Emergency Nursing

EMERGENCY NURSING

HEAD TRAUMA ABDOMINAL TRAUMA DENTAL TRAUMA NEAR DROWNING POISONING FOREIGN BODY OBSTRUCTION TRAUMA RELATED TO ENVIRONMENT EXPOSURE BITES (ANIMAL, SNAKES, INSECTS)

SUBMITTED TO: MR. ALFREDO LIM INSTRUCTOR ± NCM 104

SUBMITTED BY: LORNA B. ARELLANO BSN IV ± 2

HEAD TRAUMA/ HEAD INJURY

A head injury is any trauma that leads to injury of the scalp, skull, or brain. The injuries can range from a minor bump on the skull to serious brain injury. Types of Head Injury I. OPEN HEAD INJURY ± An open, or penetrating, head injury means you were hit with an object that broke the skull and entered the brain. This usually happens when you move at high speed, such as going through the windshield during a car accident. It can also happen from a gunshot to the head. Types of skull fractures associated with open head injury: i. Linear fracture ± it is the most common type ; simple, clean or straight break of an area of a skull ii. Depressed fracture ± skull is pressed inward into the brain tissue iii. Open fracture ± the scalp is lacerated, which leaks to direct opening to the brain tissue iv. Comminuted fracture ± the bone is pressed into brain tissue and there are bone fragments involved II. CLOSED HEAD INJURY ± A closed head injury is a trauma in which the brain is injured as a result of a blow to the head, or a sudden, violent motion that causes the brain to knock against the skull.

Types of closed head injuries: a. Concussion ± brief interruption in brain activity with or without loss of consciousness b. Diffuse axonal injury - diffuse (means widespread) injury to axons, the corpus callosum, white matter, and the brainstem. c. Contusion ± blunt trauma causes a bruise to the cortical surface of the brain resulting in permanent damage to the brain tissue. Bruised and necrotic tissues are eventually replaced with scar tissue and/or ³crater´ d. Hematoma - vascular bleedi Risk factors for a head injury A number of factors increase the risk of developing head injury. Not all people with risk factors will get head injury. Risk factors include:
y y y y

Alcohol or illicit drug use Driving while intoxicated Driving without seatbelts Participation in sports, especially without the proper safety gear

Causes of Head Injury Common causes of head injury include: y traffic accidents y falls y physical assault y accidents at home, work, outdoors, or while playing sports Common symptoms of a head injury You may experience head injury symptoms daily or only occasionally. Any of these head injury symptoms can be severe:
y

Abrupt changes in personality, such as anger or irritability, without an apparent cause

y y y y y y y y y y y

Bone fractures or deformity, especially of the skull or face Clear or blood-tinged fluid coming from the mouth, ears or nose Confusion; drowsiness; clumsiness; memory loss; lethargy; or trouble speaking, seeing or hearing Loss of control of bodily functions Pupils that are different sizes, or pupils that do not change when exposed to light and dark Seizure or unexplained shaking or convulsions Severe headache Slow or stopped breathing Unconsciousness and coma Vomiting Weakness (loss of strength) or paralysis

Serious symptoms that might indicate a life-threatening condition: In many cases, head injuries can be life threatening. Seek immediate medical care if you, or someone you are with, have any of these life-threatening symptoms including:
y y y y y y y y

Abrupt confusion, fatigue, changes in thinking, or lethargy soon after a head trauma Deformity or fracture of bones Multiple unexplained episodes of vomiting after a head trauma Neck or back injury Seizures Severe bleeding from the head or face, especially if the wound is deep Slowed or stopped breathing Unconsciousness (even if brief)

For a moderate to severe head injury, take the following steps: 1. Check the person's airway, breathing, and circulation. If necessary, begin rescue breathing and CPR. 2. If the person's breathing and heart rate are normal but the person is unconscious, treat as if there is a spinal injury. Stabilize the head and neck by placing your hands on both sides of the person's head, keeping the head in line with the spine and preventing movement. Wait for medical help. 3. Stop any bleeding by firmly pressing a clean cloth on the wound. If the injury is serious, be careful not to move the person's head. If blood soaks through the cloth, do NOT remove it. Place another cloth over the first one. 4. If you suspect a skull fracture, do NOT apply direct pressure to the bleeding site, and do NOT remove any debris from the wound. Cover the wound with sterile gauze dressing. 5. If the person is vomiting, roll the head, neck, and body as one unit to prevent choking. This still protects the spine, which you must always assume is injured in the case of a head injury. (Children often vomit once after a head injury. This may not be a problem, but call a doctor for further guidance.) 6. Apply ice packs to swollen areas. DO NOT
y y y y y y y

Do NOT wash a head wound that is deep or bleeding a lot. Do NOT remove any object sticking out of a wound. Do NOT move the person unless absolutely necessary. Do NOT shake the person if he or she seems dazed. Do NOT remove a helmet if you suspect a serious head injury. Do NOT pick up a fallen child with any sign of head injury. Do NOT drink alcohol within 48 hours of a serious head injury.

When to Contact a Medical Professional

y y y y

There is severe head or facial bleeding The person is confused, drowsy, lethargic, or unconscious The person stops breathing You suspect a serious head or neck injury, or the person develops any signs or symptoms of a serious head injury

Prevention
y y y y y y y

Always use safety equipment during activities that could result in head injury. These include seat belts, bicycle or motorcycle helmets, and hard hats. Obey traffic signals when riding a bicycle. Be predictable so that other drivers will be able to determine your course. Be visible. Do NOT ride a bicycle at night unless you wear bright, reflective clothing and have proper headlamps and flashers. Use age-appropriate car seats or boosters for babies and young children. Make sure that children have a safe area in which to play. Supervise children of any age. Do NOT drink and drive, and do NOT allow yourself to be driven by someone whom you know or suspect has been drinking alcohol or is otherwise impaired.

Diagnostic Examination Techniques and Devices Used in Head Injury y Plain Radiography  Cross ± table lateral cervical spine  Caregivers must ensure that cervical spine is immobilized and protected until radiographic studies and clinical examination have ruled out injury.  Swimmer¶s view  If a cross-table lateral film cannot visualize the cervical spine adequately from C1 to T1, a ³swimmer¶s view´ should be obtained. Alternatively, obtain a CT scan of the neck. Computed Axial Tomography - A non contrast CT scan (also called a CAT scan) can detect acute bleeding accurately in about 85% of head trauma patients. This test should be performed quickly in any patient with an altered LOC, hemiparesis, aphasia. Magnetic Resonance Imaging - It can detect early changes in diffuse axonal injuries, can identify even small amounts of subarachnoid blood but it is contraindicated if the patient is dependent on traction, ventilators, pumps, or other equipment that contains ferrous metals. Angiography - To diagnose the presence of traumatic cerebrovascular abnormalities such as tears or thrombosis. Intracranial Pressure Monitoring - Indicated for any patient with severe head injury (GCS” 8) and for those with abnormal CT scan findings.

y

y

y y

Nursing Diagnosis: y y y y y Disturbed sensory perception related to neurologic impairment Risk for impaired skin integrity related to immobility Imbalanced nutrition, less than body requirements, related to increased metabolic demands, fluid restriction, and inadequate intake Risk for injury related to disorientation, restlessness and brain damage Altered cerebral tissue perfusion related to increased intracranial pressure

ABDOMINAL TRAUMA

Blunt abdominal trauma usually results from motor vehicle collisions (MVCs), assaults, recreational accidents, or falls. The most commonly injured organs are the spleen, liver, retroperitoneum, small bowel, kidneys, bladder, colorectum, diaphragm, and pancreas. Men tend to be affected slightly more often than women. Common abdominal injuries after blunt trauma: Liver Injuries ± The liver may be lacerated by either blunt or penetrating trauma. y Clinical findings include:  pain or tenderness in the upper right quadrant (rebound tenderness is often present)  the source of pain is often due to blood ( it only needs to be present for two hours) in the abdominal cavity that causes peritoneal irritation  liver laceration should be suspected when penetrating trauma involves the right lower chest or right upper abdomen, or when right upper quadrant tenderness accompanies blunt trauma y Diagnosis of a liver laceration  CT (for stable patients)  Diagnostic Peritoneal Lavage (DPL) - if the patient is exhibiting signs of shock or has other urgent injuries to confirm intra-peritoneal hemorrhage y Treatment for large liver lacerations:  require surgical intervention to either pack or repair the injury  for smaller injuries close observation, frequent assessment including labs to monitor hemoglobin will be required Spleen Injuries ± The spleen is the most commonly injured organ in blunt abdominal trauma. y Clinical findings include:  tachycardia  hypotension (the most common presentation)  upper left quadrant pain  Rib fractures (9th and 10th), on the left side is also a common clinical finding  If injury to the phrenic nerve is present, the patient may complain of left shoulder/scapular pain as well  Peritoneal signs such as rebound sensitivity and guarding will be delayed until the blood has had time to cause local irritation to the peritoneum y Diagnosis of a spleen injury:  obtaining a CT (for stable patients)  Diagnostic Peritoneal Lavage (DPL) - if the patient is exhibiting signs of shock or has other urgent injuries to confirm intra-peritoneal hemorrhage y Treatment for large spleen injuries:  Splenectomy  For smaller injuries close observation, frequent assessment including labs to monitor hemoglobin will be required Kidney Injuries ± Injuries to the kidney are more commonly seen with falls, automobile accidents and other blunt trauma usually to the lower back. When there are fractures to the 11th and 12th ribs or complaints of flank pain or tenderness, an injury to one or both kidneys should be suspected. y Clinical findings include:  complaints of pain on inspiration  hematuria (of any degree)  complaints of abdominal or flank pain  flank discoloration (bruising) is a late finding y Diagnosis:  Differentiating between the lacerated kidney and the contused kidney requires IVP examination or CT scan  The lacerated kidney will show leakage of dye

 the contused kidney will either be normal or show a ³blush´ of dye in the kidney stoma. Observation is appropriate for a kidney contusion y Intervention:  surgical consultation is necessary for a lacerated kidney or any type of kidney injury that shows extravasations of dye during IVP or CT

Ruptured Bowel ± It is penetrating injuries that most commonly cause the bowel to rupture. The small bowel is most frequently injured, followed by the stomach and then the large intestine. Though penetrating injury is the most common source of injury, crushing injuries (steering wheel, lap belts) are also common sources of injury (in these cases it is the duodenum that most often becomes injured). y Clinical findings include:  complaints of abdominal pain (most likely due to intestinal contents rather than blood in the peritoneum. Description of the pain from stomach or intestinal rupture is described as a vague generalized pain or epigastric burning.  back pain may be a complaint if there is duodenal injury y Diagnosis of a ruptured bowel:  by visualizing free air in the peritoneal cavity either with x-ray or CT  Diagnostic peritoneal lavage (DPL) will show WBC¶s and intestinal contents. y Surgical intervention for a patient with a ruptured bowel is required. Diagnostic Peritoneal Lavage Diagnostic Peritoneal Lavage (DPL) is performed when intra-abdominal bleeding secondary to trauma is suspected. The procedure is performed when CT or Ultrasound are not available or when the patient is too unstable and time is of the essence. The following is a step by step approach to performing a DPL. y y y y y Using local anesthesia, the surgeon makes a small incision in the abdomen just below the umbilicus A cannula is inserted in the incision and is used to penetrate the midline fascia of the abdominal wall During insertion, a sudden give or "pop" can be felt as the cannula passes through the fascia A catheter is introduced through the incision into the abdomen Saline is infused into the abdomen through the catheter, and then removed

If blood or intestinal contents are present in the saline after removal, it is highly probable that there is a serious intraabdominal injury. Positive DPL findings include: y y y y Bloody Lavage Fluid Red Blood Cells > 100,000 cells/mm White Blood Cells > 500 cells/mm Amylase > 175 U/100 ml

The presence of any of the following is considered a positive DPL: y y y y Bacteria Fecal Material Bile Food Products

Clinical Manifestations of Abdominal Trauma:

y y y y y y y

Guarding and splinting of the abdominal wall A hard, distended abdomen (indicating intra-abdominal bleeding) Decreased or absent bowel sounds Contusions, abrasions, or bruising over the abdomen Abdominal pain Pain over the scapula caused by irritation of the phrenic nerve by free blood in the abdomen Hematemesis or hematuria

Nursing Assessment/Documentation of the Patient with Blunt Abdominal Trauma Includes: y y y y Appearance (distention, ecchymosis, lap belt signs, abrasions, wounds) Auscultation (bowel sounds, bruits) Tenderness (guarding, rebound pain) Palpation (organomegaly, pulsating masses)

Nursing Care and Management of the Patient With Blunt Abdominal Trauma Includes:
y y y y y y y y y y y y

Monitor vital signs Monitor respiratory status Pain assessment Routine Labs (notify physician of trends/abnormal values) CBC (special attention to WBC¶s and HgB/Hct Electrolytes Foley Catheter (can be used for intra-abdominal pressure monitoring) Urine output (check for hematuria with kidney injury) Complete and ongoing abdominal assessment Patient should remain NPO until surgical intervention is ruled out NG to low continuous suction IV or nutritional support

Post-op patient family education:
y y y y y y

Incision site care (signs and symptoms of infection) Pain Management Work/Exercise/Rest balance Diet Prescriptions Follow-up care

Stabbed Wounds Stab wounds are caused by penetration of the abdominal wall by a sharp object. This type of wound generally has a more predictable pattern of organ injury. However, occult injuries can be overlooked, resulting in devastating complications. In penetrating abdominal trauma due to stab wounds, the most commonly injured organs are as follows:
y y y y

Liver (40%) Small bowel (30%) Diaphragm (20%) Colon (15%)

Characteristics of stab wounds
y y y y y y y y

Clean cut edges One or both ends pointed Non-pointed end may be squared off or split (fish tail or boat shaped defect) Often gape (related to skin elasticity and Langer¶s lines) Cross section of weapon may be illustrated when edges of wounds opposed Underlying bone may be scored by blade Abrasions may be present Frequently shows notching or a change in direction (caused by relative movement of the knife and body)

Nursing Diagnosis: Abdominal Trauma
y y y y y

Alteration in Comfort: Pain Alteration in Nutrition Risk for Infection Immobility Knowledge Deficit

DENTAL TRAUMA Definition: Dental trauma is injury to the mouth, including teeth, lips, gums, tongue, and jawbones. The most common dental trauma is a broken or lost tooth. Description: Dental trauma may be inflicted in a number of ways: y contact sports, y motor vehicle accidents, y fights, y falls, y eating hard foods, y drinking hot liquids y As oral tissues are highly sensitive, injuries to the mouth are typically very painful. Dental trauma should receive prompt treatment from a dentist. Causes and Symptoms:
y y y y

Soft tissue injuries, such as a "fat lip," a burned tongue, or a cut inside the cheek, are characterized by pain, redness, and swelling with or without bleeding. A broken tooth often has a sharp edge that may cut the tongue and cheek. Depending on the position of the fracture, the tooth may or may not cause toothache pain. When a tooth is knocked out (evulsed), the socket is swollen, painful, and bloody. A jawbone may be broken if the upper and lower teeth no longer fit together properly (malocclusion), or if the jaws have pain with limited ability to open and close (mobility), especially around the temporomandibular joint (TMJ).

Diagnosis:

y

Dental trauma is readily apparent upon examination. Dental x rays may be taken to determine the extent of the damage to broken teeth. More comprehensive x rays are needed to diagnose a broken jaw.

Treatment:
y y y y

Soft tissue injuries may require only cold compresses to reduce swelling. Bleeding may be controlled with direct pressure applied with clean gauze. Deep lacerations and punctures may require stitches. Pain may be managed with aspirin or acetaminophen (Tylenol, Aspirin Free Excedrin) or ibuprofen (Motrin, Advil).

Risk factors:
y y y y y y

Young children Sports, especially contact sports Piercing in tongue and lips Military trainings Acute changes in barometric pressure, i.e. dental barotraumas which can affect scuba divers and aviators Class II malocclusion

Treatment of a broken tooth will vary depending on the severity of the fracture: y y y y y y y For immediate first aid, the injured tooth and surrounding area should be rinsed gently with warm water to remove dirt, then covered with a cold compress to reduce swelling and ease pain If a piece of the outer tooth has chipped off, but the inner core (pulp) is undisturbed, the dentist may simply smooth the rough edges or replace the missing section with a small composite filling. In some cases, a fragment of broken tooth may be bonded back into place. If enough teeth is missing to compromise the entire tooth structure, but the pulp is not permanently damaged, the tooth will require a protective coverage with a gold or porcelain crown. If the pulp has been seriously damaged, the tooth will require root canal treatment before it receives a crown. A tooth that is vertically fractured or fractured below the gum line will require root canal treatment and protective restoration. A tooth that no longer has enough remaining structure to retain a crown may have to be extracted (surgically removed).

When a permanent tooth has been knocked out, it may be saved with prompt action. y y y y y y y y y The tooth must be found immediately after it has been lost. It should be picked up by the natural crown (the top part covered by hard enamel). It must not be handled by the root. If the tooth is dirty, it may be gently rinsed under running water. It should never be scrubbed, and it should never be washed with soap, toothpaste, mouthwash, or other chemicals. The tooth should not be dried or wrapped in a tissue or cloth. It must be kept moist at all times. The tooth may be placed in a clean container of milk, cool water with or without a pinch of salt, or in saliva. If possible, the patient and the tooth should be brought to the dentist within 30 minutes of the tooth loss. Rapid action improves the chances of successful re-implantation; however, it is possible to save a tooth after 30 minutes, if the tooth has been kept moist and handled properly. The body usually rejects re-implantation of a primary (baby) tooth. In this case, the empty socket is treated as a soft tissue injury and monitored until the permanent tooth erupts. A broken jaw must be set back into its proper position and stabilized with wires while it heals. Healing may take six weeks or longer, depending on the patient's age and the severity of the fracture.

Prevention:
y y y y y

Yearly dental exams (including x rays). Teeth should be brushed and flossed thoroughly at least once a day. A mouthguard and helmet should be worn while playing all contact sports (football, soccer, hockey, baseball, boxing, basketball). A seatbelt should always be worn when in a moving vehicle. Foreign objects (pencils, fingernails, pens) should be kept out of the mouth.

Nursing Diagnosis: y y y y y Acute Pain related to traumatized tissue secondary to open wound and closed fracture Fluid Volume Deficit related to profuse bleeding from multiple wounds Acute pain related to inflammation Risk for infection related to trauma Imbalanced nutrition, less than body requirements, related to increased metabolic demands, fluid restriction, and inadequate intake

NEAR DROWNING "Near drowning" means a person almost died from not being able to breathe (suffocating) under water. Assessment Findings: 1. Clinical Manifestations: y y y y y y y Altered level of consciousness, restlessness, and apprehension Pulmonary edema with pink froth visible in the mouth and nose Possible hypothermia Complaints of headache and chest pain Vomiting Cyanosis Possible cardiac arrest

2. Laboratory Findings and Diagnostic Study Findings: Arterial Blood Gas (ABG) values show severe hypoxia and metabolic acidosis Causes:
y y y y y y

Attempted suicide Blows to the head or seizures while in the water Drinking alcohol while boating or swimming Falling through thin ice Inability to swim or panicking while swimming Leaving small children unattended around bathtubs and pools

Statistical Risk Factors:

y y y

Predisposing Illnesses: Epilepsy, seizures Trauma: Diving and boating accidents, falls Mental impairment: Drugs and alcohol

Predisposing Factors: ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Coma, seizures Alcohol/Drugs Exhaustion Hyperventilation Rapidly moving water Poor swimming ability Exhaustion Panic Hypothermia Trauma

First Aid: When someone is drowning:
y y y y

Do NOT place yourself in danger. Do NOT get into the water or go out onto ice unless you are absolutely sure it is safe. Extend a long pole or branch to the person, or use a throw rope attached to a buoyant object, such as a life ring or life jacket. Toss it to the person, then pull him or her to shore. If you are trained in rescuing people, do so immediately only if you are absolutely sure it will not cause you harm. Keep in mind that people who have fallen through ice may not be able to grasp objects within their reach or hold on while being pulled to safety.

 If the person's breathing has stopped, begin rescue breathing as soon as you can. This often means starting the breathing process while still in the water.  Continue to breathe for the person every few seconds while moving him or her to dry land. Once on land, give CPR if needed.  Always use caution when moving a person who is drowning. Assume that the person may have a neck or spine injury, and avoid turning or bending their neck. Keep the head and neck very still during CPR and while moving the person. You can tape the head to a backboard or stretcher, or secure the neck by placing rolled towels or other objects around it. DO NOT:
y y y y

Do NOT attempt a swimming rescue yourself unless you are trained in water rescue. Do NOT go into rough or turbulent water that may endanger you. Do NOT go out on the ice to rescue a drowning person if you can reach the person with your arm or an extended object. The Heimlich maneuver is NOT part of the routine rescue of near drowning. Do NOT perform the Heimlich maneuver unless repeated attempts to position the airway and to use rescue breathes to get air into the lungs have failed and you suspect the person¶s airway is blocked. Performing the Heimlich maneuver increases the chances that an unconscious person will vomit and subsequently choke on the vomit.

Nursing Management: 1. Provide emergency care y Initiate vigorous, purposeful cardiopulmonary resuscitation y Ventilate with 100% oxygen and positive end-expiratory pressure y Insert an IV line, a central venous line, an indwelling urinary catheter, or a nasogastric tube, as ordered. y Initiate cardiac monitoring y Begin internal rewarming (e.g. warm peritoneal dialysis, warm aerosol inhalation) and external rewarming(e.g. hyperthermia blanket) if necessary. 2. Provide ongoing assessment. Monitor vital signs, level of consciousness, electrocardiogram findings, central venous pressure, intake and output, ABG values and serum electrolytes. 3. Admit the client to the intensive care unit.

Prevention
y y y y y y y y

Avoid drinking alcohol whenever swimming or boating. Drowning can occur in any container of water. Do not leave any standing water (in empty basins, buckets, ice chests, kiddy pools, or bathtubs). Secure the toilet seat cover with a child safety device. Fence all pools and spas. Secure all the doors to the outside, and install pool and door alarms. If your child is missing, check the pool immediately. Never allow children to swim alone or unsupervised regardless of their ability to swim. Never leave children alone for any period of time or let them leave your line of sight around any pool or body of water. Drowning have occurred when parents left "for just a minute" to answer the phone or door. Observe water safety rules. Take a water safety course.

Nursing Diagnosis: y y y y y Ineffective breathing pattern related to anxiety Impaired gas exchange related to effects of near-drowning Anxiety related to hypoxemia Ineffective breathing pattern related to anxiety Risk for decreased cardiac output related to mechanical ventilation

POISONING Poisoning is the harmful effect that occurs when a toxic substance is swallowed, is inhaled, or comes in contact with the skin, eyes, or mucous membranes, such as those of the mouth or nose.
y y y y y

Possible poisonous substances include prescription and over-the-counter drugs, illicit drugs, gases, chemicals, vitamins, and food. Some poisons cause no damage, whereas others can cause severe damage or death. The diagnosis is based on symptoms, on information gleaned from the poisoned person and bystanders, and sometimes on blood and urine tests. Medications should always be kept in original child-proof containers and kept out of the reach of children. Treatment consists of supporting the person, preventing additional absorption of the poison, and sometimes increasing elimination of the poison.

Food Poisoning

Bacterial contamination is the most common cause of food poisoning. The most common causative organisms are Staphylococcus aureus, Salmonella, Escherichia coli, Clostridium perfringes, Campylobacter jejuni, and Bacillus cereus.
Differential Diagnosis of Bacterial Causes for Diarrhea and Food Poisoning Symptoms Bacterial Abd¶l Diarrhea Pathogenesis Fever Diarrhea Dysentery* Pain Vomiting C. perfringes Enterotoxin + + ++ E. coli Enterotoxin _ Salmonella Bacteria + + (endotoxin) Shigella Bacteria + + + (endotoxin) Staphylococci Enterotoxin + 0 + Streptococci Bacteria + V. cholera Enterotoxin C. botulinum Neurotoxin Bacillus cereus Type I Enterotoxin _ + Type II Enterotoxin ++ + Campylobacter Enterotoxin + + + jejuni *Dysentery means diarrhea with blood and mucus +, occurs regularly , May or may not occur 0, does not occur

IP

Signs and symptoms: y y y y y Nausea, vomiting, abdominal cramping, diarrhea (may be watery or contain mucus or blood) Fever or hypothermia Headache Dehydration Hemolytic uremic syndrome

Causes of food poisoning can be divided into two categories: infectious agents and toxic agents. y Infectious agents include viruses, bacteria, and parasites. y Toxic agents include poisonous mushrooms, improperly prepared exotic foods (such as barracuda - ciguatera toxin), or pesticides on fruits and vegetables.

Therapeutic Interventions: y y y y y y Encourage oral fluid intake if the patient can tolerate it. Begin IV hydration for patients with symptoms of dehydration. Collect and send stool cultures Initiate antibiotic therapy for suspected shigella or streptococcal infections. Also start antibiotics on immunocompromised patients Administer an antiemetic agent Replace electrolytes as needed

Prevention and education:

     
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8-24 hr 24-72 hr 8-48 hr 24-72hr 2-6 hr 24-72hr 24-72hr 12-36hr 1-6 hr 10-12hr 1-7days

   

 

       

   

     

 

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y y y y y y y

Wash hands well before handling food or eating Wash all utensils and cutting surfaces between food preparation sessions Wash all fresh fruits and vegetables Thoroughly cook all meat and poultry Use warmers to keep unrefrigerated foods at a temperature of 140ºF (during prolonged serving periods) Check the expiration dates on all food products Refrigerate dairy products and other susceptible foods at 40ºF (or less)

Risk Factors for Food Poisoning: y y y y Older adults. As you get older, your immune system may not respond as quickly and as effectively to infectious organisms as when you were younger. Pregnant women. During pregnancy, changes in metabolism and circulation may increase the risk of food poisoning. Your reaction may be more severe during pregnancy. Rarely, your baby may get sick, too. Infants and young children. Their immune systems haven't fully developed. People with chronic disease. Having a chronic condition ² such as diabetes, liver disease or AIDS ² or receiving chemotherapy or radiation therapy for cancer reduces your immune response.

Botulism Botulism is a paralytic illness that results from neurotoxins produced by the organism Clostridium botulinum. This condition can result from toxin ingestion or from wound contamination. Risk factors for botulism food poisoning Risk factors for botulism food poisoning include the consumption of home-canned foods and foods that have been improperly preserved. Not all people with risk factors will get botulism food poisoning. Signs and symptoms: y y y y y y y y Presenting signs and symptoms are often vague Lethargy, weakness Constipation Headache Normal or subnormal temperature Dry, sore throat, hoarseness, inability to swallow, impaired speech Visual disturbances (diplopia), limited eye movement, dilated pupils Decreased deep tendon reflexes, descending paralysis

Therapeutic interventions: y y y y y y Provide basic and advanced supportive care as indicated ABC¶s Patients frequently require a tracheostomy and long term ventilator assistance Gastric emptying is only of benefit immediately following ingestion of food known to contain botulinum toxin Asymptomatic individuals who were probably exposed should be hospitalized, closely observed, and treated with antitoxin as soon as symptoms appear Draw and send blood to determine the specific toxin serotype. The type determines the specific antitoxin to be used for treatment

Prevention: Use proper canning techniques Be sure to use proper techniques when canning foods at home to ensure that any botulism germs in the food are destroyed:
y y

Pressure cooks these foods at 250 F (121 C) for at least 30 minutes. Consider boiling these foods for 10 minutes before serving them.

Prepare and store food safely
y y y

Don't eat preserved food if its container is bulging or if the food smells spoiled. However, taste and smell won't always give away the presence of C. botulinum. Some strains don't make food smell bad or taste unusual. If you wrap potatoes in foil before baking them, eat them hot or store them in the refrigerator ² not at room temperature. Store oils infused with garlic or herbs in the refrigerator.

Infant botulism To reduce the risk of infant botulism, avoid giving honey ² even a tiny taste ² to babies under the age of 1 year. Wound botulism To prevent wound botulism and other serious blood borne diseases, never inject or inhale street drugs. SULFURIC ACID POISONING Sulfuric acid is a very strong chemical that is corrosive. Corrosive means it can cause severe burns and tissue damage when it comes into contact with the skin or mucous membranes. Poisonous Ingredient: Sulfuric acid Where Found: y y y y y Car battery acid Certain detergents Chemical munitions Some fertilizers Some toilet bowl cleaners

Symptoms: Initial symptoms include severe pain on contact. Symptoms from swallowing may also include:
y y y y y y y

Breathing difficulty due to throat swelling Burns in the mouth and throat Drooling Fever Rapid development of low blood pressure Severe pain in the mouth and throat Speech problems

y y

Vomiting, with blood Vision loss

Symptoms from breathing in the poison may include:
y y y y y y y y y y y

Bluish skin, lips, and fingernails Breathing difficulty Body weakness Chest pain (tightness) Choking Coughing Coughing up blood Dizziness Low blood pressure Rapid pulse Shortness of breath

Home Care: y y y Do NOT make a person throw up. Seek immediate medical help. If the chemical is on the skin or in the eyes, flush with lots of water for at least 15 minutes. If the chemical was swallowed, immediately give the person water or milk. Do NOT give water or milk if the patient is having symptoms (such as vomiting, convulsions, or a decreased level of alertness) that make it hard to swallow If the person breathed in the poison, immediately move him or her to fresh air. Before Calling Emergency:

y y

 Determine the following information:
y y y y

Patient's age, weight, and condition Name of the product (as well as the ingredients and strength if known) Time it was swallowed Amount swallowed

Take the container with you to the emergency room. Therapeutic interventions and management:
y y y y y y y y

Breathing tube and oxygen Bronchoscopy -- camera down the throat to see burns in the airways and lungs Endoscopy -- camera down the throat to see burns in the esophagus and the stomach Fluids through a vein (IV) Milk of magnesia Surgery to repair any tissue damage Surgical removal of burned skin (skin debridement) Washing of the skin (irrigation) -- perhaps every few hours for several days

METAL POISONINGS Iron

Toxic levels of iron are most commonly a result of iron supplement ingestion. Normal serum iron levels range from 50 to 175 mcg/100 mL. Ingestion of greater than 20 mL/kg is thought to be toxic; ingestion of 300 mg/kg is considered lethal. Signs and symptoms: Initial Stage (within 2 hours of ingestion) y Nausea, vomiting, abdominal pain y Hematemesis, bloody stools y Hyperglycemia Second Stage (2 ± 48 hours postingestion) y Resolution of gastrointestinal disturbances y Dehydration may be the only symptom present Third Stage (48 -96 hours) y Metabolic acidosis y Coagulopathy y Hemorrhage and ahock y Hepatic and renal failure y Hypoglycemia Therapeutic interventions: y y y y y y Provide basic and advanced supportive care as indicated Induced emesis is preferred over gastric lavage in children because most adult-strength pills (e.g. prenatal vitamins) are large and will not fit through as pediatric lavage tube. Activated charcoal does not bind well with iron. Initiate whole-bowel irrigation if there I radiograph evidence of iron tablets past the pylorus or if iron remains in the stomach after attempts at decontamination. Draw and send a serum iron level 4-6 hrs. after ingestion Consider chelation theraphy with Deferoxamine (Desferal) 15mg/kg/hr by continuous infusion

Indications: y Symptomatic patients y Ingestion of greater than 20 mg/kg of elemental iron y Serum iron levels greater than 350 mcg/100 mL y Deferoxamine administration turns the urine a pink ³vin rose´ color POISONOUS PLANTS Mushrooms Mushrooms species range from delectable to lethal. Typically, wild mushrooms ingestions are nontoxic Signs and symptoms: y y y y y Mushroom poisoning may mimic food poisoning Symptoms that develop within 2 hrs of ingestion are unlikely to be fatal (gastrointestinal symptoms) Symptoms that develop after 6 hrs suggest hepatotoxicity Signs of liver failure CNS disturbances (vertigo, seizures, incoordination)

y

Hepatorenal syndrome

Therapeutic interventions: y y y y y y y y Provide basic and advanced supportive care as indicated If the mushroom is not available, obtain a detailed description of it appearance If a sample of the mushroom is available, save it in a paper bag and place it in a refrigerator The type of mushroom and symptom severity determine interventions Consider inducing emesis if ingestion was recent Administer activated charcoal and a cathartic Observe the patient for seizures and hypotension Give analgesics, sedatives, antispasmodics, and antiemetic as indicated

Nursing Diagnosis: y y y Nutrition imbalanced less than body requirements related to nausea and vomiting Ineffective breathing pattern related to hyperventilation Risk for injury (suffocation) related to contact with chemical pollutants or poisonous agents

FOREIGN BODY OBSTRUCTION Introduction: Foreign bodies in the ear, nose, airway and esophagus sometimes occur in children. Foreign bodies refer to any object that is placed in the ear, nose, or mouth that is not meant to be there and could cause harm without immediate medical attention. Foreign bodies can be classified as either inorganic or organic. Inorganic materials are typically plastic or metal. Common examples include beads and small parts from toys. These materials are often asymptomatic and may be discovered incidentally. Organic foreign bodies, including food, rubber, wood, and sponge, tend to be more irritating to the nasal mucosa and thus may produce earlier symptoms. Foreign body aspiration occurs most frequently in children under the age of 9. Symptoms vary widely and may even be delayed depending on the extent of obstruction. Patients may be asymptomatic or exhibit acute airway compromise Etiology: y y y y y y Young children comprise the most common age group for foreign body obstruction because of the following: They lack molars for proper grinding of food. They tend to be running or playing at the time of aspiration. They tend to put objects in their mouth more frequently. They lack coordination of swallowing and glottis closure. Curiosity, boredom

Signs and symptoms: y y y y y y Sudden onset of choking or gagging Stridor Wheezing Diminished breath sounds (unilateral or bilateral) Dyspnea Cough

y y

Cyanosis Sense of impending doom

Interventions: y y y y y y y y y y y Rapidly assess airway, breathing, and circulatory system Remove (with fingers, suction, or Magill forceps) any objects visible in the mouth If the moving is moving air, encourage coughing (leaning forward to facilitate expulsion) If the patient is moving air, provide supplemental oxygen by any means the patient will tolerate Monitor oxygen saturation and cardiac rhythm continuously Obtain airway equipment and cricothyrotomy tray If the patient is not moving, perform abdominal thrusts (chest thrusts in infants) Facilitate oral tracheal intubation Of the unconscious, nonbreathing patient Direct visualization of the upper airway (with a laryngoscope) may permit foreign body removal If oral intubation is not effective, proceed immediately to a surgical airway

Diagnosis: y y y y y y y The history is given by a parent who has seen the child with an object in his or her mouth and suspects the child might have swallowed it. ABG analysis Administer the test in conjunction with an assessment of appearance, voice, speech, vital signs, physical examination, and pulse- oximetry. Chest radiography CT scanning Fluoroscopy Barium or Gastrografin swallow

Foreign bodies in the ear: Foreign bodies of the ear are relatively common in emergency medicine. They are seen most often but not exclusively in children. Various objects may be found, including toys, beads, stones, folded paper, and biologic materials such as insects or seeds. Clinical features: y y y May be asymptomatic Some may cause pain in the ear, redness, or drainage. Hearing may be affected if the object is blocking the ear canal.

Treatment: y y y y Emergency department care Patients in extreme distress secondary to an insect in the ear require prompt attention. The insect should be killed prior to removal, using mineral oil or lidocaine (2%). EMLA cream has also been reported as being effective to kill the insect as well as provide local anaesthesia.

Methods of removal: y Irrigation is the simplest method of foreign body removal, provided the tympanic membrane is not perforated.

y y y y

Irrigation with water is contraindicated for soft objects, organic matter, or seeds, which may swell if exposed to water. Suction is sometimes a useful means of foreign body removal. Suction the ear with a small catheter held in contact with the object. Grasp the object with alligator forceps. Place a right-angled hook behind the object and pull it out. Form a hook with a 25-gauge needle to snag and remove a large, soft object such as a pencil eraser. Avoid any interventions that push the object in deeper.

Nasal foreign bodies (NFBs) These are commonly encountered in emergency departments. Although more frequently seen in the pediatric setting, they can also affect adults, especially those with mental retardation or psychiatric illness. Children's interests in exploring their bodies make them more prone to lodging foreign bodies in their nasal cavities. In addition, they may also insert foreign bodies to relieve preexisting nasal mucosal irritation or epistaxis Pathophysiology Nasal foreign bodies, Damage to the nasal cavity and surrounding structures. q They can produce local inflammation, which may result in a pressure necrosis. q Mucosal ulceration and erosion into blood vessels producing epistaxis. q Obstruction to sinus drainage q Secondary sinusitis. q Firmly impacted and unrecognized foreign bodies can in time become coated with calcium, magnesium, phosphate, or carbonate and become a rhinolith. Organic foreign bodies tend to swell and are usually more symptomatic than inorganic foreign bodies. Clinical features: y y y y A thorough history from the patient and his or her primary guardian unilateral nasal discharge. Nasal irritation, epistaxis, sneezing, snoring, sinusitis, stridor, wheezing, or fever. Unusual patient presentations, such as irritability, halitosis, or generalized bromhidrosis (body malodor). The physical examination - otorhinolaryngologic examination. Sedation is often helpful in the pediatric population.  Positioning children younger than 5 years in a supine lying position and older children in a sitting "sniffing" position to allow optimal visualization.

 A nasal speculum may also help to view the nasal cavity. Planning/Pretreatment: y Repeated attempts at nasal foreign body (NFB) removal are likely to be successively more difficult, and the object may become more deeply lodged. Therefore, careful planning is important to maximize the likelihood of removal on the first attempt. Having the necessary instruments at the bedside is essential In addition, emergency airway supplies should be readily available in the event that manipulation of the foreign body results in aspiration Pharmacological vasoconstriction of the nasal mucosa can facilitate both examination and removal of a NFB. Anesthesia and mucosal vasoconstriction can be accomplished by applying several drops of 1% lidocaine (without epinephrine) and 0.5% phenylephrine to the affected nostril.

y y

Specific Removal Techniques: y y y y For easily visualized nonspherical and nonfriable objects, most clinicians prefer direct instrumentation. If the object is poorly visualized, spherical, or unsuccessfully removed by direct instrumentation, balloon-catheter removal is a preferred method. For large, occlusive NFBs, positive pressure techniques are commonly used. All attempts at removal can be complicated by mucosal damage and bleeding.

Direct instrumentation: y This technique is ideal for easily visualized, nonspherical, and nonfriable foreign bodies. y Friable and spherical foreign bodies are particularly difficult to remove by this technique: friable objects may tear, and spherical objects may be difficult to grasp and result in posterior displacement. y Instruments include hemostats, alligator forceps, or bayonet forceps, hooked probes (ie, right-angle hook) can be used for objects that are easily visualized but difficult to grasp. y The hook is placed behind the NFB and then rotated so the hook angle is behind the bulk of the object. The object is then pulled forward. Balloon catheters y This approach is ideal for small, round objects that are not easily grasped by direct instrumentation. y Foley catheters (ie, 5, 6, or 8) and the Katz Extractor oto-rhino foreign body remover. y First, the balloon is inspected, and the catheter is coated with 2% lidocaine jelly. Then, it is inserted past the foreign body and inflated with air or water (2 mL in small children and 3 mL in larger children). After inflation, the catheter is withdrawn, pulling the foreign body with it. y Positive pressure y Large and occlusive foreign bodies are especially amenable to the positive pressure technique. y Techniques to expel the NFB out "forced exhalation," can be accomplished by occluding the unaffected nostril and asking the child to blow hard out his or her nose. y If this fails, the positive pressure can be applied by either the parent's mouth ("parent's kiss´) or a bag-valve-mask.  With either method, a tight seal is formed around the child's mouth, while avoiding the nose.  The unaffected nostril is then occluded, and a forceful puff of air is provided.  A potential complication unique to positive pressure techniques is barotrauma to the lungs or the tympanic membranes. However, to date, no cases of this have been reported. Suction y This technique is ideal for easily visualized smooth or spherical foreign bodies. y The catheter tip is placed against the object, and suction is turned on to 100-140 mm Hg (readily supplied by standard medical suction equipment). Posterior displacement

y

y

Rarely, a foreign body may be so posterior that the above techniques will not work. In these cases, after consultation with a specialist, it may be necessary to induce further posterior displacement of the object into the oropharynx for removal. Of course, this would require general anesthesia, endotracheal intubation, and esophageal occlusion.

Magnet y A case report demonstrated successful removal of a loose ball bearing from a nasal cavity using a household magnet Irrigation y This technique has been strongly criticized for carrying a significant risk of aspiration or choking. y The authors do not recommend use of this method; however, it will be reviewed so that clinicians can be aware of its existence. y The irrigation technique is performed by forceful squeezing of a bulb syringe filled with 7 mL of normal saline into the unaffected naris. Foreign body airway obstruction Can be partial or complete blockage of the breathing tubes to the lungs due to a foreign body (e.g., food, a bead, toy, etc.). The onset of respiratory distress may be sudden with cough. There is often agitation in the early stage of airway obstruction. The signs of respiratory distress include labored, ineffective breathing until the person is not longer breathing (apneic). Loss of consciousness occurs if the obstruction is not relieved. Degrees of airway obstructions: Partial obstruction y Good air exchange: forceful cough, wheezing, talking do not interfere y Poor air exchange: weak ineffective cough, high pitched breath sounds, cyanotic, clutches throat (universal distress signal) manage as complete obstruction Complete obstruction y Unable to speak, breath, or cough y Clutches neck (universal distress signal) y Cyanotic (bluish color) Treatment of airway obstruction due to a foreign body includes: y y y Children over 1 year of age: A series of 5 abdominal thrusts (a children's version of the Heimlich maneuver Infants under 1 year of age: A combination of 5 back blows (with the flat of the hand) and 5 abdominal thrusts (with 2 fingers on the upper abdomen). Almost all aspirated foreign bodies can be extracted bronchoscopically.  If rigid bronchoscopy is unsuccessful, surgical bronchotomy or segmental resection may be necessary.  Chronic bronchial obstruction with bronchiectasis and destruction of lung parenchyma may require segmental or lobar resection

Esophageal foreign body Foreign bodies in the upper GI tract are usually swallowed, purposefully or accidentally. After reaching the stomach, a foreign body has greater than a 90% chance of passage. Coins reaching the stomach are very likely to pass into the small bowel. Objects larger than 2 cm in diameter are less likely to pass the pylorus, and objects longer than 6 cm may become entrapped at either the pylorus or the duodenal sweep. Symptoms of Esophageal Foreign Bodies

Oropharyngeal foreign bodies  Patients with oropharyngeal foreign bodies normally present with a foreign body sensation  Variable degrees of discomfort, from minor to more severe.  Inability to swallow secretions.  Rarely, patients may have airway compromise Patients can usually localize the foreign body sensation in the oropharynx.
y

y

Esophageal foreign bodies  35% of children with esophageal foreign bodies are asymptomatic  Gagging, vomiting, and neck or throat pain are common presentations.

Children with chronic esophageal foreign bodies may have y Coughing y Irritability y Blood in saliva y Pain in neck, throat, or chest y Recurrent aspiration pneumonia y Gagging y Respiratory distress y Drooling y Dysphagia y Stridor y Tachypnea or dyspnea y Failure to thrive y Fever y Vomiting y Food refusal y Wheezing y Foreign body sensation in throat y Stomach/small intestine foreign bodies  Patients with foreign bodies in the stomach or small intestine may present with a history of swallowing an object, which has passed through the esophagus.  Patients may present with vague symptoms such as fever, abdominal pain, or vomiting. Management: y Endoscopy- GI foreign body y Smooth-muscle relaxation agents may be used to relax the LES, thereby allowing the passage of foreign bodies lodged in this location. Diagnosis: y The history is given by a parent who has seen the child with an object in his or her mouth and suspects the child might have swallowed it. y ABG analysis y Administer the test in conjunction with an assessment of appearance, voice, speech, vital signs, physical examination, and pulse- oximetry. y Chest radiography y CT scanning y Fluoroscopy y Barium or Gastrografin swallow Complications: y Local inflammation y Edema y cellular infiltration y Ulceration and granulation tissue formation may contribute to airway obstruction y The airway becomes more likely to bleed with manipulation; y the object is more likely to be obscured and becomes more difficult to dislodge y Mediastinitis y Distal to the obstruction, air trapping may occur, leading to y Local emphysema, atelectasis,

y y y y y y y y y

Hypoxic vasoconstriction Post obstructive pneumonia And the possibility of volume loss Necrotizing pneumonia or abscess Supportive pneumonia or bronchiectasis. Entrapment of object within a Meckel's diverticulum Perforation leading to peritonitis and advanced sepsis Acute or sub-acute small-intestinal obstruction Metal poisoning (coins)

Nursing management: y y y Recognize the signs of aspiration Immediate measures to relieve the symptoms Parental education as prevention

Patient Education: y y Educate parents, and other caregivers about providing foods of appropriate size and texture, based on the patient's ability to chew and swallow. Train caregivers in methods of clearing the airway (e.g., Heimlich maneuver, finger sweep).

Nursing Diagnosis of Foreign Body Obstruction: y Anxiety/fear related to loss of vision y High risk for infection related to interruption of body surface y Risk for injury related to sensory dysfunction y Imbalanced nutrition: less than body requirements related to inability to altered taste sensation y Risk for infection related to insufficient knowledge to avoid exposure to pathogens TRAUMA RELATED TO ENVIRONMENT EXPOSURE Heat ±Induced Illnesses Heat Cramps: Heat cramps are caused by sweat-induced electrolyte depletion during intense physical activity in hot weather. Signs and symptoms: y y y y y y y Cramps, particularly in the shoulders, lower extremities, and abdominal wall muscles Weakness Thirst Nausea Tachycardia Profuse diaphoresis Pale, cool, moist skin

Therapeutic interventions:

y

y y

Replace sodium chloride orally or intravenously, depending on the patient¶s clinical status. Commercially prepared balanced electrolyte drinks (e.g., Gatorade, POWERade, or any sports drink) work well for oral electrolyte replacement. Move the patient to a cool location Encourage rest. Following an episode of heat cramps, patients should not return to the hot environment for 1-2 days.

Heat Exhaustion: Heat exhaustion occurs from a combination of prolonged period of fluid loss (from perspiration, diarrhea, or diuretic use) and exposure to warm ambient temperatures without adequate fluid and electrolyte replacement. Untreated heat exhaustion can progress to heat stroke. Signs and symptoms: y y y y y y y y y y Thirst Anorexia, nausea, vomiting Anxiety, general malaise Muscle cramps Sweating: may be profuse, but small children and the elderly have limited sweat capabilities Headache Dehydration, orthostatic hypotension Tachycardia Muscle incoordination Syncope

Therapeutic interventions: y y y y Provide basic and advanced supportive care as indicated Encourage rest Place the patient in a cool environment Administer fluids and electrolytes intravenously

Heat Stroke: Signs and symptoms: y y y y y y y y Rapid symptom onset Hyperthermia: Core temperature is greater than 41º C (105.8º F) Nausea, vomiting, diarrhea Classically, the skin is hot and dry, but perspiration is often present in the early stages, particularly in young, healthy individuals Tachycardia, tachypnea Decreased LOC, abnormal posturing, seizures Dilated, unresponsive pupils Hypotension, decreased urinary output

Therapeutic interventions: y y Cool the patient as rapidly as possible Remove clothing

y y

 Spritz and fan the patient. This involves repeatedly spraying patients with a fine mist and blowing a fan over the skin. This technique minimizes shivering and promotes evaporative cooling.  Place ice packs in the groin and axilla  Iced peritoneal lavage and cardiopulmonary bypass have been used in refractory cases Rehydrate patients with room temperature intravenous fluids Monitor electrolytes and clotting factors

Cold-Induced Injuries Chilblains Also known as pernio, are localized areas of itching, painful redness, and recurrent edema on exposed areas such as the earlobes, fingers, and toes. Symptoms: y y Numbness Tingling

Treatment: y Place the patient in a warm location and cover the affected area

Immersion Foot Immersion foot, or ³trench foot¶, occurs when the feet are wet and subjected to cold temperatures for prolonged periods inside a nonbreathing boot or shoe. Initially, the foot appears pale and wrinkled. Tissue sloughing can develop if the condition if allowed to persist. Therapeutic interventions: y y Warm the affected foot in tepid water Change into dry socks and shoes

Frostbite Frostbite is a traumatic condition that results when ice crystals form in the cells and extracellular spaces.

Superficial Frostbite involves the fingertips, ears, nose, cheeks, or toes. Signs and symptoms: y y y Local burning, numbness, tingling Whitish, waxy skin color After the skin thaws, the area will sting and feel hot. Depending on the length of exposure, large blisters may develop

Therapeutic interventions:

y y y y y

Soak the affected area in warm (40º - 43.3ºC or 104º-110ºF) water. Do not rub injured tissues. Elevate the area Keep the patient warm.(Avoid heavy blankets or materials that may cause friction or weight on the affected area) Give analgesic; rewarming can be painful Ensure tetanus prophylaxis

Deep Frostbite ± produces local vascular and tissue changes resulting in cellular injury and death. Deep frostbite can involve muscle, fat, bones, and tendons as well as skin Several factors influence the probability of sustaining frostbite: y Ambient temperature y Duration of exposure y Contact with moisture or metal objects y Type and number of layers of clothing Other factors that may contribute to an individual s predisposition to frostbite: y y y y y y y Dark skin pigmentation Lack of acclimatization Previous frostbite injury Poor peripheral vascular status Anxiety, exhaustion Frail body type Alcoholism, homelessness

Signs and symptoms: y y y y y y Slight burning pain, followed by a feeling or warmth and then numbness as they are freezes Whitish or yellow-white discoloration of the skin, followed by a waxy appearance Swelling and intense burning accompanying thawing Blisters (usually appear 1 ± 7 days) Edema of the entire extremity that may persist for months Severe discoloration and gangrene are late findings

Therapeutic interventions: Prehospital (or Wilderness) y Prevent further heat loss: o Remove the patients¶ clothing o Cover the patient with dry blankets or sheets o Give warm, noncaffeinated liquids if the patient is conscious and ha an intact gag reflex Protect the injured part from further damage Do not use ice or snow and friction to massage the frozen extremity Do not thaw areas if they are likely to be frozen before definitive care

y y y

In the Emergency Department y y y Immerse the frostbitten part in warm water (40º-433ºC or 104º-110ºF). Maintain the water at a constant temperature Administer warm liquids by mouth if the patient is alert and ha an intact gag reflex Cover the patient with warm blankets; be careful not to place pressure on frostbitten areas

y y

Administer narcotic analgesics (rewarming is painful) Consider tetanus and antibiotic administration

Prevention: y y y y y y Dress properly for the climate; wear layers of loose-fitting clothing When outdoors in cold areas, eat a diet high in carbohydrates and fats Do not smoke or drink alcoholic or caffeinated beverages Prevent bare skin contact with metal objects Keep skin and clothing dry Protect previously frostbitten parts from exposure

BITES Snakebites Of the more than 3000m species most snakes, 375 of these, from different families, are venomous. The five toxic snake families are the following: y y y y y Crotalidae (pit vipers): Copperheads, rattlesnakes, cottonmouths, and water moccasins Elapidae: Coral snakes, cobras, mambas Viperidae (true vipers): Puff adders Hydrophidae: Sea snakes Colubridae: Boomslangs

Risk factors for snakebites include:
y

Outdoor activities

Signs and symptoms: The extent of the reaction depends on the following: y y y y y y y y y Then species and size of the snake The location and depth of the bite The number of bites He amount of venom injected The age of the snake: Young snakes do not release a consistent amount of venom with each bite The age and size of the patient: Small children receive a proportionally greater venom dose Individual sensitivity to venom The concentration of microorganisms in the mouth of the snake The patient¶s general history (e.g., history of diabetes, cardiovascular disease, or renal failure)

Initial Reactions: y y y Burning sensation Odd (metallic or rubber) taste in the mouth Oral and facial numbness and tingling

Local Reactions: y y y y y y Fang marks (usually two) Edema (occurs within 5 mins., can last 36 mins. And may be severe) Pain at the site Petechiae, ecchymosis Loss of limb function Tissue necrosis (16 -36 hrs. after injury)

Systemic Reactions: y y y y y y y y y y y Abnormal vital signs: tachycardia, tachypnea, blood pressure may be elevated initially Dyspnea Nausea, vomiting Diaphoresis Syncope Constricted pupils (unilateral or bilateral), ptosis, diplopia Muscle twitching: mouth, face, and the affected extremity (app. 1 hr. after the bite) Paresthesias: numbness and tingling orally and the wound site Salivation Difficulty peaking, confusion Bleeding disorders manifested by ecchymosis, hematemesis, hemoptysis, hematuria, epistaxis, melena

Severe Systemic Reactions: y y y y y y Pulmonary edema Seizures Severe coagulopathies and hemorrhage Renal failure Paralysis Hypovolemic shock

Therapeutic interventions: y y y y y Remove potentially constricting clothing or jewelry Immobilized the involved area at or below the level of the heart Cleanse the wound and provide tetanus prophylaxis as indicated Give analgesics for pain Begin antivenin therapy in patients with progressive deterioration.

Insect Bites Insect bites and stings cause skin reactions. They can include itching, rashes, and sometimes swelling. Most bites and stings can be safely treated at home. Those that cause allergic reactions may require prompt medical attention. Causes:
y y

Biting insects (e.g., mosquitoes, fleas, ticks, and spiders) Stinging insects (e.g., bees, yellow jackets, hornets, wasps, and fire ants)

Risk Factors: y y y y y y The following factors increase your chances of being bitten or stung by an insect: Performing work or spending time outdoors Living in warmer climates Lacking proper protection Forgetting to use flea and tick preventive measures for pets Collecting insects as a hobby

Symptoms:
y y y y y

Mild swelling around the affected area Redness around the affected area Pain around the affected area Heat around the affected area Itching around the affected area

If you experience a severe allergic reaction, get medical help immediately. Symptoms of a severe allergic reaction include:
y y y y y y y y y y

Shortness of breath Wheezing Swelling, redness, or hives covering most of your body A feeling that your throat is closing up Nausea or vomiting Chills, muscle aches, or cramps Weakness Fever Abdominal pain Headache sweating

Diagnosis:
y y y y y y y

Complete blood count Electrolytes Calcium Glucose BUN Creatinine Creatine kinase

Treatment: Most insect bites and stings can be safely treated at home. If this is the case, take the following steps:
y y y y y

If there is a stinger, carefully remove it. This can be done by scraping it with a sharp edge, such as a credit card. If you find a tick, carefully remove it from the head as soon as possible. Tweezers are often effective in doing this. Be careful to gently tug on the tick. Rock it back and forth until the jaws release. Wash the affected area thoroughly with soap and water. Place an ice pack or cold compress on the affected area for 15 minutes every few hours. If necessary, to alleviate itching:

 Use calamine lotion  Antihistamines  Topical steroid cream (e.g., hydrocortisone ) y

If necessary, to reduce swelling and pain take pain relievers such as:
 Acetaminophen  Ibuprofen

If you were bitten by a brown recluse or black widow spider, or are unsure and you feel sick, get medical treatment quickly. Treatment may include:
y y y

Stabilization of symptoms you may have Medications to reduce pain Antivenin to rapidly relieve symptoms

If you or someone you know is having a severe allergic reaction, seek medical help immediately. Once you arrive at the hospital, treatment may include:
y y y y

Emergency treatment to stabilize life-threatening symptoms Medications ( e.g., epinephrine, antihistamines, and/or corticosteroids) Intravenous fluids Oxygen venom immunotherapy²administering increasing doses of venom to stimulate your immune system to reduce the risk of a future allergic reaction

Prevention: y y y y y y y y y y y y y y y y Use insect repellents. These work against biting insects such as mosquitoes. Use caution around areas where insects nest. Areas include walls, bushes, trees, and open garbage cans. Reduce the amount of skin exposed when you are outdoors. Regularly treat your home for fleas during warmer months. Treat fire ant mounds with insecticides. Never swat at a flying insect. Keep foods covered as much as possible when eating outdoors. Cover outdoor garbage cans with tight-fitting lids. Avoid sweet-smelling perfumes, deodorants, lotions, hair sprays, and colognes. Avoid wearing bright colors. Wear gloves when gardening. Stay away from areas where mosquitoes breed, such as areas around still water. Stay inside at dawn and dusk, when mosquitoes are most active. Do not disturb bee or wasp nests. Be cautious in areas where spiders might be hiding. Areas include undisturbed piles of wood, seldom-opened containers, or corners behind furniture. Use flea and tick control for pets.

Animal bites An animal bite can result in a break in the skin, a bruise, or a puncture wound.

Causes: Pets are the most common cause of bites, with dog bites occurring most often. Cat bites may have a higher chance of infection (due to their longer, sharper teeth, which can produce deeper puncture wounds). Stray animals and wild animals, such as skunks, raccoons, and bats; also bite thousands of people each year. If you are bitten by a wild animal or an unknown pet, try to keep it in view while you notify animal control authorities for help in capturing it. They will determine if the animal needs to be impounded and checked for rabies. Any animal whose rabies vaccination status is unknown should be captured and quarantined. Symptoms Possible symptoms include:
y y y y

Break or major cuts in the skin with or without bleeding Bruising Crushing injuries Puncture-type wound

Certain diseases can also be spread through bites from various animals. These diseases may cause flu-like symptoms, headache, and fever. First Aid y y y y y Calm and reassure the person. Wear latex gloves or wash your hands thoroughly before attending to the wound. Wash hands afterwards, too. If the bite is not bleeding severely, wash the wound thoroughly with mild soap and running water for 3 to 5 minutes. Then, cover the bite with antibiotic ointment and a clean dressing. If the bite is actively bleeding, apply direct pressure with a clean, dry cloth until the bleeding stops. Raise the area of the bite. If the bite is on the hand or fingers, call the doctor right away. Over the next 24 to 48 hours, watch the area of the bite for signs of infection (increasing skin redness, swelling, and pain). If the bite becomes infected, call the doctor or take the person to an emergency medical center.

y

Prevention: y y Teach children not to approach strange animals. Do NOT provoke or tease animals.

Nursing Diagnosis for Bites: y y y y y Impaired skin integrity related to disruption of skin surface with destruction of skin layers Anxiety related to perceived threat of death Deficient fluid volume related to wounds Risk for impaired skin integrity related to increased susceptibility to infection. Potential impaired skin integrity related to insect bites, scratching.

ANTIDOTES: Exposure/Condition Black widow spider Rattlesnake Carbamates Organophosphates Neuroleptic drugs (haloperidol, phenothiazines, Thioxanthenes) and metoclopramide Botulism Calcium channel blockers Hydrofluoric acid burns Lead Cyanide Gold Iron Cocaine Snakebites Beta-blockers Methanol Antidote Antivenin Antivenin Atropine, Pralidoxime Benztropine (Cogentin)

Botulinum antitoxin Calcium chloride Calcium gluconate Calcium disodium edentate Nitrite, Sodium thiosulfate Dimercaprol Deferoxamine Diazepam Antivenin Glucagon Ethanol, fomepizole

References: Sheehy¶s Manual of Emergency Care 6th Edition, Elsevier Mosby Textbook of Medical-Surgical Nursing 6th Edition, Brunner/Suddarth http://www.mayoclinic.com/health/food-poisoning/DS00981/DSECTION=risk-factors http://www.nlm.nih.gov/medlineplus/ency/article/002492.htm http://www.scribd.com/doc/35910851/Foreign-Body-Obstruction http://www.nlm.nih.gov/medlineplus/ency/article/000034.htm