restricted mobility. - Repositioning the patient every 2 hours helps to mobilize pulmonary secretions and prevent stasis. - After the patient regains consciousness, additional measures to expand collapsed alveoli can be instituted, such as yawning, sighing, deep breathing, incentive spirometry, and coughing (unless contraindicated). - If necessary, the oropharynx and trachea are suctioned to remove secretions that cannot be raised by coughing; however, coughing and suctioning increase ICP. Therefore, suctioning should be used cautiously. - Increasing the humidity in the oxygen delivery system may help to loosen secretions. The nurse and the respiratory therapist work together to monitor the effects of chest physiotherapy.

Cerebral Edema and Herniation.

- The patient with a head injury is at risk for additional complications such as increased ICP and brainstem herniation. - Cerebral edema is the most common cause of increased ICP in the patient with a head injury, with the swelling peaking approximately 48 to 72 hours after injury. - Bleeding also may increase the volume of contents within the rigid, closed compartment of the skull, causing increased ICP and herniation of the brainstem and resulting in irreversible brain anoxia and brain death

Medical Management of Long-Term Complications of Spinal Cord Injury

- The patient with an SCI has a shorter life expectancy compared to those who have not had an SCI - Lifetime care includes assessment of the urinary tract at prescribed intervals, because there is the likelihood of continuing alteration in detrusor and sphincter function, and the patient is prone to UTI - Long-term problems and complications of SCI include disuse syndrome, autonomic dysreflexia (discussed earlier), bladder and kidney infections, spasticity, and depression - Pressure ulcers with potential complications of sepsis, osteomyelitis, and fistulas occur in about 10% of patients. Spasticity may be particularly disabling. - Heterotopic ossification (overgrowth of bone) in the hips, knees, shoulders, and elbows occurs in many patients after SCI. Spasticity and heterotopic ossification of these complications are painful and can produce a loss of range of motion - Management includes observing for and addressing any alteration in physiologic status and psychological outlook, as well as the prevention and treatment of long-term complications. The nursing role involves emphasizing the need for vigilance in self-assessment and care.

Optimizing tissue perfusion in increased ICP

- The patient's head is kept in a neutral (midline) position, maintained with the use of a cervical collar if necessary, to promote venous drainage. Elevation of the head is maintained at 30 to 45 degrees unless contraindicated. - If monitoring reveals that turning the patient raises ICP, rotating beds, turning sheets, and holding the patient's head during turning may minimize the stimuli that increase ICP. - The Valsalva maneuver, which can be produced by straining at defecation or even moving in bed, raises ICP and is to be avoided. Stool softeners may be prescribed. If the patient is alert and able to eat, a diet high in fiber may be indicated. Abdominal distention, which increases intra-abdominal and intrathoracic pressure and ICP, should be noted. Enemas and cathartics are avoided if possible. When moving or being turned in bed, the patient can be instructed to exhale (which opens the glottis) to avoid the Valsalva maneuver - Before suctioning, the patient should be preoxygenated and briefly hyperventilated using 100% oxygen on the ventilator. Suctioning should not last longer than 15 seconds. High levels of positive end-expiratory pressure (PEEP) must be utilized cautiously, because they may decrease venous return to the heart and decrease venous drainage from the brain through increased intrathoracic pressure - During nursing interventions, the ICP should not increase above 25 mm Hg, and it should return to baseline levels within 5 minutes. - Emotional stress and frequent arousal from sleep are avoided. A calm atmosphere is maintained. Environmental stimuli (e.g., noise, conversation) should be minimal.

Supratentorial and Infratentorial Approaches: Pre-Op Nursing Management

- The preoperative assessment serves as a baseline against which postoperative status and recovery are compared. This assessment includes evaluating the LOC and responsiveness to stimuli and identifying any neurologic deficits, such as paralysis, visual dysfunction, alterations in personality or speech, and bladder and bowel disorders. Baseline distal and proximal motor strength in both upper and lower extremities is tested and recorded. - The patient is assessed for neurologic deficits and their potential impact after surgery. For motor deficits or weakness or paralysis of the arms or legs, trochanter rolls are applied to the extremities, and the feet are positioned against a footboard or the ankles are supported in a neutral position with orthotic boots. A patient who can ambulate is encouraged to do so. If the patient is aphasic, writing materials or picture and word cards showing the bedpan, glass of water, blanket, and other frequently used items may help improve communication. - The patient should plan to shower and wash their hair prior to surgery using the preferred cleansing solution. Hair is removed with the use of clippers and the surgical site prepared immediately before surgery (usually in the operating room), and intravenous antibiotics are given 1 hour prior to the incision to decrease the chance of infection - An indwelling urinary catheter is inserted in the operating room to drain the bladder during the administration of diuretic agents and to permit monitoring of urinary output. The patient may have a central and an arterial line placed for fluid administration and monitoring of pressures after surgery. The large head dressing applied after surgery may impair hearing temporarily. Vision may be limited if the eyes are swollen shut.

Endotracheal Intubation

- The purpose of endotracheal intubation is to establish and maintain the airway in patients with respiratory insufficiency or hypoxia. - Endotracheal intubation is indicated to establish an airway for a patient who cannot be adequately ventilated with an oropharyngeal or nasopharyngeal airway, bypass an upper airway obstruction, prevent aspiration, permit connection of the patient to a resuscitation bag or mechanical ventilator, or facilitate the removal of tracheobronchial secretions - Because of the level of skill required, endotracheal intubation is performed only by those who have had extensive training. These may include physicians, nurse anesthetists, respiratory therapists, flight nurses, and nurse practitioners. However, the emergency nurse commonly assists with intubation. - Rapid sequence intubation may be indicated, which provides management of the patient in a situation similar to that in the operating room. Medications used to facilitate rapid sequence intubation include a sedative, an analgesic, and a neuromuscular blockade agent; these are usually given by the practitioner performing the intubation.

Monitoring Intracranial Pressure and Cerebral Oxygenation

- The purposes of ICP monitoring are to identify increased pressure early in its course (before cerebral damage occurs), to quantify the degree of elevation, to initiate appropriate treatment, to provide access to CSF for sampling and drainage, and to evaluate the effectiveness of treatment. - ICP can be monitored with the use of an intraventricular catheter (ventriculostomy), a subarachnoid bolt, an epidural or subdural catheter, or a fiberoptic transducer-tipped catheter placed in the subdural space or in the ventricle. - The catheter is connected by a fluid-filled system to a transducer, which records the pressure in the form of an electrical impulse. - In addition to obtaining continuous ICP recordings, the ventricular catheter allows CSF to drain, particularly during acute increases in pressure. - The ventriculostomy can also be used to drain blood from the ventricle. - Continuous drainage of CSF under pressure control is an effective method of treating intracranial hypertension. - Another advantage of a ventricular catheter is access for the intraventricular administration of medications and the occasional instillation of air or a contrast agent for ventriculography. - Complications associated with its use include infection, meningitis, ventricular collapse, occlusion of the catheter by brain tissue or blood, and problems with the monitoring system.

Increased Intracranial pressure

- The rigid cranial vault contains brain tissue (1400 g), blood (75 mL), and CSF (75 mL). The volume and pressure of these three components are usually in a state of equilibrium and produce the ICP. - ICP is usually measured in the lateral ventricles, with the normal pressure being 0 to 10 mm Hg, and 15 mm Hg being the upper limit of normal - Although elevated ICP is most commonly associated with head injury, it also may be seen as a secondary effect in other conditions, such as brain tumors, subarachnoid hemorrhage, and toxic and viral encephalopathies. - Increased ICP from any cause decreases cerebral perfusion, stimulates further swelling (edema), and may shift brain tissue, resulting in herniation—a dire and frequently fatal event.

Skin Contamination Poisoning (Chemical Burns)

- The severity of a chemical burn is determined by the mechanism of action, the penetrating strength and concentration, and the amount and duration of exposure of the skin to the chemical. - The skin should be drenched immediately with running water from a shower, hose, or faucet, except in the case of lye and white phosphorus, which should be brushed off the skin dry. - Water should not be applied to burns from lye or white phosphorus because of the potential for an explosion or for deepening of the burn. All evidence of these chemicals should be brushed off the patient before any flushing occurs. - The skin should be flushed with a constant stream of water as the patient's clothing is removed. - Prolonged lavage with generous amounts of tepid water is important. - The decontamination shower (deluge) in the ED is the optimal place for total body flushing. The staff attending the patient should wear proper personal protective equipment (PPE) to prevent cross-contamination. - Attempts to determine the identity and characteristics of the chemical agent are necessary in order to specify future treatment. - The standard burn treatment appropriate for the size and location of the wound (antimicrobial treatment, débridement, tetanus prophylaxis, antidote administration as prescribed) is instituted - The patient may require plastic surgery for further wound management. - The patient is instructed to have the affected area reexamined at 24 and 72 hours and in 7 days because of the risk of underestimating the extent and depth of these types of injuries.

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions. Select all that apply. 1. Head midline 2. Neck in neutral position 3. Head of bed elevated 30 to 45 degrees 4. Head turned to the side when flat in bed 5. Neck and jaw flexed forward when opening the mouth

1, 2, 3

Emergency Nursing

- The term emergency management traditionally refers to care given to patients with urgent and critical needs. - However, because many people lack access to health care, the emergency department (ED) is increasingly used for nonurgent problems. Therefore, the philosophy of emergency management has broadened to include the concept that an emergency is whatever the patient or the family considers it to be. - The emergency nurse has had specialized education, training, experience, and expertise in assessing and identifying patients' health care problems in crisis situations. - Nurse establishes priorities, monitors, and continuously assesses patients who are acutely ill and injured, supports and attends to families, supervises allied health personnel, and educates patients and families within a time-limited, high-pressured care environment. - Triage nurse, only experienced, they decide priorities and who needs to be seen immediately. - Nursing interventions are accomplished interdependently, in consultation with or under the direction of a physician or advanced practitioner such as a nurse practitioner or physician assistant. Many times, ED nurses start nurse driven pathways or protocols because of long wait times to see the MD. - ED nurses need know when to ask for verbal orders for things that patients needs and the RN needs to tell the provider why its needed. - Large numbers of people seek emergency care for serious life-threatening conditions, such as cardiac dysrhythmias, acute coronary syndrome, acute heart failure, pulmonary edema, and stroke.

Assessment and diagnostic findings of CJD

- The three diagnostic tests currently used in suspicious clinical presentations to support the diagnosis of CJD are immunologic assessment, EEG, and MRI scanning. - Immunologic assessment of CSF detects a protein kinase inhibitor referred to as 14-3-3. The presence of this inhibitor indicates neuronal cell death, which is not specific to CJD but does support the diagnosis. - The EEG reveals a characteristic pattern over the duration of the disease. After initial slowing, the EEG shows periodic activity. Later in the course of the disease, the EEG shows burst suppressions characterized by periodic spikes alternating with slow periods. - The MRI scan demonstrates symmetric or unilateral hyperintense signals arising from the basal ganglia

Nonfatal drowning Management

- Therapeutic goals include maintaining cerebral perfusion and adequate oxygenation to prevent further damage to vital organs. - The most important priority in resuscitation is to manage the hypoxia, acidosis, and hypothermia. - Prevention and management of hypoxia are accomplished by ensuring an adequate airway and respiration, thus improving ventilation (which helps correct respiratory acidosis) and oxygenation. - Arterial blood gases are monitored to evaluate oxygen, carbon dioxide, bicarbonate levels, and pH. - The use of endotracheal intubation with PEEP improves oxygenation, prevents aspiration, and corrects intrapulmonary shunting and ventilation-perfusion abnormalities (caused by aspiration of water). - Because of submersion, the patient is usually hypothermic. A rectal probe or other core measurement device is used to determine the degree of hypothermia. - Prescribed rewarming procedures (e.g., extracorporeal warming, warmed peritoneal dialysis, inhalation of warm aerosolized oxygen, torso warming) are started during resuscitation. - Intravascular volume expansion and inotropic agents are used to treat hypotension and impaired tissue perfusion. - ECG monitoring is initiated, because dysrhythmias frequently occur. - An indwelling urinary catheter is inserted to measure urine output. - Hypothermia and accompanying metabolic acidosis may compromise kidney function. - Nasogastric intubation is used to decompress the stomach and to prevent the patient from aspirating gastric contents. - Even if the patient appears healthy, close monitoring continues with serial vital signs, serial arterial blood gas values, ECG monitoring, intracranial pressure assessments, serum electrolyte levels, intake and output, and serial chest x-rays. - After a nonfatal drowning, the patient is at risk for complications such as hypoxic or ischemic cerebral injury, ARDS, and life-threatening cardiac arrest. The patient is also at heightened risk for aspiration; vomiting frequently occurs in patients requiring rescue breathing and in up to 86% of patients requiring CPR

Spider Bites

- There are two venomous spiders found in the United States that may interact with humans: the brown recluse and the black widow. Both are usually found in dark places such as closets, woodpiles, and attics, as well as in shoes. - Brown recluse spider bites are painless. Systemic effects such as fever and chills, nausea and vomiting, malaise, and joint pain develop within 24 to 72 hours. The site of the bite may appear reddish to purple in color within 2 to 8 hours after the bite. Necrosis occurs in the next 2 to 4 days in approximately 10% of cases. The center of the bite may become necrotic, and surgical débridement may be necessary. Wound care consists of cleansing with soap and water, and hyperbaric oxygen treatments may be helpful. Most wounds heal within 2 to 3 months. - Black widow spider bites feel like pinpricks. Systemic effects usually occur within 30 minutes—much more rapidly than with brown recluse spider bites. Signs and symptoms include abdominal rigidity, nausea and vomiting, hypertension, tachycardia, and paresthesias. Severe pain also develops within 60 minutes and increases over 1 to 2 days. Treatment involves application of ice to the site to decrease swelling and discomfort, along with elevation and assessment of tetanus immunization status. Analgesic agents and benzodiazepines may relieve muscle spasms. Cardiopulmonary monitoring is essential. Antivenin is effective for severe black widow spider bites. This antivenin is horse serum based; therefore, testing for sensitivity must be performed prior to administration

As brain tissue swells within the rigid skull, several mechanisms attempt to compensate for the increasing ICP.

- These compensatory mechanisms include autoregulation as well as decreased production and flow of CSF. - Autoregulation refers to the brain's ability to change the diameter of its blood vessels to maintain a constant cerebral blood flow during alterations in systemic blood pressure. This mechanism can be impaired in patients who are experiencing a pathologic and sustained increase in ICP.

Causes of airway obstruction

- Upper airway obstruction has a number of causes, including aspiration of foreign bodies, anaphylaxis, viral or bacterial infection, trauma, and inhalation or chemical burns. - For older adult patients, especially those in extended care facilities, sedative and hypnotic medications, diseases affecting motor coordination (e.g., Parkinson disease), and mental dysfunction (e.g., dementia, intellectual disability) are risk factors for asphyxiation by food. - As patients age, atrophy of the posterior pharynx occurs, resulting in aspiration or difficulty swallowing. In adults, aspiration of a bolus of meat is the most common cause of airway obstruction. - Peritonsillar abscesses, epiglottitis, and other acute infectious processes of the posterior pharynx can also result in airway obstruction. - The most common causes of airway obstruction are from an allergic reaction (i.e., causing laryngospasm), infection, or angioedema

Intraventricular Catheter (aka Ventriculostomy

- Used to monitor ICP, and allows the CSF to drain and treat intracranial hypertension. - It is a fine bore catheter is inserted into lateral ventricle of the brain and records the pressure in the form of an electrical impulse. - Complications include infection, meningitis, ventricular collapse, occlusion of catheter by tissue and blood, and monitoring issues.

The Patient Who Has Undergone Intracranial Surgery: Monitoring for potential complications

- These include increased ICP, bleeding and hypovolemic shock, altered fluid and electrolyte balance (e.g., water intoxication and diabetes insipidus), infection, identification of a CSF leak, and seizures. - If signs and symptoms of increased ICP occur, efforts to decrease the ICP are initiated: alignment of the head in a neutral position without flexion to promote venous drainage, elevation of the head of the bed to 30 degrees (when prescribed), administration of mannitol (an osmotic diuretic), and possible administration of pharmacologic paralyzing agents. - Oral fluids are usually resumed after the first 24 hours. - Patients undergoing surgery for brain tumors often receive large doses of corticosteroids and are at risk for hyperglycemia. - Serum glucose levels are measured every 4 to 6 hours, and sliding scale insulin is prescribed as needed. These patients are prone to stress ulcers, so histamine-2 receptor antagonists (H2 blockers) are prescribed to suppress the secretion of gastric acid. - If the surgical site is near to (or causes edema to) the pituitary gland and hypothalamus, the patient may develop symptoms of diabetes insipidus, which is characterized by excessive urinary output, elevated serum osmolality, decreased urine osmolality, hypernatremia, and a low urine-specific gravity. The urine-specific gravity is measured hourly, and fluid intake and output are monitored. Fluid replacement must compensate for urine output, and serum potassium levels must be monitored. - SIADH, which results in water retention with hyponatremia and serum hypo-osmolality, occurs in a wide variety of CNS disorders (e.g., brain tumor, head trauma) causing fluid disturbances. Nursing management includes careful intake and output measurements, specific gravity determinations of urine, and monitoring of serum and urine electrolyte levels while following directives for fluid restriction. SIADH is usually self-limited. - After a craniotomy, the patient is instructed to avoid coughing, sneezing, or nose blowing, which can cause CSF leakage by creating pressure on the operative site. - Any sudden discharge of fluid from a cranial incision is reported at once, because a large leak requires surgical repair. Attention should be paid to the patient who complains of a salty taste or "postnasal drip," because this can be caused by CSF trickling down the throat.

After initial focused assessment to determine actual or potential threats to life, proceed with more detailed assessment.

- This is performed in a systematic approach to decrease the time needed to identify potential threat to like and limit the threats of overlooking conditions. - Use of primary and secondary survey for all patients.

Tick Bites

- Tick bites usually occur in grassy or wooded areas. It is important to learn the place where the bite occurred as well as the location of the bite on the body. - Ticks can carry diseases such as Rocky Mountain spotted fever, tularemia, west Nile virus, and Lyme disease. - Ticks transmit pathogens through their saliva - The tick should be removed with tweezers using a straight upward pull, and the patient should be informed of the signs and symptoms of diseases carried by ticks, especially if the patient lives in or has visited an area endemic for tick-related diseases (e.g., Lyme disease). - Lyme disease has three stages. Stage I may present with a classic "bull's-eye" rash (i.e., erythema migrans) that typically can be found in the axilla, groin, or thigh area and that appears within 4 weeks after the tick bite, with a peak manifestation time of 7 days after the bite. - Classically, this rash is at least 5 cm in diameter with bright red borders. It is accompanied by flulike signs and symptoms that may include chills, fever, myalgia, fatigue, and headache. Without treatment, the rash subsides within 3 to 4 weeks. - The rash and flulike manifestations can be significantly reduced within days if prompt treatment with antibiotic agents (e.g., doxycycline [Vibramycin]) is initiated. - If antibiotics are not given, stage II Lyme disease may present within 4 to 10 weeks following the tick bite and may manifest with joint pain, memory loss, poor motor coordination, adenopathy, and cardiac abnormalities. - Facial nerve palsy is the most common manifestation of stage II Lyme disease - Stage III can begin anywhere from weeks to more than a year after the bite and has serious long-term chronic sequelae, including arthritis, neuropathy, myalgia, and myocarditis. - Even after appropriate treatment with antibiotics, 10% to 20% of patients may experience long-term effects including fatigue and arthralgias; some experience neurologic symptoms that may persist for over 10 years

Small Pox Treatment

- Treatment includes supportive care with antibiotic agents for any additional infection. - The patient must be isolated with the use of transmission precautions. - Laundry and biologic wastes should be autoclaved before being washed with hot water and bleach. - Standard decontamination of the room is effective. - All people who have household or face-to-face contact with the patient after the fever begins should be vaccinated within 4 days to prevent infection and death. - A patient with a temperature of 38°C (101°F) or higher within 17 days after exposure must be placed in isolation. - Cremation is preferred for all deaths, because the virus can survive in scabs for up to 13 years

Brain Abscess: Medical Management

- Treatment is aimed at controlling increased ICP, draining the abscess, and providing antimicrobial therapy directed at the abscess and the main source of infection. - Antibiotics should be started as soon as possible and thus the initial antibiotic started typically is ceftriaxone, which will be adjusted based on the culture and sensitivity results. - Corticosteroids may be prescribed to help reduce the inflammatory cerebral edema if the patient shows evidence of an increasing neurologic deficit. - Anticonvulsant medications may be prescribed to prevent or treat seizures - A stereotactic CT-guided aspiration may be used to drain the abscess and identify the causative organism. Surgical excision is the preferred method, but is not done as often as needle aspiration due to higher risk of neurologic complications

Triage in disasters

- Triage is the sorting of patients to determine the priority of their health care needs and the proper site for treatment. - In nondisaster situations, health care workers assign a high priority and allocate the most resources to those who are the most critically ill. However, in a disaster, when health care providers are faced with a large number of casualties, the fundamental principle guiding resource allocation is to do the greatest good for the greatest number of people. - Decisions are based on the likelihood of survival and consumption of available resources. - The triage officer rapidly assesses those injured at the disaster scene. Patients are immediately tagged and transported or given lifesaving interventions. One person performs the initial triage while other EMS personnel perform immediate lifesaving measures (e.g., intubation) and transport patients. - Staff should control all entrances to the acute care facility so that patients who are incoming are directed to the triage area first. - Some patients who have already been seen in the field may be reclassified in the triage area based on their current presentation. - Triage categories separate patients according to severity of injury. - A special color-coded tagging system is used during an MCI so that the triage category is immediately obvious. - The North Atlantic Treaty Organization (NATO) triage system is one that is widely used. It consists of four colors: red, yellow, green, and black. Each color signifies a different level of priority.

Signs and symptoms of airway obstruction

- Typically, a person with a foreign-body airway obstruction cannot speak, breathe, or cough. - The patient may clutch the neck between the thumb and fingers (i.e., universal distress signal). - Other common signs and symptoms include choking, apprehensive appearance, refusing to lie flat, inspiratory and expiratory stridor, labored breathing, the use of accessory muscles (suprasternal and intercostal retraction), flaring nostrils, increasing anxiety, restlessness, and confusion. - Cyanosis and loss of consciousness, which develop as hypoxia worsens, are late signs.

Vesicants

- Vesicants are chemicals that cause blistering and result in burning, conjunctivitis, bronchitis, pneumonia, hematopoietic suppression, and death. - Examples of vesicants include lewisite, phosgene, nitrogen mustard, and sulfur mustard. - Vesicants were the main incapacitating agents, resulting in minimal (less than 5%) death but large numbers of injuries - Liquid sulfur mustard was the most frequently used vesicant in these conflicts. - The initial presentation after exposure to a vesicant is similar to that of a large superficial to partial-thickness burn in the warm and moist areas of the body (i.e., perineum, axillae, antecubital spaces). - There is stinging and erythema for approximately 24 hours, followed by pruritus, painful burning, and small vesicle formation after 2 to 18 hours. These vesicles can coalesce into large, fluid-filled bullae. - Lewisite and phosgene result in immediate pain after exposure. Tissue damage occurs within minutes. - If the eye is exposed, there is pain, photophobia, lacrimation, and decreased vision. This progresses to conjunctivitis, blepharospasm, corneal ulcer, and corneal edema. - Respiratory effects are more serious and often are the cause of mortality with vesicant exposure. Purulent fibrinous pseudomembrane discharge may cause obstruction of the airways. - Bacterial pneumonia may be the cause of death within approximately a week of pulmonary exposure - Gastrointestinal exposure may cause nausea and vomiting, leukopenia, and upper gastrointestinal bleeding. - Appropriate decontamination includes soap and water. Scrubbing and the use of hypochlorite solutions should be avoided because they increase penetration. Once the substance has penetrated, it cannot be removed. - Eye exposure requires copious irrigation. - For respiratory exposure, intubation and bronchoscopy to remove necrotic tissue are essential. - With lewisite exposure, dimercaprol (BAL In Oil) is administered IV for systemic toxicity and topically for skin lesions. - All persons with sulfur mustard exposures should be monitored for 24 hours for delayed (latent) effects

Monitoring ICP

- When ICP is monitored with a fluid system, the transducer is calibrated at a particular reference point, usually 2.5 cm (1 inch) above the ear with the patient in the supine position; this point corresponds to the level of the foramen of Monro. - For subsequent pressure readings, the head should be in the same position relative to the transducer. - When technology is associated with patient management, the nurse must be certain that the technologic equipment is functioning properly. The most important concern must be the patient to whom equipment is attached. The patient and family must be informed about the technology and the goals of its use. The patient's response is monitored, and appropriate comfort measures are implemented to ensure that the patient's stress is minimized.

Caring for People With Disabilities During a Disaster

- When a disaster occurs, the multiple agencies involved attempt to provide food, water, and shelter to all those affected. - People with disabilities have specific needs that require attention. It is recommended that people with disabilities have a personal support network to check on them after a disaster and to provide needed assistance. They should also have a backup system and an evacuation plan. - Agencies need to be aware that service animals are also affected during a disaster and may be brought to shelters with their companions. - Evacuation assistance is imperative for people with disabilities. - Directions to personal equipment (e.g., communication aids, medications, oxygen) should be available to rescue personnel. - In a rapid evacuation, mobility devices, oxygen, suction, and medications will be needed at the shelters. - Special efforts to keep those with vision or hearing impairment informed should be implemented. People skilled in sign language are also valuable resources during a disaster.

Retraining the bladder

- When an indwelling urinary catheter is in place, the detrusor muscle does not actively contract the bladder wall to stimulate emptying because urine is continuously draining from the bladder. As a result, the detrusor may not immediately respond to bladder filling when the catheter is removed, resulting in either urine retention or urinary incontinence. - Immediately after the indwelling catheter is removed, the patient is placed on a timed voiding schedule, usually every 2 to 3 hours. - The bladder is then scanned using a portable ultrasonic bladder scanner, and if the bladder has not emptied completely, straight catheterization may be performed - After a few days, as the nerve endings in the bladder wall become resensitized to the bladder filling and emptying, bladder function usually returns to normal. - If the patient has had an indwelling catheter in place for an extended period (e.g., greater than 1 month), bladder retraining will take longer; in some cases, function may never return to normal, and long-term intermittent catheterization may become necessary.

Assisting With Intermittent Self-Catheterization

- When educating the patient about how to perform self-catheterization, the nurse must use aseptic technique to minimize the risk of cross-contamination. However, the patient may use a "clean" (nonsterile) technique at home, where the risk of cross-contamination is reduced. - Either antibacterial liquid soap or povidone-iodine (Betadine) solution is recommended for cleaning urinary catheters at home. - The catheter is thoroughly rinsed with warm tap water after soaking in the cleaning solution. It must dry before reuse. It should be kept in its own container, such as a plastic food storage bag. - In educating the patient, the nurse emphasizes the importance of frequent catheterization and emptying the bladder at the prescribed time. - The average daytime clean intermittent catheterization schedule is every 4 to 6 hours and just before bedtime. If the patient is awakened at night with an urge to void, catheterization may be performed after an attempt is made to void normally. - Patients who follow an intermittent catheterization routine should consult a primary provider at regular intervals to assess urinary function and to detect complications. - An alternative to self-catheterization is creation of the Mitrofanoff umbilical appendicovesicostomy, which provides easy access to the bladder but requires an extensive surgical procedure. In this procedure, the bladder neck is closed and the appendix is used to create access to the bladder from the skin surface through a submucosal tunnel created with the appendix. One end of the appendix is brought to the skin surface and used as a stoma, and the other end is tunneled into the bladder. The appendix serves as an artificial urinary sphincter when an alternative is necessary to empty the bladder. A surgically prepared continent urine reservoir with a sphincter mechanism is required in cases of bladder cancer and severe interstitial cystitis. Various types of urinary diversions may be used when a radical cystectomy (surgical removal of the bladder) is necessary

Fluid replacement for hemorrhage

- Whenever a patient is hemorrhaging—whether externally or internally—a loss of circulating blood results in a fluid volume deficit and decreased cardiac output. - Typically, two large-gauge IV catheters are inserted, preferably in an uninjured extremity, to provide a means for fluid and blood replacement. - Blood samples are obtained for analysis, typing, and cross-matching. - Replacement fluids are given as prescribed, depending on clinical estimates of the type and volume of fluid lost. - Replacement fluids may include isotonic electrolyte solutions (e.g., lactated Ringer's, normal saline), colloids, and blood component therapy. - The infusion rate is determined by the severity of the blood loss and the clinical evidence of hypovolemia. Any blood replacement therapy should be given via warmer when possible, because administration of large amounts of blood that has been refrigerated has a core cooling effect that may lead to cardiac arrest and coagulopathy.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. 1.Keeping the linens wrinkle-free under the client 2.Preventing unnecessary pressure on the lower limbs 3.Limiting bladder catheterization to once every 12 hours 4.Turning and repositioning the client at least every 2 hours 5.Ensuring that the client has a bowel movement at least once a week

1, 2, 4

Initial evaluation of snake bite in the ED is performed quickly and includes information about the following:

- Whether the snake was venomous or nonvenomous; discourage bringing the snake for identification—even a dead snake's venom is poisonous. Do not handle any snake brought to the ED. If the snake is transported to the ED, caution should be taken because the snake is frequently in a stunned, not dead, state. The bite reflex can remain intact for up to 90 minutes after the death of the snake. - Where and when the bite occurred and the circumstances of the bite. - Sequence of events, signs, and symptoms (fang punctures, pain, edema, and erythema of the bite and nearby tissues). - Severity of poisonous effects. Call the local poison control phone number to gain access to information about an exotic snakebite presentation and management, as necessary. The poison control center may also be able to assist with retrieving antivenin for these particular species. - Vital signs. - Circumference of the bitten extremity or area at several points. The circumference of the extremity that was bitten is compared with the circumference of the opposite extremity. - Laboratory data (complete blood count, urinalysis, and coagulation studies).

Caring for Families

- families and friends should not be allowed in the triage or treatment area - they should be in a designated area staffed by available social workers counselors therapist or clergy - Friends and family members converging on the scene must be cared for by the facility. - The public information officer's role is to provide direction for the families and provide them with information as it becomes available. - They may be feeling intense anxiety, shock, or grief and should be provided with information and updates about their loved ones as soon as possible and regularly thereafter. - They should not be in the triage or treatment areas but in a designated area staffed by available social workers, counselors, therapists, or clergy. Access to this area should be controlled to prevent families from being disturbed. - Information regarding loved ones can also be obtained at this time, which assists in identification of both the injured and deceased.

Priority Management in Patients With Multiple Injuries

1. Establish and maintain a patent airway 2. Control hemorrhage 3. Prevent and treat hypovolemic shock 4. Assess for head and neck injuries 5. Evaluate for other injuries- expose and reassess head and neck, chest; assess abdomen, back and extremities. 6. Splint fractures and then reassess pulses and neurovascular status. 7. Perform a more thorough and ongoing examination and assessment; diagnostic studies.

787. The nurse has completed discharge instructions for a client with application of a halo device. Which statement indicates that the client needs further clarification of the instructions? 1."I will use a straw for drinking." 2."I will drive only during the daytime." 3."I will be careful because the device alters balance." 4."I will wash the skin daily under the lamb's wool liner of the vest."

2

In this type of radiation-induced injury decontamination is not necessary and it is not a medical emergency 1. incorporation 2. external irradiation 3. contamination 4. None of the above

2

The ED nurse receives a telephone call and is informed that a tornado has hit a local residential area and numerous casualties have occurred. The victims will be brought to the ED. Which should be the initial nursing action? 1. prepare the triage rooms 2. activate the agency emergency response plan 3. obtain additional supplies from the central supply department 4. obtain additional nursing staff to assist with treating the casualties

2

The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client's peripheral response to pain? 1. Sternal rub 2. Nail bed pressure 3. Pressure on the orbital rim 4. Squeezing of the sternocleidomastoid muscle

2

The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1.Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2.Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3.Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4.Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

2

The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate teaching was effective? Select all that apply. 1.Bites from ticks or deer flies 2.Inhalation of bacterial spores 3.Through a cut or abrasion in the skin 4.Direct contact with an infected individual 5.Sexual contact with an infected individual 6.Ingestion of contaminated undercooked meat

2, 3, 6

The ESI assigns patients into five levels, from level 1 (most urgent) to level 5 (least urgent). With the ESI, patients are assigned to triage levels based on both their acuity and their ________. 1. symptoms 2. resource needs 3. age 4. diagnosis

2.

You know when your patient's temperature reaches this you will stop the cooling interventions in the patient with heat stroke 1. 39 °C 2. 38 °C 3. 37 °C 4. 36 °C

2. 38 °C

In patients with heat stroke, you want to cool them rapidly to this temperature: 1. 40 °C 2. 39 °C 3. 38 °C 4. 37 °C 5. none of the above

2. 39 °C

786. The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? 1.A negative Kernig's sign 2.Absence of nuchal rigidity 3.A positive Brudzinski's sign 4.A Glasgow Coma Scale score of 15

3

A client with terminal cancer arrives at the emergency department dead on arrival (DOA). After an autopsy is prescribed, the client's family requests that no autopsy is performed. Which response to the family is most appropriate? 1."The decision is made by the medical examiner." 2."An autopsy is mandatory for any client who is DOA." 3."I will contact the medical examiner regarding your request." 4."It is required by federal law. Tell me why you don't want the autopsy done?"

3

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? 1.Hyperreflexia 2.Positive reflexes 3.Flaccid paralysis 4.Reflex emptying of the bladder

3

This category of predicted survival of radiation patients have acute onset of vomiting, bloody diarrhea, and shock. 1. possible 2. probable 3. improbable 4. none of the above

3

A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client? 1. Begin to teach relaxation techniques 2. Encourage the client to discuss event 3. Remain with the client until anxiety decreases 4. Place the client in a quiet room alone to decrease stimulation

3.

Name and describe each of the four affects that a blast wave has on a victim:

A blast wave has four effects. These include spalling, which refers to the pressure wave itself; implosion, which refers to rupture of organs from entrapped gases; shearing, which refers to the blast response of different body tissues, dependent on their density; and irreversible work, which refers to the presence of forces that exceed the tensile strength of an organ or tissue.

Head Injury

A broad classification that includes injury to the scalp, skull, or brain 2.5 million people receive head injuries every year in the United States The most common cause of death from trauma Most common cause of brain trauma is falls Groups at highest risk for brain trauma include children 0 to 4 years old, adolescents ages 15 to 19 years, and adults 65 years and older Prevention is the best approach!

jaw-thrust maneuver

A technique used to open the airway of a trauma patient with possible neck or spine injury, face or upper chest. - The jaw-thrust maneuver to open airway of unconscious patient with possible spine or neck injury. The patient lies supine and nurse lies on top of the head, place one hand on each side of the patient's head, rest elbows on surface, grasp patient's lower jaw and lift the jaw upward with both hands without tilting the head and pushing down on the chin with the thumbs to open the mouth. - When the mandible is displaced forward, the tongue is pulled forward and prevent s the obstruction of the tongue from the entrance of the trachea.

A college student goes to the infirmary with a fever, headache, and stiff neck. The nurse suspects the student may have meningitis and has the student transferred to the hospital. If the diagnosis is confirmed, what should the nurse institute for those who have been in contact with this student? (Select all that apply.) A. administration of rifampin (Rifadin) B. administration of ciproflaxocin hydrochloride (Cipro) C. administration of ceftriaxone sodium (Rocephin) D. amoxicillin (Amoxil) E. rofecoxib (Vioxx)

A, B, C

A patient with a SCI at T5 begins to complain of a severe headache and is diaphoretic and nauseated. Which nursing intervention would not be appropriate? A. Place the patient immediately in a sitting position B. Lower the patient to a flat, side lying position C. Assess for bladder distention D. Assess the rectum for a fecal mass

A. Place the patient immediately in a sitting position - When a patient with SCI displays symptoms of autonomic dysreflexia, their body is communicating that there is a problem needing immediate intervention. The nurse should complete a rapid assessment to identify and alleviate the cause. The patient is placed immediately in a sitting position to lower blood pressure. The bladder is emptied immediately via a urinary catheter. If an indwelling catheter is not patent, it is irrigated or replaced with another catheter. The rectum is examined for a fecal mass. If one is present, a topical anesthetic agent is inserted 10 to 15 minutes before the mass is removed because visceral distention or contraction can cause autonomic dysreflexia. Other causes may involve skin pressure or positioning abnormalities

A non-smoking patient present from a house fire with carboxyhemoglobin level of 40%, and a pulse reading of 99%. He is alert but confused; and c/o a headache. What is the priority treatment for this patient? A. Provide 100% oxygen until carboxyhemoglobin level is <10% B. Intubate STAT C. Apply nasal cannula at a 2L/min and administer the cyanide kit D. Administer acetylcysteine prior to hyperbaric (HBO)

A. Provide 100% oxygen until carboxyhemoglobin level is <5% - Give them a non-rebreather

A basic and widely used triage system has several categories. What does an emergent category for a patient mean? A. Signifying potentially life-threatening injuries or illnesses requiring immediate treatment B. Episodic or minor injury or illness in which treatment may be delayed for several hours without increased morbidity C. Serious illness or injury that is not immediately life threatening D. Process of assessing patients to determine management priorities

A. Signifying potentially life-threatening injuries or illnesses requiring immediate treatment - Emergent signifies potentially life-threatening injuries or illnesses requiring immediate treatment. Nonurgent is episodic or minor injury or illness in which treatment may be delayed for several hours without increased morbidity. Urgent is serious illness or injury that is not immediately life threatening. Triage is the process of assessing patients to determine management priorities

Primary Survey: ABCDE

A: airway: establish airway B: breathing: provide adequate ventilation C: circulation: evaluate and restore cardiac output; control hemorrhage, prevent and treat shock D: disability: determine neurologic status; AVPU mnemonic (alert, verbal, pain, unresponsive) E: exposure: undress to assess wounds or areas of injury

What is a major goal for patients with brain injuries?

Achieve as high level of functioning and enhance the quality of life of patients with neurological deficits. - The patient is encouraged to continue the rehabilitation program after discharge, because improvement in status may continue 3 or more years after injury. Changes in the patient with a TBI and the effects of long-term rehabilitation on the family and their coping abilities need ongoing assessment. Continued education and support of the patient and family are essential as their needs and the patient's status change.

Radiation: Death

After manifest illness phase Increased intracranial pressure is a sign of impending death

Increased ICP and bleeding are life threatening to the patient who has undergone intracranial surgery. The following points must be kept in mind when caring for any patient who has undergone such surgery:

An increase in blood pressure and decrease in pulse with respiratory failure may indicate increased ICP. An accumulation of blood under the bone flap (extradural, subdural, or intracerebral hematoma) may pose a threat to life. A clot must be suspected in any patient who does not awaken as expected or whose condition deteriorates. An intracranial hematoma is suspected if the patient has any new postoperative neurologic deficits (especially a dilated pupil on the operative side). In these circumstances, the patient is returned to the operating room immediately for evacuation of the clot, if indicated. Cerebral edema, infarction, metabolic disturbances, and hydrocephalus are conditions that may mimic the clinical manifestations of a clot.

During these crises, family members are encouraged to recognize and talk about their feelings of anxiety. Asking questions is encouraged.

Anxiety and Denial - Honest answers given at the level of the family's understanding must be provided. Although denial is an ego-defense mechanism that protects one from recognizing painful and disturbing aspects of reality, prolonged denial is not encouraged or supported. - The family must be prepared for the reality of what has happened and what may come.

Often, as the patient emerges from coma, a period of lethargy and stupor is followed by a period of agitation. Strategies to preventing injuries include:

Assessing the patient to ensure that oxygenation is adequate and the bladder is not distended. Dressings and casts are checked for constriction Using padded side rails or wrapping the patient's hands in mitts to protect the patient from self-injury and dislodging of tubes. Restraints are used judiciously, because straining against them can increase ICP or cause other injury. Enclosed or floor-level specialty beds may be indicated Avoiding opioids as a means of controlling restlessness, because they depress respiration, constrict the pupils, and alter responsiveness Reducing environmental stimuli by keeping the room quiet, limiting visitors, speaking calmly, and providing frequent orientation information (e.g., explaining where the patient is and what is being done) Providing adequate lighting to prevent visual hallucinations Minimizing disruption of the patient's sleep-wake cycles Lubricating the patient's skin with oil or emollient lotion to prevent irritation due to rubbing against the sheet Using an external sheath catheter for a male patient if incontinence occurs. Because prolonged use of an indwelling catheter inevitably produces infection, the patient may be placed on an intermittent catheterization schedule.

Disasters can present a disparity between the resources of the health care agency and the needs of the victims. This generates ethical dilemmas for nurses and other health care providers. Issues include conflicts related to the following:

Assisted suicide Confidentiality Consent Duty Futile therapy Rationing care Resuscitation Nurses may find it difficult to not provide care to the dying or to withhold information to avoid spreading fear and panic. - Other ethical dilemmas may arise out of health care providers' instincts for self-protection and protection of their families. - Nurses can plan for the ethical dilemmas they will face during disasters by establishing a framework for evaluating ethical questions before they arise and by identifying and exploring possible responses to difficult clinical situations. They can consider how the fundamental ethical principles of nonmaleficence, beneficence, and distributive justice will influence their decisions and care in disaster response

Earthquakes

Associated with multiple aftershocks, tsunami Buildings require tethering in earthquake-prone areas Injuries: Physical injury; dehydration; pulmonary problems

Intermittent Self-Catherization: Male

Assume a Fowler position Lubricate catheter Retract foreskin with one hand, grasp penis with other hand & hold at a right angle to body Insert catheter 15-25 cm until urine begins to flow After urine flow has stopped, remove catheter Soak catheter in cleaning solution Rinse, dry and place in plastic bag or case

Intermittent Self-Catherization: Female

Assume a Fowler position Use mirror to locate urinary meatus Lubricate catheter Insert catheter 7.5 cm in a downward and backward direction After urine flow has stopped, remove catheter Soak catheter in cleaning solution Rinse, dry and place in plastic bag or case

Management of the Client With a Head Injury

Assume cervical spine injury until it is ruled out Do not move the victim after the accident, they are put on a flat board with the head and neck maintained at alignment with axis of the body. Place a cervical collar on the patient until SCI is ruled out Therapy to preserve brain homeostasis and prevent secondary damage: - Treat cerebral edema - Maintain cerebral perfusion; treat hypotension, hypovolemia, and bleeding; monitor and manage ICP - Maintain oxygenation; Make sure the cardiovascular and respiratory function are adequate for cerebral perfusion - Manage fluid and electrolyte balance - Control hemorrhage and hypovolemia and improve blood gasses.

Preventing Infection in the Patient With an Indwelling Urinary Catheter

Avoid contamination of the drainage spout. A receptacle in which to empty the bag is provided for each patient. Avoid routine catheter changes. The catheter is changed only to correct problems such as leakage, blockage, or encrustations. Avoid unnecessary handling or manipulation of the catheter by the patient or staff. Carry out hand hygiene before and after handling the catheter, tubing, or drainage bag. Ensure a free flow of urine to prevent infection. Improper drainage occurs when the tubing is kinked or twisted, allowing pools of urine to collect in the tubing loops. Evaluate the benefit of placing an indwelling urinary catheter versus the risk the patient developing a catheter-associated urinary tract infection. If the collection bag must be raised above the level of the patient's bladder, clamp the drainage tube. This prevents backflow of contaminated urine into the patient's bladder from the bag. Monitor the patient's voiding when the catheter is removed. The patient must void within 8 hours; if unable to void, the patient may require catheterization with a straight catheter. Never disconnect the tubing to obtain urine samples, to irrigate the catheter, or to ambulate or transport the patient. Never irrigate the catheter routinely. If the patient is prone to obstruction from clots or large amounts of sediment, use a three-way system with continuous irrigation. Never leave the catheter in place longer than is necessary to decrease the risk of CAUTI. Obtain a urine specimen for culture at the first sign of infection. To prevent contamination of the closed system, never disconnect the tubing. The drainage bag must never touch the floor. The bag and collecting tubing are changed if contamination occurs, if urine flow becomes obstructed, or if tubing junctions start to leak at the connections. To reduce the risk of bacterial proliferation, empty the collection bag at least every 8 hours through the drainage spout—more frequently if there is a large volume of urine. Use scrupulous aseptic technique during insertion of the catheter. Use a preassembled, sterile, closed urinary drainage system of the smallest catheter size possible to minimize trauma. Wash the perineal area with soap and water at least twice a day; avoid a to-and-fro motion of the catheter. Dry the area well, but avoid applying powder because it may irritate the perineum.

AVPU mnemonic:

A—alert. Is the patient alert and responsive? V—verbal. Does the patient respond to verbal stimuli? P—pain. Does the patient respond only to painful stimuli? U—unresponsive. Is the patient unresponsive to all stimuli, including pain?

Emergency nurses may develop injury prevention programs using a focus similar to the ABCDE approach used in the primary survey in trauma care. In this case, however:

A—describes assessment of the community for common injury mechanisms B—is used to describe building a coalition of key community members C—refers to communicating awareness of the trauma mechanisms and risks prevalent in the local community D—stands for developing and implementing interventions, which may be educational or legislative E—refers to evaluating the injury prevention program soon after it is launched, which may result in either continuation or revision of the program.

The nurse is the first responder after a tornado has destroyed many homes in the community. Which of the following victims should the nurse attend to first? A. A pregnant woman who exclaims, "my baby is not moving" B. A child who is complaining, "my leg is bleeding so bad, I am afraid it will fall off" C. A young child standing next to an adult family member who is screaming "I want my mommy" D. An older victim who is sobbing "my husband is dead"

B

A nurse is performing triage in the Emergency Department (ED). Using the Emergency Severity Index (ESI), in what priority order should the following clients be seen? A. A 27-year-old male self-administered an EpiPen prior to arrival for an anaphylactic reaction and states he feels better now. Vital signs: BP 136/84, HR 102, RR 20, SpO2 97%. B. An 18-year-old female with a suspected medication overdose and a history of depression. She has multiple superficial lacerations to both wrists. RR is 8, and SpO2 on room air is 85%. C. A 12-year-old male fell while skateboarding and has a 4 cm open laceration to his right knee. Immunizations are up to date. D. A 2-year-old female is brought in by her mother for an earache. She has no fever and vital signs are within normal limits for her age.

B. An 18-year-old female with a suspected medication overdose and a history of depression. She has multiple superficial lacerations to both wrists. RR is 8, and SpO2 on room air is 85%. - The client with a drug overdose is unstable and needs to be seen immediately. (ESI 1) A. The client post anaphylactic reaction is high risk for rebound anaphylaxis and requires close monitoring (ESI 2) C. The client with the laceration is stable but will require the use of 1 resource - suturing. (ESI 4). D. The pediatric client will only require a physical exam and no additional resources. (ESI 5).

A workplace explosion has left a 40-year-old man with full thickness burns over 75% of his body. Despite his injuries, the man is conscious. How would this person be triaged? A. Green B. Black C. Red D. Yellow

B. Black - The purpose of triaging in a disaster is to do the greatest good for the greatest number of people. The client would be triaged as black due to the unlikelihood of survival. (2nd/3rd degree burns over 60% of body) Persons triaged as green, yellow, or red have a higher chance of recovery. Red is immediate and a priority one with life-threatening injuries; however, the injuries are survivable with minimal intervention. Yellow is priority two which is delayed. The injuries are significant and require medical care but can wait hours without threat to life or limb. Green is minimal and considered priority three. These injuries are minor, and treatment can be delayed hours to days. Individuals in this group should be moved away from the main triage area

A nurse is caring for a client in a coma who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in ICP? A. Suction the airway B. Elevate the HOB 30 degrees C. Turn client every 2 hours D. Maintain a well-lit room.

B. Elevate the HOB 30 degrees

Isolation Precautions for Biological Terrorism Agents

Biological agents may be delivered or spread in a number of ways. Because off modern travel, spread of infection may occur in areas thousands of miles apart. Health care providers need to be aware of potential signs of biological weapon dissemination. Signs and symptoms are similar to those of common disease process. Isolation practices depend on the infecting agent. Always use standard precautions. Some agents require transmission-based precautions. Terminal disinfection and disposal of wastes depend on the infecting agent.

Flooding

Can accompany other natural disasters Results in home and community destruction Injuries: Nonfatal drowning/drowning (e.g., people swept away in currents); waterborne and vector-borne disease (e.g., shigellosis, Escherichia coli infection, hepatitis A, giardiasis, leptospirosis, malaria, plague, dengue fever); physical injury from debris

Exposure—heat/cold

Cold: Frostbite, hypothermia Heat: Burns, heat exhaustion/stroke

Brain Abscess

Collection of infectious material within brain tissue Bacteria is the most common causative organism Prevent by treating otitis media, rhinosinusitis - They are more frequently diagnosed in people who are immunosuppressed as a result of an underlying disease or the use of immunosuppressive medications.

What is a key component of disaster management?

Communication

For non-critical patients, the primary survey is followed by the secondary survey.

Complete health history, including the history of the current event Head-to-toe assessment (includes a reassessment of airway and breathing parameters and vital signs) Diagnostic and laboratory testing Insertion or application of monitoring devices such as ECG electrodes, arterial lines, or urinary catheters Splinting of suspected fractures Cleansing, closure, and dressing of wounds Performance of other necessary interventions based on the patient's condition * PERFORMED ONLY WHEN THE PATIENT HAS BEEN DETERMINDED TO BE STABLE*

Multisystem Assessment Measures for the Patient With Traumatic Brain Injury: Respiratory

Complete or partial airway obstruction will compromise the oxygen supply to the brain. An altered respiratory pattern can result in cerebral hypoxia. A short period of apnea at the moment of impact can result in spotty atelectasis. Systemic disturbances from head injury can cause hypoxemia. Brain injury can alter brainstem respiratory function. Shunting of blood to the lungs as a result of a sympathetic discharge at the time of injury can cause neurogenic pulmonary edema. Assessment of respiratory function:Auscultate chest for breath soundsNote the respiratory pattern, if possible (not possible if a ventilator is being used)Note the respiratory rateNote whether the cough reflex is intact Arterial blood gas levels Complete blood count Chest x-ray studies Sputum cultures Oxygen saturation using pulse oximetry

Emergency Severity Index (4 Decision Points)

Does this client require immediate life-saving intervention? Is this a client who shouldn't wait? How many resources will this client need? What are the client's vital signs?

According to _____, every emergency department with a Medicare provider agreement must perform a medical screening examination on all patients arriving with an emergency medical complaint if they are acute signs and symptoms could result in serious injury or death if left untreated

Emergency medical treatment and active labor act

Describe the indications for endotracheal intubation:

Endotracheal intubation is indicated to establish an airway for a patient who cannot be adequately ventilated with an oropharyngeal airway, bypassing upper airway obstruction, prevent aspiration, permit connection of the patient to a resuscitation bag or mechanical ventilator, or facilitate the removal of tracheobronchial secretions

Drugs Producing Sedation, Intoxication, or Psychological and Physical Dependence (nonbarbiturate sedatives) management

Endotracheal tube is inserted as a precaution; use assisted ventilation to stabilize and correct respiratory depression. Observe for sudden apnea and laryngeal spasm. Assess for hypotension.Insert indwelling urinary catheter for patient who is comatose; decreased urinary volume is an index of reduced renal flow associated with reduced intravascular volume or vascular collapse.Start volume expansion with saline or dextrose as prescribed. Evacuate stomach contents; lavage (if within 1 hour of ingestion); activated charcoal. Start ECG monitoring. Observe for dysrhythmias. Administer flumazenil (Romazicon), a benzodiazepine antagonist (reversal agent). Refer patient for psychiatric evaluation (potential suicide intent).

T or F: Trauma is the 7th leading cause of death

False - Trauma (an unintentional or intentional wound or injury inflicted on the body from a mechanism against which the body cannot protect itself) is the fourth leading cause of death in the United States. Trauma is the leading cause of death in children and in adults younger than 44 years. The incidence is increasing in adults older than 44 years. Alcohol and drug abuse are often implicated as factors in both blunt and penetrating trauma

T or F: Use ABCs and reduce temperature to 39.6°C as quickly as possible

False - Use ABCs and reduce temperature to 39.0°C as quickly as possible

What is the best method of rewarming in hypothermia?

Forced-air warming blanket

Basilar skull manifestations

Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone. Therefore, they frequently produce hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva. Battle sign—ecchymosis behind the ear Raccoon eyes- swelling and ecchymosis around both eyes CSF leak: Halo sign—ring of fluid around the blood stain from drainage. The halo sign can be used to detect CSF but not exclusive. If there is clear drainage from the nose, then it can be checked for glucose. CSF will test positive for glucose. - Basal skull fractures are suspected when CSF escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea). - Drainage of CSF is a serious problem, because meningeal infection can occur if organisms gain access to the cranial contents via the nose, ear, or sinus through a tear in the dura.

Encephalitis Manifestations

Headache, fever, confusion, hallucinations Vector borne—rash, flaccid paralysis, Parkinson-like movements Aches, fatigue, stiffness Drowsiness, coma, paralysis, seizures, ataxia, and psychoses Focal neurologic symptoms reflect the areas of cerebral inflammation and necrosis and include fever, headache, behavioral changes, focal seizures, dysphasia, hemiparesis, and altered LOC - The initial symptoms of herpes simplex encephalitis include fever, headache, confusion, and hallucinations.

Use the following questions to elicit information about the circumstances surrounding the possibility of food poisoning:

How soon after eating did the symptoms occur? (Immediate onset suggests chemical, plant, or animal poisoning.) What was eaten in the previous meal? Did the food have an unusual odor or taste? (Most foods causing bacterial poisoning do not have unusual odor or taste.) Did anyone else become ill from eating the same food? Did vomiting occur? What was the appearance of the vomitus? Did diarrhea occur? (Diarrhea is usually absent with botulism and with shellfish or other fish poisoning.) Are any neurologic symptoms present? (These occur in botulism and in chemical, plant, and animal poisoning.) Does the patient have a fever? (Fever is characteristic in salmonella, ingestion of fava beans, and some fish poisoning.)

Cocaine manifestations

Increased heart rate and blood pressure Hyperpyrexia Seizures Sluggish, dilated pupillary response Muscle rigidity Increased energy, agitation, aggression Ventricular dysrhythmias Intense euphoria, then anxiety, sadness, insomnia, and sexual indifference Cocaine hallucinations with delusions Psychosis with extreme paranoia and ideas of persecution Hypervigilance Chronic psychotic symptoms may persist. Overall psychotic symptoms are short-lived compared to methamphetamines

Multisystem Assessment Measures for the Patient With Traumatic Brain Injury: GI

Injury to the GI tract can result in paralytic ileus. Constipation can result from bed rest, NPO status, fluid restriction, and opioids given for pain control. Bowel incontinence is related to the patient's unconscious state or altered mental state. Assessment of abdomen for bowel sounds and distention Monitoring for decreased hemoglobin

Bladder Retraining After Indwelling Catheterization

Instruct the patient to drink a measured amount of fluid from 8 am to 10 pm to avoid bladder overdistention. Offer no fluids (except sips) after 10 pm. At specific times, ask the patient to void by applying pressure over the bladder, tapping the abdomen, or running water to trigger the bladder. Immediately after the voiding attempt, perform a bladder scan to determine the amount of residual urine. Measure the volumes of urine voided. Palpate the bladder at repeated intervals to assess for distention. Instruct the patient who has no voiding sensation to be alert to any signs that indicate a full bladder, such as perspiration, cold hands or feet, or feelings of anxiety. Perform straight catheterization, as prescribed, usually for residual urine of >300 mL. Lengthen the intervals between catheterizations as the volume of residual urine decreases. Catheterization is usually discontinued when the volume of residual urine is <100 mL

Labs for trauma

Labs: Lactate, ABGs, coagulant therapy, H&H, CBC, CMP, and type and screen

Any disaster or mass casualty incident can be expected to involve members of diverse religious, ethnic, and cultural groups or may be targeted at and predominately affect a specific religious or ethnic group. Health care providers likewise include members of all religious, ethnic, and cultural backgrounds and should bear in mind that victims may have needs relating to the following:

Language difficulties that increase fears and frustrations Specific religious practices related to medical treatment, hygiene, or diet Specific places/times for prayer Rituals about handling the dead Timing of funeral services Family roles and extended family importance Privacy

Characteristics of Chemicals: Latency

Latency is the time from absorption to the appearance of signs and symptoms. Sulfur mustards and pulmonary agents have the longest latency, whereas other vesicants, nerve agents, and cyanide produce signs and symptoms within seconds.

Tylenol manifestations

Lethargy to encephalopathy and death GI upset, diaphoresis Right upper quadrant pain Abnormal liver function tests, prolonged prothrombin time, increased bilirubin, disseminated intravascular coagulation Hepatomegaly leading to liver failure Metabolic acidosis Hypoglycemia Stage I—within 24 hours; GI irritation, possible metabolic acidosis and coma if severe ingestion Stage II—24-48 hours; monitor liver and coagulation studies. Stage III—after 48 hours; hepatic encephalopathy/jaundice, vomiting, right upper quadrant pain, coagulopathy, hypoglycemia, acute kidney injury

Tylenol management

Maintain airway. Obtain acetaminophen level. Levels ≥140 mg/kg are toxic. Laboratory studies—liver function tests, prothrombin time/partial thromboplastin time, complete blood count, blood urea nitrogen, creatinine. Lavage (if within 1 hour after ingestion); activated charcoal. Prepare for possible hemodialysis, which clears acetaminophen but does not halt liver damage. Administer N-acetylcysteine (Mucomyst) as soon as possible. N-acetylcysteine replenishes essential liver enzymes and requires a total of 18 doses every 4 hours. Charcoal absorbs N-acetylcysteine; do not administer together. Repeat N-acetylcysteine dose if patient vomits. Refer patient for psychiatric evaluation (potential suicide intent).

Improving Mobility (SCI)

Maintain proper body alignment Turn only if spine is stable and as indicated by physician * Monitor blood pressure with position changes, Especially orthostatic hypotension* PROM at least four times a day The feet are prone to footdrop; therefore, various types of splints are used to prevent footdrop. When used, the splints are removed and reapplied every 2 hours. Patients with lesions above the midthoracic level have loss of sympathetic control of peripheral vasoconstrictor activity, leading to hypotension. These patients may tolerate changes in position poorly and require monitoring of blood pressure when positions are changed. Use neck brace or collar, as prescribed, when client is mobilized Move gradually to erect position Prevent contractures: Contractures and other complications may be prevented by range-of-motion exercises that help preserve joint motion and stimulate circulation. Passive range-of-motion exercises should be implemented as soon as possible after injury. Toes, metatarsals, ankles, knees, and hips should be put through a full range of motion at least four, or ideally five, times daily. - For most patients who have a cervical fracture without neurologic deficit, reduction in traction followed by rigid immobilization for 6 to 8 weeks restores skeletal integrity. These patients are allowed to move gradually to an erect position. A neck brace or molded collar is applied when the patient is mobilized after traction is removed

Interventions to ensure an adequate exchange of air include the following:

Maintaining the patient who is unconscious in a position that facilitates drainage of oral secretions, with the head of the bed elevated about 30 degrees to decrease intracranial venous pressure Establishing effective suctioning procedures (pulmonary secretions produce coughing and straining, which increase ICP) Guarding against aspiration and respiratory insufficiency Closely monitoring arterial blood gas values to assess the adequacy of ventilation. The goal is to keep blood gas values within normal limits to ensure adequate cerebral blood flow. Monitoring the patient who is receiving mechanical ventilation for pulmonary complications such as acute respiratory distress syndrome and pneumonia

Client Outcomes (Brain injury)

Maintenance of patent airway Normal CPP Fluid and electrolyte balance Adequate nutritional status Prevention of secondary injury Maintenance of normal temperature Maintenance of skin integrity Improvement of cognitive function Prevention of sleep deprivation Effective family coping Support with rehabilitation Absence of complications Achieve highest level of function

Tornadoes

Minimal warning, fast moving (approximately 30 mph and travel approximately 20 km) Massive destruction, shelter loss Injuries: Physical injury; blastlike effects from pressure.

Promotion of Effective Breathing and Airway Clearance (SCI)

Monitor carefully to detect potential respiratory failure: observing the patient, measuring vital capacity, monitoring oxygen saturation through pulse oximetry, lung sounds and monitoring arterial blood gases. Early and vigorous pulmonary care to prevent and remove secretions Suctioning may be indicated, but it should be used with caution to avoid stimulating the vagus nerve and producing bradycardia and cardiac arrest. Breathing exercises to increase the strength and endurance of the inspiratory muscles, particularly the diaphragm. Assisted coughing, incentive spirometer, Chest physiotherapy If the patient cannot cough effectively because of decreased inspiratory volume and inability to generate sufficient expiratory pressure, chest physiotherapy and assisted coughing may be indicated. Assisted coughing promotes clearing of secretions from the upper respiratory tract and is similar to the use of abdominal thrusts to clear an airway. Assisted coughing can be more effective than traditional suctioning because traditional suctioning clears the right mainstem bronchus, whereas sites for atelectasis and pneumonia are most commonly in the left lower lung lobe Humidification and hydration are important to prevent secretions from becoming thick and difficult to remove even with coughing. Monitor for infection= cough, fever, dyspnea Ascending edema of the spinal cord in the acute phase may cause respiratory difficulty that requires immediate intervention. Therefore, the patient's respiratory status must be monitored closely.

Other management of increased ICP

Monitor for Secondary Complications Lab's electrolytes, I&O, UA SIADH low urine output and low serum sodium bc body is hanging onto water DI high urine output and high serum sodium, dehydrated and low level of ADH and diluted urine. - hyponatremia serum and hypo-osmolarity and urine osmolality

Assessment of the Client With SCI

Monitor respirations and breathing pattern: Assist the client with coughing by applying abdominal pressure. Teach them how to use IS. Chest physiotherapy is also helpful. Vital signs: Watch for orthostatic hypotension. Lung sounds and cough Monitor for changes in motor or sensory function; report immediately Assess for spinal shock: Spinal shock with bradycardia and hypotension must be managed to keep MAP above 85 to prevent further damage to SC. Monitor for bladder retention or distention, gastric dilation, and ileus Skin integrity Prevention: ulcers, VTE, orthostatic hypotension, autonomic dysreflexia. Position changes every 2 hours. - A detailed neurologic examination is performed. - Diagnostic x-rays and CT scanning are usually performed initially. An MRI scan may be ordered as a further workup if a ligamentous injury is suspected, because significant spinal cord damage may exist even in the absence of bony injury - If an MRI scan is contraindicated, a myelogram may be used to visualize the spinal axis.

B5. When a patient sustains a head injury and is admitted to the hospital for observation, what will be monitored?

Monitoring includes observing the patient for a decrease in LOC, worsening headache, dizziness, seizures, abnormal pupil response, vomiting, irritability, slurred speech, and numbness or weakness in the arms and legs.

MCI Triage Considerations: The Nurse's Role

Nurse's role varies during disaster May be asked to take on duties outside of their area of expertise: intubate, insert chest tube, suture May serve as triage officer Nurses must strive to maximize client safety Be aware of state regulations Disaster management- must know agency's response plan

Characteristics of Chemicals: Persistence

Persistence means that the chemical is less likely to vaporize and disperse. More volatile chemicals do not evaporate very quickly. Most industrial chemicals (e.g., cyanide) are not very persistent. Weaponized agents (chemicals developed as weapons by the military or terrorists [e.g., mustard gas]) are more likely than industrial chemicals to penetrate skin and mucous membranes and also cause secondary exposure.

Meningitis Medical Management

Prevention with meningococcal vaccine Swab nasopharyngeal mucosa for culture Cultures before antibiotics Early administration of high doses of appropriate IV antibiotics for bacterial meningitis Dexamethasone Treatment for dehydration, shock, and seizures Treat ICP as necessary - Labs: CBC, CSF blood culture. - ABCs, and neuro assessments. - Manage pain. - IV fluids and drugs. -ROM every 4 hours. - Monitor for complications. - Droplet precautions for bacterial meningitis. - Instituting infection control precautions until 24 hours after initiation of antibiotic therapy (oral and nasal discharge is considered infectious) - Assisting with pain management due to overall body aches and neck pain - Assisting with getting rest in a quiet, darkened room - Implementing interventions to treat the elevated temperature, such as antipyretic agents and cooling blankets - Encouraging the patient to stay hydrated either orally or peripherally.

B3. What is the difference between primary and secondary brain injury?

Primary injury is the initial damage to the brain that results from the traumatic event. This may include contusions, lacerations, and torn BV due to impact, acceleration/deccelerations, or foreign object penetration. - Secondary injury evolves over the ensuing hours and days following the event and results from inadequate delivery of nutrients and oxygen to the cells. These processes include intracranial hemorrhage, cerebral edema, increased ICP, hypoxic brain damage, and infection.

The nurse assists the patient to compensate for sensory and perceptual alterations that occur with SCI. The intact senses above the level of the injury are stimulated through touch, aromas, flavorful food and beverages, conversation, and music. Additional strategies include the following:

Providing glasses to enable the patient to see from the supine position Encouraging the use of hearing aids, if indicated, to enable the patient to hear conversations and environmental sounds Providing emotional support to the patient and family Educating the patient and family about strategies to compensate for, or cope with, sensory deficits

Meningitis Nursing Management

Safety: Clients going to college require vaccine Infection control precautions: Droplet precautions and wash hands Frequent or continual assessment, including VS and LOC Protect client from injury related to seizure activity or altered LOC Pain and fever management Monitor daily weight, serum electrolytes, urine volume, specific gravity, and osmolality Supportive care Measures to facilitate coping of client and family

Laboratory studies that aid in assessment of intra-abdominal injuries include the following:

Serial hemoglobin and hematocrit levels to evaluate trends reflecting the presence or absence of bleeding Lactate to determine acidosis and need for continued resuscitation Arterial blood gas (ABG) for pH (acidosis), base deficit for resuscitation evaluation, and ventilation parameters (PaCO2, PaO2) International normalized ratio (INR) to identify coagulopathy or presence of chemically induced anticoagulation White blood cell (WBC) count to detect elevation (generally associated with trauma)

A patient is transported to the ED via EMS for HA, V, and progressive confusion after a fall three days ago. Which of the following head injuries is the most likely cause of these symptoms? A. Concussion B. Epidural hematoma C. Subdural hematoma

Subdural hematoma

opioids management

Support respiratory and cardiovascular functions. Establish IV lines; obtain blood for chemical and toxicologic analysis. Patient may be given bolus of glucose to eliminate possibility of hypoglycemia. Administer narcotic antagonist (naloxone hydrochloride IV, IM [Narcan]) as prescribed to reverse severe respiratory depression and coma. Continue to monitor level of responsiveness and respirations, pulse, and blood pressure. Duration of action of naloxone hydrochloride is shorter than that of heroin; repeated dosages may be necessary. Send urine for analysis; opioids can be detected in urine. Obtain an ECG. Do not leave patient unattended; he or she may lapse back into coma rapidly. Clinical status may change from minute to minute. Hemodialysis may be indicated for severe drug intoxication. Activated charcoal may be considered if opioids were taken orally and if the patient is alert. Monitor for pulmonary edema, which is frequently seen in patients who abuse/overdose on narcotics. Refer patient for psychiatric and drug rehabilitation evaluation before discharge.

The Nurse's Role in Disaster Response Plans

The Nurse's Role in Disaster Response Plans - Nurses may be asked to perform duties outside their areas of expertise and may take on responsibilities normally held by physicians or advanced practice nurses. - A nurse may perform wound débridement or suturing. - A nurse may serve as the triage officer. In these situations, it is imperative that nurses strive to maximize patient safety and be aware of state regulations related to nursing practice. - Although the exact role of a nurse in disaster management depends on the specific needs of the facility at the time, it should be clear which nurse or physician is in charge of a given patient care area and which procedures each individual nurse may or may not perform. - Assistance can be obtained through the HICS, and nonmedical personnel can provide services where possible. For example, family members can provide nonskilled interventions for their loved ones. - Nurses should remember that nursing care in a disaster focuses on essential care from a perspective of what is best for all patients. In addition, acquiring knowledge of the hospital disaster plan, participating in drills, and honing competencies relating to disaster management are essential - Nurse leaders/administrators should be cognizant of potential security issues and assess and plan for surge capacity capability and in-house resources such as water, supplies, pharmaceuticals, and generator power. They also should predetermine means to evacuate the hospital if necessary, including an ultimate destination or destinations. The hospital must take into account in its plans shortages of all kinds—staff, medications, water/food, and equipment - New settings and atypical roles for nurses arise during a disaster—for example, the nurse may provide shelter care in a temporary housing area or bereavement support and assistance with identification of deceased loved ones. People may require crisis intervention, or the nurse may participate in counseling other staff members and in Critical Incident Stress Management (CISM). Special care may be warranted for at-risk populations during a disaster

What role does incident Command System perform in the event of a specific local mass casualty incident?

The incident Command System as a management tool for organizing personnel, facilities, equipment, and communication for any emergency. It's activation during emergencies is mandated by the federal government. Successful incident management requires equipment compatibility, effective communication, adequate distribution of resources, and clear differentiation of members rules. The ICS ensures that any hazardous substances used during an MCI are identified promptly and that appropriate personal protection equipment is distributed. In addition to all of these responsibilities, the ICS is also responsible for determining when an MCI has ended.

Multisystem Assessment Measures for the Patient With Traumatic Brain Injury: Cardio

The patient may develop cardiac dysrhythmias, tachycardia, or bradycardia. The patient may develop hypotension or hypertension. Because of immobility and unconsciousness, the patient is at high risk for DVT and PE. Fluid and electrolyte imbalance can be related to several problems, including alterations in antidiuretic hormone secretion, the stress response, or fluid restriction. Specific conditions may occur:Diabetes insipidusSyndrome of inappropriate secretion of antidiuretic hormoneElectrolyte imbalanceHyperglycemic hyperosmolar syndrome Assessment of vital signs Monitoring for cardiac dysrhythmias Assessment for venous thromboembolism including PE and DVT Electrocardiogram Electrolyte studies Blood coagulation studies Blood glucose level Blood acetone level Blood osmolality Urine-specific gravity

Multisystem Assessment Measures for the Patient With Traumatic Brain Injury

The patient with TBI is unconscious. The family needs emotional support to deal with the crisis. Alternative methods of assessment for pain are indicated in the patient who is unconscious Collection of information about the family and the role within the family of the person with head injury Assessment of the family to determine how functional it was before the injury occurred

Characteristics of Chemicals: Toxicity

Toxicity is the potential of an agent to cause injury to the body. The median lethal dose (LD50) is the amount of the chemical that will cause death in 50% of those who are exposed. For example, cyanogen chloride has the highest LD50, twice that of hydrogen cyanide and eight times higher than sulfur mustard. The median effective dose (ED50) is the amount of the chemical that will cause signs and symptoms in 50% of those who are exposed. The concentration time (CT) is the concentration released multiplied by the time exposed (in milligrams per minute). For example, if 1000 mg of a chemical is released and the time a person is exposed to this amount of chemical is 10 minutes, then the CT would be 10,000 mg/min.

Salicylate Poisoning Aspirin (present in compound analgesic tablets) management

Treat respiratory depression. Induce gastric emptying by lavage (if within 1 hour after ingestion). Give activated charcoal to adsorb aspirin. Support patient with IV infusions as prescribed to establish hydration and correct electrolyte imbalances, including administration of sodium bicarbonate. Enhance elimination of salicylates as directed by forced diuresis, alkalinization of urine, peritoneal dialysis, or hemodialysis, according to severity of intoxication. Monitor serum salicylate level for efficacy of treatment. Administer specific prescribed pharmacologic agent for bleeding and other problems. Recognize that concretions formed in the gut may result in prolonged exposure as they are digested. Refer patient for psychiatric evaluation (potential suicide intent). Monitor thromboelastography for platelet function.

T or F: barbiturate coma method used to control ICP that cannot be controlled by other means.

True

T or F: Dose of radiation determines if ARS will develop

True - Any patient with neurologic symptoms suggest lethal dose and these patients still require decontamination to prevent further contamination of area and others. PPE is essential because it is impossible to fully decontaminate these clients.

T or F: In addition to the management of the illness or injury, the ED nurse must also focus on providing comfort and emotional support to the patient and family. Included in this is pain management.

True - Effective pain management must be instituted early and should include rapid-acting agents that result in minimal sedation so that the patient can continue to interact with the staff for ongoing assessment. - Moderate sedation can help facilitate short procedures in the ED; the patient will not remember the procedure later. The patient is closely monitored during the procedure and then rapidly awakens when it is complete. - It is essential that family crisis intervention services are available for families of patients in the ED. Even if a patient's condition is not emergent, the situation may be perceived as such by the family.

T or F: The injury regarded as the least significant in appearance may be the most lethal.

True - For example, the pelvic fracture not identified until an x-ray is obtained may cause rapid and massive hemorrhage into the pelvic cavity, but an obvious amputation of the arm may have already stopped bleeding from the body's normal response of vasoconstriction.

Disaster types correspond to anticipated incident duration and number of resources required:

Type 1 & 2: National and State Level Type 3: State or Metropolitan Area Level Type 4: City, County, or Fire District Level Type 5: Local Village and Township Level

Parietal Lobe

Understand sensation, texture, size, shape & spatial relationships Important for singing, playing musical instruments

A patient brought to the ED by the rescue squad after getting off a plane at the airport reports severe joint pain, numbness, and an inability to move the arms. The patient was on a diving vacation and went for a last dive this morning before flying home. What is a priority action by the nurse? a. Ensure a patent airway and that the patient is receiving 100% oxygen b. Send the patient for a chest x-ray c. Send the patient to the hyperbaric chamber d. Draw labs for a chemistry panel

a

A patient was involved in an avalanche that killed many people on a ski trip, including the patient's brother. The nurse is educating the patient about recognition of stress reactions and ways to manage stress. What type of process is the nurse introducing to the patient? a. Defusing b. Debriefing c. Preparedness d. Demobilization

a

A soldier is preparing to enter an area in which there is a high risk for chemical exposure to a nerve agent. What should the soldier be given prior to entering this area? a. Mark I automatic injectors that contain 2 mg atropine and 600 mg pralidoxime chloride b. Mark I automatic injectors that contain an anticonvulsant medication such as carbamazepine c. Mark I automatic injector filled with morphine 10 mg d. Mark I automatic injector filled with cyanide

a

E13. The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring? a. Increased ICP b. Exacerbation of uncontrolled hypertension c. Infection d. Increase in cerebral perfusion pressure

a

E13A patient with a C7 spinal cord fracture informs the nurse, "My head is killing me!" The nurse assesses a blood pressure of 210/140 mm Hg, heart rate of 48 and observes diaphoresis on the face. What is the first action by the nurse? A. place the patient in a sitting position B. call the physician C. assess the patient for a full bladder D. assess the patient for a fecal impaction

a

E2. A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? a. 3 b. 6 c. 9 d. 12

a

E2A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound? A. irrigates the wound to remove debris B. administers an oral analgesic for pain C. administers acetaminophen (Tylenol) for headache D. shaves the hair around the wound

a

E6A patient brought to the hospital after a skiing accident was unconscious for a brief period of time at the scene, then woke up disoriented and refused to go to the hospital for treatment. The patient became very agitated and restless, then quickly lost consciousness again. What type of TBI is suspected in the situation? A. epidural hematoma B. acute subdural hematoma C. chronic subdural hematoma D. grade 1 concussion

a

E9. A patient sustained a head injury during a fall and has changes in personality and affect. What part of the brain does the nurse recognize has been affected in this injury? A- Frontal lobe B- Parietal lobe C- Occipital lobe D- Temporal lobe

a

The nurse is caring for a patient admitted to the hospital with a brain abscess that developed from an untreated case of otitis media. What assessment data is a priority to alert the nurse to changes in intracranial pressure? A. level of consciousness B. peripheral pulses C. sensory perception D. crackles bilaterally

a

The nurse is triaging patients from a 10-car pile-up on the interstate and assesses a patient with a sucking chest wound. What category should this patient be placed in? a. Priority 1 b. Priority 2 c. Priority 3 d. Priority 4

a

The nurse received a call from EMS personnel that they are bringing in eight patients who have been exposed to a chemical after a spill. The patients have been "washed off.: After the initial assessment, what should be done? a. Remove clothing and jewelry and rinse the patients off with water b. Have the patience wash with soap and water and then rinse c. Treat the patients for any burned areas from the chemical since they have already been decontaminated d. Start an IV with lactated ringer's solution at 125 mL/h

a

E6. A nurse caring for a patient with head trauma will be monitoring the patient for Cushing triad. What will the nurse recognize as the symptoms associated with Cushing triad? (Select all that apply.) a. Bradycardia b. Bradypnea c. Hypertension d. Tachycardia e. Pupillary constriction

a, b, c

The nurse is admitting a patient with a penetrating abdominal injury from a knife wound. What are the priority action by the nurse for this patient? (Select all that apply.) a. Assessing for manifestations of hemorrhage b. Covering any protruding viscera with sterile dressing soaked in normal saline solution c. Looking for any associated chest injuries d. Exploring the abdominal wound with a gloved finger e. Irrigating the wound with normal saline and a syringe

a, b, c

E9The nurse is planning the care of a patient with a TBI in the neurosurgical ICU. In developing the plan of care, what interventions should be a priority? (Select all that apply.) A. making nurse assessments B. setting priorities for nursing interventions C. anticipating needs and complications D. initiating rehabilitation E. ensuring that the patient regains full brain function

a, b, c, d

A patient is brought to the ED by a friend, who states that a tree fell on the patient's leg and crashed it while they were cutting firewood. What priority action should the nurse perform? (Select all that apply.) a. Applying a clean dressing to protect the wound b. Elevating the site to limit the accumulation of fluid in the interstitial spaces c. Inserting an indwelling catheter d. Splinting the wound in a position of rest to prevent motion e. Performing a fasciotomy

a, b, d

E10The nurse is planning to provide education about prevention in the community YMCA due to the increase in numbers of spinal cord injuries (SCIs). What predominant risk factors does the nurse understand will have to be addressed? (Select all that apply.) A. young age B. male gender C. older adult D. substance abuse E. low-income community

a, b, d

E11. The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure? (Select all that apply.) a. Loosening constrictive clothing b. Opening the patient's jaw and inserting a mouth gag c. Positioning the patient on their side with head flexed forward d. Providing for privacy e. Restraining the patient to avoid self-injury

a, c,d

A client presents in the ED with a bite wound from an unknown dog 8 hours ago. The nurse will anticipate which of the following? Select all that apply. a. Irrigation of the wound b. Tetanus prophylaxis c. Antibiotic therapy d. Administration of rabies immune globulin e. Suturing of the wounds

all except e - Initial treatment for animal and human bites includes cleaning with copious irrigation, debridement, tetanus prophylaxis, and analgesics as needed. Prophylactic antibiotics are used for animal and human bites at risk for infection, such as wounds over joints, those greater than 6 to 12 hours old, puncture wounds, and bites of the hand or foot. Report animal and human bites to the police and regulatory agencies (such as Animal Control) as required. Always provide rabies prophylaxis when the animal is not found or when a wild animal causes the bite. To the reduce risk of infection, puncture wounds from bites marks are left open and lacerations are only loosely sutured.

An adolescent is brought to the ED after a motor vehicle accident and is pronounced dead on arrival. When the parents arrive at the hospital, what is a priority action by the nurse? a. Ask them to sit in the waiting room until the nurse can spend time alone with them b. Speak to both parents together and encourage them to support each other and express their emotions freely c. Speak to one parent at a time in a private setting so that each can ventilate feelings of loss without upsetting the other d. Ask the ED healthcare provider to medicate the parents so that they can handle their child's unexpected death quietly

b

E12A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit form the application of the halo device? A. it is the only device that can be applied for stabilization of a spinal fracture B. it allows for stabilization of the cervical spine along with early ambulation C. it is less bulky and traumatizing for the patient to use D. the patient can remove it as needed

b

E4. The nurse is caring for a patient in the neurologic ICU who sustained head trauma in a physical altercation. What would the nurse know is an optimal range of ICP for this patient? a. 8 to 15 mmHg b. 0 to 10 mmHg c. 20 to 30 mmHg d. 25 to 40 mmHg

b

E5While stopped at a stop sign, a patient was struck from behind by another vehicle. The patient sustained a cerebral contusion and was admitted to the hospital. During what time period after the injury will the effects of the injury peak? A. 6 to 8 hours b. 18 to 36 hours C. 12 to 24 hours D. 48 to 72 hours

b

The department of homeland security issues a code "blue" relative to a situation. What does the nurse recognize that this indicates? a. Perceived low risk b. Guarded risk c. Possible risk but ill-defined d. High risk with no specific site

b

The nurse caring for a patient with bacterial meningitis is administering dexamethasone (Decadron) that has been ordered as an adjunct to antibiotic therapy. When does the nurse know is the appropriate time to administer this medication? A. 1 hour after the antibiotic has infused and daily for 7 days B. 15 to 20 minutes before the first does of antibiotic and ever 6 hours for the next 4 days C. 2 hours prior to the administration of antibiotics for 7 days D. it can be administered every 6 hours for 10 days

b

The nurse in the ED is triaging patients during the shift. What does the nurse know is the first priority in treating any patient in the ED? a. Controlling hemorrhage b. Establishing an airway c. Obtaining consent for treatment d. Restoring cardiac output

b

The nurse is caring for a patient in the ED who is breathing but unconscious. In order to avoid an upper airway obstruction, the nurse is inserting an oropharyngeal airway. What technique should the nurse use during insertion? a. At an angle of 90° b. Upside down and then rotated 180° c. With the concave portion touching the posterior pharynx d. With the convex portion facing upward

b

During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the client is alert with an unobstructed airway. Which action should the nurse take next? a. Palpate extremities for bilateral pulses b. Observe the client's respiratory effort c. Determine a Glasgow Coma Score d. Examine the client for any external bleeding

b. Observe the client's respiratory effort - Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient's breathing. The other actions are also part of the initial survey, but assessment of breathing should be done immediately after assessing for airway patency and alertness.

What color category would penetrating head wound with ice pack fall under?

black

What color category would radiation exposure with seizures 24 hours after exposure fall under?

black

What color category would third degree burns over 75% total body surface area fall under?

black

Ecchymosis/contusion:

blood trapped under the surface of the skin

A nuclear reactor overheated, releasing radiation throughout the plant. They were here close to the reactor received at least 800 rads and has had an onset of vomiting, bloody diarrhea, and, when brought to the hospital, was in shock. What is this patients predicted survival? a. Possible b. Probable c. Likely d. Improbable

c

A patient is suspected to have an air embolus after being in a close proximity to an explosion at a sports arena. What position should the nurse place the patient in to prevent migration of the embolus? a. Supine with head of the bed at 30° b. High Fowler position c. Prone left lateral position d. Lithotomy

c

A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self-care and requires assistance with activities of daily living. What stage of Lyme disease does the nurse recognize the patient is in? a. Stage I b. Stage II c. Stage III d. Stage IV

c

A patient was suspected of being in direct contact with anthrax but is exhibiting no signs or symptoms. What type of prophylaxis does the nurse know this patient will have to take? a. Penicillin G IM for 1 dose b. Ceftriaxone IV for 7 days c. Ciprofloxacin for 60 days d. Erythromycin for 2 weeks

c

E1. A patient sustained a head trauma in a diving accident and has cerebral hemorrhage located within the brain. What type of hematoma is this classified as? A. an epidural hematoma B. an extradural hematoma C. an intracerebral hematoma D. a subdural hematoma

c

E12. The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient? a. Low in fat b. Restricts protein to 10% of daily caloric intake c. High in protein and low in carbohydrate d. At least 50% carbohydrate

c

E14A patient has developed autonomic dysreflexia and all measures to identify a trigger have been unsuccessful. What medication can the nurse provide as ordered by the physician to decrease the blood pressure? A. nifedipine (Procardia) sublingual B. furosemide (Lasix) IV administered rapidly C. hydralazine hydrochloride (Apresoline) IV administered slowly D. Bumex rapid bolus IV

c

E15. A patient had a small pituitary adenoma removed by the transsphenoidal approach and has developed diabetes insipidus. What pharmacologic therapy will the nurse be administering to this patient to control symptoms? a. Mannitol b. Furosemide (Lasix) c. Vasopressin d. Phenobarbital

c

E3. A patient has a severe neurologic impairment from a head trauma. What does the nurse recognize is the type of posturing that occurs with the most severe neurologic impairments? a. Decerebrate b. Decorticate c. Flaccid d. Rigid

c

E5. A patient is admitted to the hospital with an ICP reading of 20 mmHg and a mean arterial pressure of 90 mmHg. What would the nurse calculate the CPP to be? a. 50 mmHg b. 60 mmHg c. 70 mmHg d. 80 mmHg

c

E7The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for? A. hypophysectomy B. application of Halo traction C. Burr holes D. insertion of Crutchfield tongs

c

E8. The nurse is caring for a patient with increased ICP. As the pressure rises, what osmotic diuretic does the nurse prepare to administer? a. Glycerin b. Isosorbide c. Mannitol d. Urea

c

For a patient who is experiencing multiple injuries, which sequence of medical or nursing management with the nurse identify as a priority? a. Assess for head injuries, control hemorrhage, establish an airway, prevent hypovolemic shock b. Control hemorrhage, prevent hypovolemic shock, establish an airway, assess for head injuries c. Establish an airway, control hemorrhage, prevent hypovolemic shock, assess for head injuries d. Prevent hypovolemic shock, assess for head injuries, establish an airway, control hemorrhage

c

The NATO triage system uses color coded tagging to identify severity of injuries. Patient was survivable but life-threatening injuries would be tagged with which color?. a. Black b. Green c. Red d. Yellow

c

Exposure to Anthrax, without clinical signs and symptoms of the disease, requires a 60 day treatment with one of two antibiotics: _______ or _______. The mortality rate associated with respiratory distress is:

ciprofloxacin, doxycycline; 100%

The emergency department triage nurse is assessing four victims involved in a motor vehicle collision. Which client has the highest priority for treatment? a. A client with no pedal pulses b. A client with an open femur fracture c. A client with paradoxical chest movement d. A client with bleeding facial lacerations

c. A client with paradoxical chest movement - Most immediate deaths from trauma occur because of problems with ventilation, so the patient with paradoxical chest movements should be treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries only has lacerations. The other two patients also need rapid intervention but do not have airway or breathing problems.

A12. The brain center responsible for balancing and coordination is the

cerebellum

A6.Nursing postoperative management includes detecting and reducing ________, relieving ________, preventing __________, and monitoring ________ and _______.

cerebral edema, pain, seizures, increased ICP and neurologic status

What is CPP?

cerebral perfusion pressure - CPP is the force driving the blood to the brain, delivering oxygen and nutrients. MAP - ICP = CPP Normal: 70 - 100 mm Hg Less than 50 irreversible neuro damage

A patient is being brought into the ED who is probably infected with anthrax. The nurse should ensure what level of personal protective equipment to wear for everyone who will come in contact with the patient? a. Level A b. Level B c. Level C d. Level D

d

A triage nurse in the ED determines that a patient with dyspnea and dehydration is not in a life-threatening situation. What triage category will the nurse choose? a. Delayed b. Emergent c. Immediate d. Urgent

d

E1. The nurse is caring for a patient with an altered LOC. What is the first priority of treatment for this patient? a. Assessment of the pupillary light reflexes b. Determination of the cause c. Positioning to prevent complications d. Maintenance of a patent airway

d

E10. A patient who has suffered a stroke is unable to maintain respiration and is intubated and placed on mechanical ventilator support. What portion of the brain is most likely responsible for the inability to breathe? A- Frontal lobe B- Occipital lobe C- Parietal lobe D- Brain stem

d

E14. A patient 3 days postoperative from a craniotomy informs the nurse, "I feel something trickling down the back of my throat and I taste something salty." What priority intervention does the nurse initiate? a. Give the patient some mouthwash to gargle with b. Request an antihistamine for the postnasal drip c. Ask the patient to cough to observe the sputum color and consistency d. Notify the physician of a possible cerebrospinal fluid leak

d

E3The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of? A. occipital skull fracture B. temporal skull fracture C. frontal skull fracture D. basilar skull fracture

d

E7. What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? a. A bounding pulse b. Bradycardia c. Hypertension d. Lethargy and stupor

d

E8A patient sustained a head injury and has been admitted to the neurosurgical intensive care unit (ICU). The patient began having seizures and was administered a sedative-hypnotic medication that is ultra-short acting and can be titrated to patient response. What medication will the nurse be monitoring during this time? A. Lorazepam (Ativan) B. Midazolam (Versed) C. Phenobarbital D. Propofol (Diprivan)

d

E9. A nurse is assessing a patient's urinary output as an indicator of diabetes insipidus related to a traumatic brain injury. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator? a. 50 to 100 mL/h b. 100 to 150 mL/h c. 150 to 200 mL/h d. More than 200 mL/h

d

A6. The sleep-wake cycle regulator and the sit of hunger center is known as the

hypothalamus

Stab:

incision of the skin with well-defined edges, usually caused by a sharp instrument; a stab wound is typically deeper than long

Cut:

incision of the skin with well-defined edges, usually longer than deep

The majority of metastatic lesions to the brain occur from six areas

lungs, breast, lower gi tract, pancreas, kidney and skin

What color category would hemothorax fall under?

red

What color category would open femur fracture fall under?

red

What color category would sucking chest wound fall under?

red

The most common sites for pressure ulcers, a significant complication of spinal cord injury, are over the ischial tuberosity, the greater trochanter, the __________, and the occiput.

sacrum

In the case of gunfire in the emergency department, what is a priority?

self protection