Emergency and Disaster Nursing
Content
EMERGENCY AND DISASTER NURSING Scope and Practice of Emergency Nursing • Emergency management traditionally refers to urgent and critical care needs; • however, the ED has increasingly been used for non-urgent problems, and emergency management has broadened to include the concept that an emergency is whatever the patient or family considers it to be The emergency nurse has: • Special training, education, experience, and expertise in assessing and identifying health care problems in crisis situations • Nursing interventions are accomplished interdependently in consultation with or under the direction of a physician or nurse practitioner • The emergency room staff works as a team Four Basic Emergency Action Principles • Survey the scene – If any kind of danger is threatening, do not approach the casualty, call EMS immediately for professional help. • Check the casualty for any for unresponsiveness • If the person does not respond, Call EMS • Check the casualty’s airway, breathing and circulation (ABC’s) : try to the airway without moving the patient Priority Emergency Measures for All Patients • Make safety the first priority • Preplan to ensure security and a safe environment • Closely observe patient and family members in the event that they respond to stress with physical violence • Assess the patient and family for psychological function • Patient and family-focused interventions – Relieve anxiety and provide a sense of security – Allow family to stay with patient, if possible, to alleviate anxiety – Provide explanations and information – Provide additional interventions depending upon the stage of crisis PRINCIPLES OF TRIAGE What is TRIAGE? - it is sorting - from the French word “trier” meaning to choose, referred to a battlefield - the rapid focused assessment What is the purpose of TRIAGE? - is to sort or classify all incoming ED patients - the goal is to get the Right Patient to the Right Place at the Right Time for the
Right Reason to receive Right Treatment
How long should the TRIAGE take? - the common goal is to assess the patient within 25 minutes for adults (but this time according to ENA caters up to 22% only of patients per hundred in 8 hours) - for pediatrics, 7 minutes Who should perform the ED TRIAGE function? - the Joint Commission on Accreditation of Healthcare Organization (JCAHO) doesn’t entails what are the specifics of the triage nurse - Emergency Nurses Association (ENA) 1999 established he standards of Emergency Nursing Practice, states that safe, effective triage can only be performed by a registered professional nurse, educated in the principles of triage and has minimum experience of 6 months in emergency nursing - The triage nurse should classify patient 24/7 What are the Essential Components of Comprehensive TRIAGE? 1. An initial across-the- room look or visualization. This includes ABCD. For pediatric clients, this may include critical look, general appearance, work of breathing and circulation 2. A rapid triage (60secs) of an appropriately elicited chief complaint, key questions, assessment such as feeling of the pulse and fracture in the extremities 3. Completion of a focused triage history and physical assessment. This include vital signs, pulse oximetry reading, diagnostics and institution’s protocol 4. The triage decision, in which the triage acuity or level is assigned. This determines the urgency of the condition, includes the MSE and additional assessment. What should the triage history include? Medications Exposure to infection Allergies Pregnancy Immunization LMP Past medical history Family history
What are the some examples of Adult Mnemonics? PQRST Pain assessment P precipitating factors Q quality R radiation S severity T time
T treatment PHOSPHATE For the history of the chief compliant Problem Onset Associated Symptoms Previous History Precipitating Factors Alleviating/ Aggravating Factors Timing Etiology CIAMEDS (from Emergency Nursing Pediatric Course) Chief Compliant Immunization Allergies Medications Past Medical History Events Surrounding Diets/ Diapers Symptoms Associated with injury or illness SAVE A CHILD (From ENA Hawaii- SAVE Are observations before touching the child, A CHILD are key history and examination components) Skin Activity Ventilation Eye Contact Abuse Cry Heat Immunization Level of Consciousness Dehydration What are some tips for better TRIAGE - Look at the patient, listen and do not write while the patient is talking to you - Never appear shocked by what the patient tells you - Do not discount the patient’s concern on triage - Watch people’s faces - Ask specifically about drugs recently started - Do not assume patients are taking their medications - Use the language of symptoms, feelings, and thoughts - Remember that he patient’s diagnosis is not necessarily the correct diagnosis - Exhibit concern for a higher acuity in the presence of other risks factors, or co-morbidities/ chronic illness - Remember hat alcoholics can be sick and intoxicated at the same time - Ask the patient at the end of he triage encounter if here is anything else the patient wants to say What are the prioritization principles? - Airway
- Breathing - Circulation - Disability - Systemic before local; life before limb - Acute before chronic; short term before long - Central before peripheral - Actual over Potential - Trending (worsening trend could consist of minor symptoms that tend to reoccur repeatedly, increase in severity, or indicate a steady progressive decline) - Potential for worsening (ex. Drug overdose and chest tightness) TOXICOLOGY (Poisoning and Drug Overdose) A. General Guidelines - maintain adequate airway, breathing and cardiac output - Patients who ingested large amounts of TCA may require intubation immediately even if mental status has not yet occurred. - Perform gastric lavage - Induce emesis for patients with alkali ingestion - Contact local poison control center at UP College of Medicine 524-1078, 524-5651 loc 2311 - East Ave Med Ctr 928-0611 - Consider possibility of suicide - All female with chemical ingestion should undergo pregnancy test B. Principles of Decontamination External Decontamination - Wash skin with soap and water - Remove cloths - Keep warm, use blankets Gastric Lavage - contraindications includes strong ingestion of strong acids, alkalis, petroleum and distillates. - Airway must be protected with endotracheal tube unless awake, alert and has a gag reflex - Position head on one side of he bed to prevent aspiration - If the patient has severe DOB stat intubation - Perform gastric lavage unless overdose with acid - Lavage is useful within two hours of ingestion Activated Charcoal - Always consider giving charcoal after emesis or lavage until specifically contraindicated - Multiple doses of charcoal in (+) metamphetamine, phenothiazines, digoxin, theophylline, phenobarb, and organophosphates - Activated charcoal is not effective for alkalis, cyanide, mineral acid and ferrous sulfate Cathartics - contraindicated with infants (risk for dehydration), intestinal obstruction, electrolyte imbalance - sodium sulfate is contraindicated in HPN and heart failure Forced Diuresis
- forced neutral diuresis may be helpful for isoniazid, bromide and ethanol intoxification - make sure to monitor electrolytes - forced alkaline diuresis may be useful for Phenobarbital, salicylates and lithium using sodium bicarbonate. C. Guidelines for Nurses - when antidotes are ordered, it is meant to be given immediately or at least reasonably within the hour in some cases. They are not given when it is the convenient dosing period for the nurses.
Digitalis Overdose - considered NGT insertion and gastric lavage - secure digitalis assay, CBC, Ca, K, Mg, CXR and ECG/ cardiac monitor - the treatment goal would be to correct hypokalemia. Hypomagnesemia or hypocalecemia. - The doctor may prescribe charcoal and cathartics - Watch out for hypotension; fluid challenge my be instituted - For arrythmias, lidocaine may be given Ethanol Toxicity - maintain adequate airway, ventilation, circulation and administer oxygen - Thiamine is useful to protect/ prevent liver damage - Phynetoin my be given in cases of seizure, but make sure to give it SIVP and hook the patient to the cardiac monitor Narcotic Overdose - maintain airway, ventilation and circulation - may start on Naloxone 2mg every 5 minutes , max 10mg IV, IM SQ - Activated charcoal if (+) for bowel sounds and cathartics - Watch out for signs of pneumonia, infections and rhabdomyolysis - Watch out for complications such as seizure, pulmonary edema and hypotension Hydrocarbon/ Kerosene Ingestion - Respiratory support - Treatment is not required in the absence of symptoms - Promote gastric emptying - Remove contaminated clothing and wash affected skin with soap and water. - Provide supplemental oxygen - secure CBC, ABG abd CXR Isoniazid Overdose - place an NGT and do gastric lavage is clean - watch out for seizure, lactic acidosis may give sodium bicarbonate - consider mannitol administration for forced diuresis - secure CBC, RBS, K, ABG Narcotic Overdose - maintain airway, ventilation and circulation - may give naloxone 2.0mg q 5 minutes initially max of 10mg IV, IM SQ - start activated charcoal if (+) with BM and cathartics - watched out for complications, PNA, hypotension, and seizures is (+) norpethidine Insecticides/ Pesticides Therapeutics 1. Decontamination - make he patient rinse with alkaline or baking soda (10gm in 100cc) - change cloths and wash the patient with gloves - insert NGT and do gastric lavage wih activate charcoal
Specific Substance Ingestion Acid Ingestion - provide airway control, ventilation, circulatory support, and fluid resuscitation - wash the oral cavity (controversial) - emesis, lavage and charcoal are contraindicated - secure serial CBC and cros-matching - maintain NPO Alkali Ingestion - immediately rinse oral cavity - administer oxygen and IVF - secure serial CBC, CXR, and monitor electrolytes - esophagoscopy and gastroscopy should be performed immediately if there is drooling, stridor and painful swallowing Amphetamine/ Metamphetamine Toxicity - start charcoal and cathartics - emesis has no role - WOF for seizure, psychosis, agitation, hypertensive crisis, arrhythmias - Secure ABG, CBC with PC, PT, PTT, RBS, BUN, Crea, Na, K, UA - Diazepam and Phenytoin for seizure - Beta-blockers, Lidocaine for dysrythmias Anticoagulant Overdose - Secure lab results such as CBC with PC, PT, PTT and Creatinine - For Heparin: Give protamine sulfate at 1mg iv for every 50-100 units of heparin infused in the preceeding 2 hours, dilute in 25-50ml fluid over 10 minutes - For Warfarin: perform gastric lavage and give activated charcoal if recently ingested; give vitamin k 5-10 mg every 8-12 hours; give FFP 2-6units for severe bleeding Diazepam Overdose - Place NGT and do gastric lavage - Protect airway - Instill activated charcoal, followed by repeated doses of 20-25 gm via NGT - Secure RBS, ABG, ECG and CXR - Watched out for hypotension, CNS and respiratory depression and withdrawal syndrome such as agitation, seizure, restlessness and insomnia.
2. Activated charcoal 3. Antidote 4. In cases of seizure; consider Phenytoin 5. wof for hypoglycemia 6. Give mannitol if with good urine output - secure CBC, RBS, ABG, SGOT and SGPT Paracetamol Overdose - Insert NGT - Activate charcoal about 30-100mg and then remove via NGT suction prior to acetylcysteine - Sodium Sulfate to induce vomiting - Antidote: N-acetylcysteine (NAC) . the initial administration would be 150mg/kg body weight infused in 200ml 5% dextrose over 15 minutes followed by IV infusion of 50mg/kg in 500ml of 5% dextrose water - NAC is very effective in preventing paracetamolinduced hepatotoxicity when administered; when administered with in 8 hours from the time of ingestion, the better. But beyond 8 hours, the protective effect diminishes progressively as the treatment interval increases Salicylate Poisoning Diagnostics: - CBC, K, RBS, ABG and UA - PT, PTT, SGOT, SGPT and alk Posh with 48 hours post ingestion Therapeutics: - Stabilize respiratory and cardiac functions - Avoid diluting the gastric contents since this may incease gastric absorption - Consider NGT insertion - Give activated charcoal 1gm/ kg body weight every 6 hours - Sodium sulfate 15-30 gm in 100cc H20 orally if tolerated or with NGT with every other doses of activated charcoal to prevent charcoal constipation or fecal impaction - To increase urine ph, consider sodium bicarbonate - Glucose and KCl should be infused with other fluids Treatment Plan - if with dehydration and hypokalemia, manage with vigorous and with electrolyte replacement - Cerebral edema can be best avoided using hypertonic rehydration solution - Alkaline diuresis to maintain urinary ph at approx 8 - Monitor urine output - Assess hydration status - Watch closely for signs of fluid overload - Hemodialysis is indicated for initial salicylate level of >160ml/dl or with profound acidosis of below 7; or when there is renal failure, severe CNS dysfunction, pulmonary edema or deterioration despite supportive therapy Other Treatments - Acidemia: NaHCO3 - Seizure: Diazepam
- Pulmo Edema: treat with high concentration of oxygen, furosemide and PEEP - Cerebral Edema: treat with hyperventilation and osmotic diuresis with Mannitol SHOCK (Multisystem Stressor) Pathophysiology - Shock is a multisystem stressor that involves inadequate tissue perfusion and altered metabolism. - Inadequate tissue perfusion can lbe a result of nay condition that alters heat function (cardiogenic), blood volume(hypovolemic), blood pressure (neurogenic) and distribution of blood volume (septic/ anaphylactic) - Shock is a very complex clinical syndrome in which tissue perfusion is inadequate to meet the demands for oxygen - It alters cellular functions and eventually impairs body organ functions - Multi Organ Dysfunction Syndrome (MODS) is a term used to describe several impairment of the human functions Sepsis and Septic Shock - Sepsis is an acute systemic clinical syndrome caused by bacteria, viruses or fungi in the blood, most commonly gram (-) bacilli - At an early phase, generalized inflammatory response is triggered, causing widespread vasodilation - The progression to septic shock is due to the toxins released from the organism involved - Bacterial endotoxins activates the complement, coagulation and fibrinolytic system; inceases vascular permeability and trigger the vasoactive kinins causing vasodilation and increased capillary permeability thereby decreasing the vascular resistance and facilitating fluid shifting from intravascular to interstitial - Another response would be due to the histamine release causing increase in vascular permeability - This changes are further stimulated by the catecholamine and prostaglandins that are released from ischemic tissues - “COLD SHOCK” is he term used during the stage in which tissue perfusion becomes severely compromised and ischemic cellular damage occurs. - In addition the, fever is present due to the pyrogens released by the organism Anaphylactic Shock - systemic anaphylactic shick is potentially life threatening situation - it is he result of an exaggerated hypersensitivity response to an antigen - the classic form of anaphylaxis occurs in a sensitized person usually 1-20 minutes ater the exposure to the antigenic substance - the most common substance that can cause reactions would be, drugs, antibiotics, foods, anesthetics, antisera and blood products - hypersensitivity reaction occurs over the surface of
he mast cells which are located primarily in he lungs, small blood vessels and connective tissues - it also attacks basophils circulating in the blood - the antigenic substance triggers the release of kinins, histamines, prostaglandins, eosinophils, neutrophils - “sow reacting substance of anaphylaxis” (SRSA) such as prostaglandins and leukotrienes produces deleterious results icluding profound shock - Histamine is he primary mediator of anaphylactic attack. Leukotrienes produces vasoconstriction that is even worst than histamine - The prostaglandins exaggerate the bronchoconstriction; kinins increases the vascular permeability - The combined effects of the substance causes respiratory distress and obstruction Toxic Shock - it is another syndrome of shock believed caused by bacterial toxins - e.g. Staph A enters he blood steam from the site of infection, commonly the vagina, diffusing across the mucus membranes. Hey are then circulated throughout the body - thise toxins causes massive vasodilatation and eventually to a shock state For Septic Shock Assessment - history and risk factors includes, malnutrition, immunosuppresion, liver and renal diseases, recent traumayic injuries, surgical or invasive procedure - commonly caused by E Coli, Klebsiella, Enterobacter, Staph A. as well as fungi and viruses For Anaphylactic Assessment - recent exposure to pharmacological agents, blood transfusion and insect bites or stings - clinical presentation is dependent on several factors and varies with the portal of antigen entry, the amount absorbed, rate of absorption, and the degree of hypersensitivity - Ingestion: cramping, nausea, vomiting and may precede systemic shock syndrome - Inhalation: hoarseness, dyspnea and whezing - Allergic: urticaria or itching at the site of the sting, or drug injection Diagnostic Test/ Procedure -WBC, serum glucose, GS-CS, ABG, BUN, CT, BT, Liver studies Collaborative Management (Septic) - antibiotic therapy specific to he organism - Hemodynamic monitoring - Fluid resuscitation - Inotropic Agents - Ventilatory Support - Alkaline Support - Nutritional Support - Steroids - Antipyretic Agent - Naloxone
- GI solution Collaborative Management (Anaphylaxis) - Airway maintenance - Epinephrine - Supplemental Oxygen - Fluid Resuscitation - Vasopressors - Angi-histamine - Bronchodilator - Steroids - Mast cell stabilizer - Glucagon - ECG monitoring Nursing Diagnosis and Intervention (SEPSIS) 1. Fluid volume deficit related to active loss from vascular compartment secondary to increased capillary permeability and shifting of intravascular volume into interstitial spaces Desired Outcome Within 4 hours of initiation of therapy, the patient is normovolemic as eveidenced by good peripheral pulses, stable body weight, good urine output and decreased adventitious breath sounds Intervention - Monitor hemodynamic pressures - Administer crystalloid and fluid replacement as prescribed - VS hourly - Maintain proper inotropic administration - Weigh patient daily - Monitor specific gravity - Assess for interstitial edema - Proper positioning 2. Decreased Cardiac Output related to negative inotropic changes at the myocardium secondary to effects of tissue O2 deprivation Desired Outcome Within 8 hours of initiation of therapy, patient has a n adequate cardiac output as evidenced by good BP, urine output and god peripheral pulses Intervention - Assess patient for signs of deceasing CO - Administer inotropics as prescribed - Position patient on supine to increase/ optimize preload and enhance stroke volume - Monitor cardiac rhythm - Minimize cardiac oxygen demand by assisting patient with ADL 3. Altered Cerebral, renal, gastrointestinal tissue perfusion related to decreased to circulating blood volume secondary to massive vasodilatation and interruption of arterio-venous blood flow associated to vasoconstriction and clot formation Desired outcome Within 24 hours after initiating therapy, the patient
has an adequate tissue perfusion as evidenced by orientation to time, place and person, good bowel sounds and good urine output Intervention - Assess LOC hourly - Assess signs of decreasing renal perfusion - Assess/ monitor peripheral vascular resistance - Assess peripheral pulses - O2 saturation monitoring - Assess evidence of decreasing visceral circulation including bowel sounds * Other examples of nursing problems… 4. Impaired Gas exchange, related to alveolarcapillary membrane changes secondary to interstitial edema, alveolar destruction and endotoxin release with activation of histamine and kinins 5. Ineffective breathing pattern related to decreased lung function secondary to central respiratory depression occurring in the lat shock 6. Ineffective thermoregulation related to successful entry bacterial endotoxins, increasing the hypothalamic termperature regulating center 7. Altered Nutrition less than body requirements related to increased need secondary to increased metabolic rate
Intervention: - Monitor patient for the presence of SOB - Secure ABG results as necessary - Monitor pulse oximetry reading regularly - Administer steroids as prescribed - Position patient in a sitting position to enhance lung expansion - Remain with the patient, encourage slow, deep breathing if possible. Help patient alleviate anxiety by responding calmly and explaining all procedures before performing to them 3. Decreased cardiac output related to decreased preload and afterload secondary to release of vasoactive chemical mediators and associated vasodilation and increased capillary permeability Desired Outcome: After 4 hours of continuous nursing intervention, the patient has an adequate cardiac output as evidenced by a near normal BP of morethan 90/60, good urine output and normal sinus rhythm Intervention: - Assess for physical and hemodynamic parameters indicating a decreased cardiac ouput Check for apical pulse Palpate peripheral for amplitude Assess BP Calculate MAP Measure CVP - Monitor ECG changes - WOF signs of edema - Admisister fluid replacement therapy as prescribed - Administer vasopessors as prescribed Multiple Injury This includes: 1. Major Trauma 2. Craniocerebral Trauma 3. Chest Trauma 4. Abdominal Trauma 5. Renal and Lower Tract Trauma Mechanisms of Injury: - Objects Producing Injury (ex. MVA, handgun, glass, wood, metal) - Type of Energy (ex. Kinetic, thermal, chemical, radiation) - Force of Energy (ex. Velocity, tension force, shearing force) - Use of Protective devices (ex. Helmet, airbags, seat belt) Types of Injury: Blunt Injury – occurs without interruption on the skin integrity Penetrating – are produced from the motion of the objects that penetrate the tissue causing direct damage. Oxygen Delivery and Consumption - an oxygen debt is created by a profound imbalance
Nursing Diagnosis and Interventions (Anaphylaxis) 1. Ineffective airway clearance realated to tracheobronchial obstruction secondary to bronchoconstriction and increased secretions associated with histamine response and the presence of leukotrienes and prostaglandins Desired Outcome: Within 2 hours of intervention, the patient has an adequate airway clearance as evidenced by by a state of eupnea and the presence of breath sounds in all lung fields Interventions: - Assess patency of airway on a continuing basis. Auscultate all lung fields - Stand by Adrenergic agent in case of cardiopulmonary arrest - Maintain intubation set at all times - If laryngeal edema pevents intubation, prepare tracheostomy set - Monitor ABG results 2. Impaired gas exchange related to alveolocapillary membrane changes secondary to increased vascular permeability associated with histamine response Desired Outcome: Within 2hours of initiation of intervention, he patient has adequate gas exchange as evidenced by eupnea and O2 sat of more than 90%
between oxygen supply and demand brought about by hypovolemia and inadequate tissue perfusion - after initial restoration of circulating blood volume, he body develops a “hyperdynamic circulatory state”, which is associated with improved survival and fewer complications - the hyperdynamic state usually peaks within 48-72 hours and diminishes in 7 -10 days - inability to achieve this state increases the mortality Neuroendocrine Stress Response - shortly after the trauma, the CNS triggers a series of reactions that promotes cmpentation including brain, blood, and bone marrow - cathecolamines are released - these hormones mobilizes glycogen stores, increases glucose availablty, suppresses pancreatic insulin, resulting in an increase net of glucose - centrally mediated release of ADH promotes water absorption, increasing intravascular volume and diminishes urine output Systemic Inflammatory Response Syndrome - the release of cathecolamine triggers massive amount of WBC at the site of injury - SIRS is used without he presence of infection; SEPSIS is termed in the presence of a widespread inflammation and infection Multi Organ Dysfunction Syndrome Coagulopathy Hypothermia Psychologic Response Environmental Emergencies—Heat Stroke • A failure of heat regulating mechanisms • Types – Exertional: occurs in healthy individuals during exertion in extreme heat and humidity – Hyperthermia: the result of inadequate heat loss • Elderly, very young, ill, or debilitated—and persons on some medications—are at high risk • Can cause death • Manifestations: CNS dysfunction, elevated temperature, hot dry skin, anhydrosis, tachypnea, hypotension, and tachycardia Management of Patients With Heat Stroke • Use ABCs and reduce temperature to 39° C as quickly as possible • Cooling methods – Cool sheets, towels, or sponging with cool water – Apply ice to neck, groin, chest, and axillae – Cooling blankets – Iced lavage of the stomach or colon – Immersion in cold water bath • Monitor temperature, VS, ECG, CVP, LOC, urine output • Use IVs to replace fluid losses – Hyperthermia may recur in 3 to 4 hours; avoid hypothermia
Environmental Emergencies—Frostbite • Trauma from freezing temperature and actual freezing of fluid in the intracellular and intercellular spaces • Manifestations: hard, cold, and insensitive to touch; may appear white or mottled; and may turn red and painful as rewarmed • The extent of injury is not always initially known • Controlled but rapid rewarming; 37° to 40° C circulating bath for 30- to 40-minute intervals • Administer analgesics for pain • Do not massage or handle; if feet are involved, do not allow patient to walk Environmental Emergencies—Hypothermia • Internal core temperate is 35° C or less • Elderly, infants, persons with concurrent illness, the homeless, and trauma victims are at risk • Alcohol ingestion increases susceptibility • Hypothermia may be seen with frostbite; treatment of hypothermia takes precedence • Physiologic changes in all organ systems • Monitor continuously Management of Patients With Hypothermia • Use ABCs, remove wet clothing, and rewarm • Rewarming – Active core rewarming Cardiopulmonary bypass, warm fluid administration, warm humidified oxygen, and warm peritoneal lavage – Passive external rewarming Warm blankets and over-the-bed heaters • Cold blood returning from the extremities has high levels of lactic acid and can cause potential cardiac dysrhythmias and electrolyte disturbances Management Patients With Carbon Monoxide Poisoning • Inhaled carbon monoxide binds to hemoglobin as carboxyhemoglobin, which does not transport oxygen • Manifestations: CNS symptoms predominate – Skin color is not a reliable sign and pulse oximetry is not valid • Treatment – Get to fresh air immediately – Perform CPR as necessary – Administer oxygen: 100% or oxygen under hyperbaric pressure • Monitor patient continuously Management of Patients With Chemical Burns • Severity of the injury depends upon the mechanism of action of the substance, the penetrating strength and concentration, and the amount of skin exposed to the agent • Immediately flush the skin with running water from a shower, hose, or faucet – Lye or white phosphorus must be brushed off the skin dry
• Protect health care personnel from the substance • Determine the substance • Some substances may require prolonged flushing/irrigation • Follow-up care includes reexamination of the area at 24 hours, 72 hours, and 7 days Management of Patients With Substance Abuse • Acute alcohol intoxication: a multisystem toxin – Alcohol poisoning may result in death – Maintain airway and observe for CNS depression and hypotension – Rule out other potential causes of the behaviors before it is assumed the patient is intoxicated – Use a nonjudgmental, calm manner – Patient may need sedation if noisy or belligerent – Examine for withdrawal delirium, injuries, and evidence of other disorders Crisis Intervention—Rape Victims • How the patient is received and treated in the ED is important to his or her psychological well-being • Crisis intervention begins as soon as the patient enters the facility; the patient should be seen immediately • Goals are to provide support, reduce emotional trauma, and gather evidence for possible legal proceedings • Patient reaction; rape trauma syndrome • History taking and documentation • Physical examination and collection of forensic evidence • Role of the sexual assault nurse examiner (SANE) Psychiatric Emergencies • Overactive, underactive, violent, and depressed or suicidal patients • Management – Maintain the safety of all persons and gain control of the situation – Determine if the patient is at risk for injuring himself or others – Maintain the person’s self-esteem while providing care – Determine if the person has a psychiatric history or is currently under care to contact the therapist • Crisis intervention • Interventions specific to each of the conditions
Terrorism, Mass Casualty, and Disaster Nursing Emergency Operations Plan (EOP) • Health care facilities are required by the Joint Commission on Accreditation of Healthcare Organizations to create a plan for emergency preparedness and to practice this plan twice a year • Essential components of the plan: – An activation response – An internal/external communication plan – A plan for coordinated patient care – Security plans – Identification of external resources – A plan for people management and traffic flow • Essential components of the plan: – A data management strategy – Deactivation response – Post-incident response – A plan for practice drills – Anticipated resources – Mass casualty incident planning – An education for all of the above Managing Short- and Long-Term Psychological Effects After a Disaster • Provide active listening and emotional support • Provide information as appropriate • Refer to therapist or other resources • Discourage repeated exposure to media regarding the event • Encourage return to normal activities and social roles • Critical incident stress management (CISM) • Programs that include education, field support, defusing, debriefing, demobilization, and follow-up components • Persons with ongoing stress reactions should be referred to mental health specialists
Roles and Function of the Nurse in Emergency and Disaster Nursing • Educator • Counselor • Team member • Facilitator (include triaging) • Advocate • Researcher
Personal Protective Equipment (PPE) • Purpose: to shield the health care provider from chemical, physical, biological, and radiologic hazards that may exist when caring for contaminated patients • Categories of protective equipment: – Level A: self-contained breathing apparatus (SCBA) and vapor-tight chemical-resistant suit, gloves, and boots – Level B: high level of respiratory protection (SCBA) but lesser skin and eye protection; chemicalresistant suit – Level C: air-purified respirator, coverall with splash hood, and chemical-resistant gloves and boots – Level D: typical work uniform Isolation Precautions for Biological Terrorism Agents • Biological agents may be delivered or spread in a number of ways • Due to 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 upon the infecting agent • Always use Standard Precautions • Some agents require Transmission-Based Precautions • Terminal disinfection and disposal of wastes depends on the infecting agent Chemical Weapons • Chemical substances that quickly cause injury and/or death and cause panic and social disruption • Agents – Nerve agents – Blood agents – Vesicants – Pulmonary agents • Agents vary in volatility, persistence, toxicity, and period of latency • Limitation of exposure is essential with evacuation and decontamination as soon possible and as close to the scene of the incident as possible Nerve Agents • Sarin and soman organophosphates • Inhibit cholinesterase-causing cholinergic symptoms progressing to loss of consciousness, seizures, copious secretions, apnea, and death • Treatment: supportive care, atropine, benzodiazepine, and pralidoxime • Decontaminate with copious amounts of soap and water or saline for at least 20 minutes • Blot; do not wipe off • Plastic equipment will absorb sarin gas Vesicants • Lewisite, sulfur mustard, nitrogen mustard, and phosgene • Cause blistering and burning • Respiratory effects can be serious and cause death • Decontaminate with soap and water; do not scrub or use hypochlorite solutions • Eye exposure requires copious irrigation • Treatment for lewisite exposure: dimercaprol IV or topically Radiation Exposure • Radiation exposure may occur due to nuclear weapons, nuclear reactor incidents, or exposure to radioactive samples • Exposure to radiation is affected by time, distance, and shielding • Types of radiation exposure: – External radiation: all or part of the body is exposed to radiation; as decontamination is not necessary, it is not a medical emergency – Contamination: exposure to radioactive gases liquids or solids; requires immediate medical management to prevent incorporation – Incorporation: uptake of the radioactive material
into the body Radiation Decontamination • Triage outside the hospital • Cover floor and use strict isolation precautions to prevent the tracking of contaminants • Seal air ducts and vents • Waste is double bagged and put in a container labeled radiation waste • Staff protection – Water-resistant gowns, 2 pairs of gloves, caps, goggles, masks, and booties – Dosimetry devices • Patients are surveyed for radiation and directed to the decontamination area • Each patient is decontaminated with a shower outside the ED • Water, tarps, towels, soap, gowns, all the patient’s belongings, etc., must be collected and contained • Patients are surveyed and showered again as necessary • Showering should be performed so as not to contaminate clean areas with runoff from the showering • Biologic samples: nasal and throat swabs; blood • Internal contamination requires additional treatment: catharsis and gastric lavage with chelating agents Radiation Injuries • Acute radiation syndrome (ARS): dose of radiation determines if ARS will develop • All body systems are affected by ARS • Presenting signs and symptoms determine predicted survival • Probable survivors have no initial symptoms or only minimal symptoms • Possible survivors present with nausea and vomiting that persists for 24 to 48 hours • Improbable survivors are acutely ill with nausea, vomiting, diarrhea, and shock; neurologic symptoms suggest lethal dose; and survival time is variable
Right Reason to receive Right Treatment
How long should the TRIAGE take? - the common goal is to assess the patient within 25 minutes for adults (but this time according to ENA caters up to 22% only of patients per hundred in 8 hours) - for pediatrics, 7 minutes Who should perform the ED TRIAGE function? - the Joint Commission on Accreditation of Healthcare Organization (JCAHO) doesn’t entails what are the specifics of the triage nurse - Emergency Nurses Association (ENA) 1999 established he standards of Emergency Nursing Practice, states that safe, effective triage can only be performed by a registered professional nurse, educated in the principles of triage and has minimum experience of 6 months in emergency nursing - The triage nurse should classify patient 24/7 What are the Essential Components of Comprehensive TRIAGE? 1. An initial across-the- room look or visualization. This includes ABCD. For pediatric clients, this may include critical look, general appearance, work of breathing and circulation 2. A rapid triage (60secs) of an appropriately elicited chief complaint, key questions, assessment such as feeling of the pulse and fracture in the extremities 3. Completion of a focused triage history and physical assessment. This include vital signs, pulse oximetry reading, diagnostics and institution’s protocol 4. The triage decision, in which the triage acuity or level is assigned. This determines the urgency of the condition, includes the MSE and additional assessment. What should the triage history include? Medications Exposure to infection Allergies Pregnancy Immunization LMP Past medical history Family history
What are the some examples of Adult Mnemonics? PQRST Pain assessment P precipitating factors Q quality R radiation S severity T time
T treatment PHOSPHATE For the history of the chief compliant Problem Onset Associated Symptoms Previous History Precipitating Factors Alleviating/ Aggravating Factors Timing Etiology CIAMEDS (from Emergency Nursing Pediatric Course) Chief Compliant Immunization Allergies Medications Past Medical History Events Surrounding Diets/ Diapers Symptoms Associated with injury or illness SAVE A CHILD (From ENA Hawaii- SAVE Are observations before touching the child, A CHILD are key history and examination components) Skin Activity Ventilation Eye Contact Abuse Cry Heat Immunization Level of Consciousness Dehydration What are some tips for better TRIAGE - Look at the patient, listen and do not write while the patient is talking to you - Never appear shocked by what the patient tells you - Do not discount the patient’s concern on triage - Watch people’s faces - Ask specifically about drugs recently started - Do not assume patients are taking their medications - Use the language of symptoms, feelings, and thoughts - Remember that he patient’s diagnosis is not necessarily the correct diagnosis - Exhibit concern for a higher acuity in the presence of other risks factors, or co-morbidities/ chronic illness - Remember hat alcoholics can be sick and intoxicated at the same time - Ask the patient at the end of he triage encounter if here is anything else the patient wants to say What are the prioritization principles? - Airway
- Breathing - Circulation - Disability - Systemic before local; life before limb - Acute before chronic; short term before long - Central before peripheral - Actual over Potential - Trending (worsening trend could consist of minor symptoms that tend to reoccur repeatedly, increase in severity, or indicate a steady progressive decline) - Potential for worsening (ex. Drug overdose and chest tightness) TOXICOLOGY (Poisoning and Drug Overdose) A. General Guidelines - maintain adequate airway, breathing and cardiac output - Patients who ingested large amounts of TCA may require intubation immediately even if mental status has not yet occurred. - Perform gastric lavage - Induce emesis for patients with alkali ingestion - Contact local poison control center at UP College of Medicine 524-1078, 524-5651 loc 2311 - East Ave Med Ctr 928-0611 - Consider possibility of suicide - All female with chemical ingestion should undergo pregnancy test B. Principles of Decontamination External Decontamination - Wash skin with soap and water - Remove cloths - Keep warm, use blankets Gastric Lavage - contraindications includes strong ingestion of strong acids, alkalis, petroleum and distillates. - Airway must be protected with endotracheal tube unless awake, alert and has a gag reflex - Position head on one side of he bed to prevent aspiration - If the patient has severe DOB stat intubation - Perform gastric lavage unless overdose with acid - Lavage is useful within two hours of ingestion Activated Charcoal - Always consider giving charcoal after emesis or lavage until specifically contraindicated - Multiple doses of charcoal in (+) metamphetamine, phenothiazines, digoxin, theophylline, phenobarb, and organophosphates - Activated charcoal is not effective for alkalis, cyanide, mineral acid and ferrous sulfate Cathartics - contraindicated with infants (risk for dehydration), intestinal obstruction, electrolyte imbalance - sodium sulfate is contraindicated in HPN and heart failure Forced Diuresis
- forced neutral diuresis may be helpful for isoniazid, bromide and ethanol intoxification - make sure to monitor electrolytes - forced alkaline diuresis may be useful for Phenobarbital, salicylates and lithium using sodium bicarbonate. C. Guidelines for Nurses - when antidotes are ordered, it is meant to be given immediately or at least reasonably within the hour in some cases. They are not given when it is the convenient dosing period for the nurses.
Digitalis Overdose - considered NGT insertion and gastric lavage - secure digitalis assay, CBC, Ca, K, Mg, CXR and ECG/ cardiac monitor - the treatment goal would be to correct hypokalemia. Hypomagnesemia or hypocalecemia. - The doctor may prescribe charcoal and cathartics - Watch out for hypotension; fluid challenge my be instituted - For arrythmias, lidocaine may be given Ethanol Toxicity - maintain adequate airway, ventilation, circulation and administer oxygen - Thiamine is useful to protect/ prevent liver damage - Phynetoin my be given in cases of seizure, but make sure to give it SIVP and hook the patient to the cardiac monitor Narcotic Overdose - maintain airway, ventilation and circulation - may start on Naloxone 2mg every 5 minutes , max 10mg IV, IM SQ - Activated charcoal if (+) for bowel sounds and cathartics - Watch out for signs of pneumonia, infections and rhabdomyolysis - Watch out for complications such as seizure, pulmonary edema and hypotension Hydrocarbon/ Kerosene Ingestion - Respiratory support - Treatment is not required in the absence of symptoms - Promote gastric emptying - Remove contaminated clothing and wash affected skin with soap and water. - Provide supplemental oxygen - secure CBC, ABG abd CXR Isoniazid Overdose - place an NGT and do gastric lavage is clean - watch out for seizure, lactic acidosis may give sodium bicarbonate - consider mannitol administration for forced diuresis - secure CBC, RBS, K, ABG Narcotic Overdose - maintain airway, ventilation and circulation - may give naloxone 2.0mg q 5 minutes initially max of 10mg IV, IM SQ - start activated charcoal if (+) with BM and cathartics - watched out for complications, PNA, hypotension, and seizures is (+) norpethidine Insecticides/ Pesticides Therapeutics 1. Decontamination - make he patient rinse with alkaline or baking soda (10gm in 100cc) - change cloths and wash the patient with gloves - insert NGT and do gastric lavage wih activate charcoal
Specific Substance Ingestion Acid Ingestion - provide airway control, ventilation, circulatory support, and fluid resuscitation - wash the oral cavity (controversial) - emesis, lavage and charcoal are contraindicated - secure serial CBC and cros-matching - maintain NPO Alkali Ingestion - immediately rinse oral cavity - administer oxygen and IVF - secure serial CBC, CXR, and monitor electrolytes - esophagoscopy and gastroscopy should be performed immediately if there is drooling, stridor and painful swallowing Amphetamine/ Metamphetamine Toxicity - start charcoal and cathartics - emesis has no role - WOF for seizure, psychosis, agitation, hypertensive crisis, arrhythmias - Secure ABG, CBC with PC, PT, PTT, RBS, BUN, Crea, Na, K, UA - Diazepam and Phenytoin for seizure - Beta-blockers, Lidocaine for dysrythmias Anticoagulant Overdose - Secure lab results such as CBC with PC, PT, PTT and Creatinine - For Heparin: Give protamine sulfate at 1mg iv for every 50-100 units of heparin infused in the preceeding 2 hours, dilute in 25-50ml fluid over 10 minutes - For Warfarin: perform gastric lavage and give activated charcoal if recently ingested; give vitamin k 5-10 mg every 8-12 hours; give FFP 2-6units for severe bleeding Diazepam Overdose - Place NGT and do gastric lavage - Protect airway - Instill activated charcoal, followed by repeated doses of 20-25 gm via NGT - Secure RBS, ABG, ECG and CXR - Watched out for hypotension, CNS and respiratory depression and withdrawal syndrome such as agitation, seizure, restlessness and insomnia.
2. Activated charcoal 3. Antidote 4. In cases of seizure; consider Phenytoin 5. wof for hypoglycemia 6. Give mannitol if with good urine output - secure CBC, RBS, ABG, SGOT and SGPT Paracetamol Overdose - Insert NGT - Activate charcoal about 30-100mg and then remove via NGT suction prior to acetylcysteine - Sodium Sulfate to induce vomiting - Antidote: N-acetylcysteine (NAC) . the initial administration would be 150mg/kg body weight infused in 200ml 5% dextrose over 15 minutes followed by IV infusion of 50mg/kg in 500ml of 5% dextrose water - NAC is very effective in preventing paracetamolinduced hepatotoxicity when administered; when administered with in 8 hours from the time of ingestion, the better. But beyond 8 hours, the protective effect diminishes progressively as the treatment interval increases Salicylate Poisoning Diagnostics: - CBC, K, RBS, ABG and UA - PT, PTT, SGOT, SGPT and alk Posh with 48 hours post ingestion Therapeutics: - Stabilize respiratory and cardiac functions - Avoid diluting the gastric contents since this may incease gastric absorption - Consider NGT insertion - Give activated charcoal 1gm/ kg body weight every 6 hours - Sodium sulfate 15-30 gm in 100cc H20 orally if tolerated or with NGT with every other doses of activated charcoal to prevent charcoal constipation or fecal impaction - To increase urine ph, consider sodium bicarbonate - Glucose and KCl should be infused with other fluids Treatment Plan - if with dehydration and hypokalemia, manage with vigorous and with electrolyte replacement - Cerebral edema can be best avoided using hypertonic rehydration solution - Alkaline diuresis to maintain urinary ph at approx 8 - Monitor urine output - Assess hydration status - Watch closely for signs of fluid overload - Hemodialysis is indicated for initial salicylate level of >160ml/dl or with profound acidosis of below 7; or when there is renal failure, severe CNS dysfunction, pulmonary edema or deterioration despite supportive therapy Other Treatments - Acidemia: NaHCO3 - Seizure: Diazepam
- Pulmo Edema: treat with high concentration of oxygen, furosemide and PEEP - Cerebral Edema: treat with hyperventilation and osmotic diuresis with Mannitol SHOCK (Multisystem Stressor) Pathophysiology - Shock is a multisystem stressor that involves inadequate tissue perfusion and altered metabolism. - Inadequate tissue perfusion can lbe a result of nay condition that alters heat function (cardiogenic), blood volume(hypovolemic), blood pressure (neurogenic) and distribution of blood volume (septic/ anaphylactic) - Shock is a very complex clinical syndrome in which tissue perfusion is inadequate to meet the demands for oxygen - It alters cellular functions and eventually impairs body organ functions - Multi Organ Dysfunction Syndrome (MODS) is a term used to describe several impairment of the human functions Sepsis and Septic Shock - Sepsis is an acute systemic clinical syndrome caused by bacteria, viruses or fungi in the blood, most commonly gram (-) bacilli - At an early phase, generalized inflammatory response is triggered, causing widespread vasodilation - The progression to septic shock is due to the toxins released from the organism involved - Bacterial endotoxins activates the complement, coagulation and fibrinolytic system; inceases vascular permeability and trigger the vasoactive kinins causing vasodilation and increased capillary permeability thereby decreasing the vascular resistance and facilitating fluid shifting from intravascular to interstitial - Another response would be due to the histamine release causing increase in vascular permeability - This changes are further stimulated by the catecholamine and prostaglandins that are released from ischemic tissues - “COLD SHOCK” is he term used during the stage in which tissue perfusion becomes severely compromised and ischemic cellular damage occurs. - In addition the, fever is present due to the pyrogens released by the organism Anaphylactic Shock - systemic anaphylactic shick is potentially life threatening situation - it is he result of an exaggerated hypersensitivity response to an antigen - the classic form of anaphylaxis occurs in a sensitized person usually 1-20 minutes ater the exposure to the antigenic substance - the most common substance that can cause reactions would be, drugs, antibiotics, foods, anesthetics, antisera and blood products - hypersensitivity reaction occurs over the surface of
he mast cells which are located primarily in he lungs, small blood vessels and connective tissues - it also attacks basophils circulating in the blood - the antigenic substance triggers the release of kinins, histamines, prostaglandins, eosinophils, neutrophils - “sow reacting substance of anaphylaxis” (SRSA) such as prostaglandins and leukotrienes produces deleterious results icluding profound shock - Histamine is he primary mediator of anaphylactic attack. Leukotrienes produces vasoconstriction that is even worst than histamine - The prostaglandins exaggerate the bronchoconstriction; kinins increases the vascular permeability - The combined effects of the substance causes respiratory distress and obstruction Toxic Shock - it is another syndrome of shock believed caused by bacterial toxins - e.g. Staph A enters he blood steam from the site of infection, commonly the vagina, diffusing across the mucus membranes. Hey are then circulated throughout the body - thise toxins causes massive vasodilatation and eventually to a shock state For Septic Shock Assessment - history and risk factors includes, malnutrition, immunosuppresion, liver and renal diseases, recent traumayic injuries, surgical or invasive procedure - commonly caused by E Coli, Klebsiella, Enterobacter, Staph A. as well as fungi and viruses For Anaphylactic Assessment - recent exposure to pharmacological agents, blood transfusion and insect bites or stings - clinical presentation is dependent on several factors and varies with the portal of antigen entry, the amount absorbed, rate of absorption, and the degree of hypersensitivity - Ingestion: cramping, nausea, vomiting and may precede systemic shock syndrome - Inhalation: hoarseness, dyspnea and whezing - Allergic: urticaria or itching at the site of the sting, or drug injection Diagnostic Test/ Procedure -WBC, serum glucose, GS-CS, ABG, BUN, CT, BT, Liver studies Collaborative Management (Septic) - antibiotic therapy specific to he organism - Hemodynamic monitoring - Fluid resuscitation - Inotropic Agents - Ventilatory Support - Alkaline Support - Nutritional Support - Steroids - Antipyretic Agent - Naloxone
- GI solution Collaborative Management (Anaphylaxis) - Airway maintenance - Epinephrine - Supplemental Oxygen - Fluid Resuscitation - Vasopressors - Angi-histamine - Bronchodilator - Steroids - Mast cell stabilizer - Glucagon - ECG monitoring Nursing Diagnosis and Intervention (SEPSIS) 1. Fluid volume deficit related to active loss from vascular compartment secondary to increased capillary permeability and shifting of intravascular volume into interstitial spaces Desired Outcome Within 4 hours of initiation of therapy, the patient is normovolemic as eveidenced by good peripheral pulses, stable body weight, good urine output and decreased adventitious breath sounds Intervention - Monitor hemodynamic pressures - Administer crystalloid and fluid replacement as prescribed - VS hourly - Maintain proper inotropic administration - Weigh patient daily - Monitor specific gravity - Assess for interstitial edema - Proper positioning 2. Decreased Cardiac Output related to negative inotropic changes at the myocardium secondary to effects of tissue O2 deprivation Desired Outcome Within 8 hours of initiation of therapy, patient has a n adequate cardiac output as evidenced by good BP, urine output and god peripheral pulses Intervention - Assess patient for signs of deceasing CO - Administer inotropics as prescribed - Position patient on supine to increase/ optimize preload and enhance stroke volume - Monitor cardiac rhythm - Minimize cardiac oxygen demand by assisting patient with ADL 3. Altered Cerebral, renal, gastrointestinal tissue perfusion related to decreased to circulating blood volume secondary to massive vasodilatation and interruption of arterio-venous blood flow associated to vasoconstriction and clot formation Desired outcome Within 24 hours after initiating therapy, the patient
has an adequate tissue perfusion as evidenced by orientation to time, place and person, good bowel sounds and good urine output Intervention - Assess LOC hourly - Assess signs of decreasing renal perfusion - Assess/ monitor peripheral vascular resistance - Assess peripheral pulses - O2 saturation monitoring - Assess evidence of decreasing visceral circulation including bowel sounds * Other examples of nursing problems… 4. Impaired Gas exchange, related to alveolarcapillary membrane changes secondary to interstitial edema, alveolar destruction and endotoxin release with activation of histamine and kinins 5. Ineffective breathing pattern related to decreased lung function secondary to central respiratory depression occurring in the lat shock 6. Ineffective thermoregulation related to successful entry bacterial endotoxins, increasing the hypothalamic termperature regulating center 7. Altered Nutrition less than body requirements related to increased need secondary to increased metabolic rate
Intervention: - Monitor patient for the presence of SOB - Secure ABG results as necessary - Monitor pulse oximetry reading regularly - Administer steroids as prescribed - Position patient in a sitting position to enhance lung expansion - Remain with the patient, encourage slow, deep breathing if possible. Help patient alleviate anxiety by responding calmly and explaining all procedures before performing to them 3. Decreased cardiac output related to decreased preload and afterload secondary to release of vasoactive chemical mediators and associated vasodilation and increased capillary permeability Desired Outcome: After 4 hours of continuous nursing intervention, the patient has an adequate cardiac output as evidenced by a near normal BP of morethan 90/60, good urine output and normal sinus rhythm Intervention: - Assess for physical and hemodynamic parameters indicating a decreased cardiac ouput Check for apical pulse Palpate peripheral for amplitude Assess BP Calculate MAP Measure CVP - Monitor ECG changes - WOF signs of edema - Admisister fluid replacement therapy as prescribed - Administer vasopessors as prescribed Multiple Injury This includes: 1. Major Trauma 2. Craniocerebral Trauma 3. Chest Trauma 4. Abdominal Trauma 5. Renal and Lower Tract Trauma Mechanisms of Injury: - Objects Producing Injury (ex. MVA, handgun, glass, wood, metal) - Type of Energy (ex. Kinetic, thermal, chemical, radiation) - Force of Energy (ex. Velocity, tension force, shearing force) - Use of Protective devices (ex. Helmet, airbags, seat belt) Types of Injury: Blunt Injury – occurs without interruption on the skin integrity Penetrating – are produced from the motion of the objects that penetrate the tissue causing direct damage. Oxygen Delivery and Consumption - an oxygen debt is created by a profound imbalance
Nursing Diagnosis and Interventions (Anaphylaxis) 1. Ineffective airway clearance realated to tracheobronchial obstruction secondary to bronchoconstriction and increased secretions associated with histamine response and the presence of leukotrienes and prostaglandins Desired Outcome: Within 2 hours of intervention, the patient has an adequate airway clearance as evidenced by by a state of eupnea and the presence of breath sounds in all lung fields Interventions: - Assess patency of airway on a continuing basis. Auscultate all lung fields - Stand by Adrenergic agent in case of cardiopulmonary arrest - Maintain intubation set at all times - If laryngeal edema pevents intubation, prepare tracheostomy set - Monitor ABG results 2. Impaired gas exchange related to alveolocapillary membrane changes secondary to increased vascular permeability associated with histamine response Desired Outcome: Within 2hours of initiation of intervention, he patient has adequate gas exchange as evidenced by eupnea and O2 sat of more than 90%
between oxygen supply and demand brought about by hypovolemia and inadequate tissue perfusion - after initial restoration of circulating blood volume, he body develops a “hyperdynamic circulatory state”, which is associated with improved survival and fewer complications - the hyperdynamic state usually peaks within 48-72 hours and diminishes in 7 -10 days - inability to achieve this state increases the mortality Neuroendocrine Stress Response - shortly after the trauma, the CNS triggers a series of reactions that promotes cmpentation including brain, blood, and bone marrow - cathecolamines are released - these hormones mobilizes glycogen stores, increases glucose availablty, suppresses pancreatic insulin, resulting in an increase net of glucose - centrally mediated release of ADH promotes water absorption, increasing intravascular volume and diminishes urine output Systemic Inflammatory Response Syndrome - the release of cathecolamine triggers massive amount of WBC at the site of injury - SIRS is used without he presence of infection; SEPSIS is termed in the presence of a widespread inflammation and infection Multi Organ Dysfunction Syndrome Coagulopathy Hypothermia Psychologic Response Environmental Emergencies—Heat Stroke • A failure of heat regulating mechanisms • Types – Exertional: occurs in healthy individuals during exertion in extreme heat and humidity – Hyperthermia: the result of inadequate heat loss • Elderly, very young, ill, or debilitated—and persons on some medications—are at high risk • Can cause death • Manifestations: CNS dysfunction, elevated temperature, hot dry skin, anhydrosis, tachypnea, hypotension, and tachycardia Management of Patients With Heat Stroke • Use ABCs and reduce temperature to 39° C as quickly as possible • Cooling methods – Cool sheets, towels, or sponging with cool water – Apply ice to neck, groin, chest, and axillae – Cooling blankets – Iced lavage of the stomach or colon – Immersion in cold water bath • Monitor temperature, VS, ECG, CVP, LOC, urine output • Use IVs to replace fluid losses – Hyperthermia may recur in 3 to 4 hours; avoid hypothermia
Environmental Emergencies—Frostbite • Trauma from freezing temperature and actual freezing of fluid in the intracellular and intercellular spaces • Manifestations: hard, cold, and insensitive to touch; may appear white or mottled; and may turn red and painful as rewarmed • The extent of injury is not always initially known • Controlled but rapid rewarming; 37° to 40° C circulating bath for 30- to 40-minute intervals • Administer analgesics for pain • Do not massage or handle; if feet are involved, do not allow patient to walk Environmental Emergencies—Hypothermia • Internal core temperate is 35° C or less • Elderly, infants, persons with concurrent illness, the homeless, and trauma victims are at risk • Alcohol ingestion increases susceptibility • Hypothermia may be seen with frostbite; treatment of hypothermia takes precedence • Physiologic changes in all organ systems • Monitor continuously Management of Patients With Hypothermia • Use ABCs, remove wet clothing, and rewarm • Rewarming – Active core rewarming Cardiopulmonary bypass, warm fluid administration, warm humidified oxygen, and warm peritoneal lavage – Passive external rewarming Warm blankets and over-the-bed heaters • Cold blood returning from the extremities has high levels of lactic acid and can cause potential cardiac dysrhythmias and electrolyte disturbances Management Patients With Carbon Monoxide Poisoning • Inhaled carbon monoxide binds to hemoglobin as carboxyhemoglobin, which does not transport oxygen • Manifestations: CNS symptoms predominate – Skin color is not a reliable sign and pulse oximetry is not valid • Treatment – Get to fresh air immediately – Perform CPR as necessary – Administer oxygen: 100% or oxygen under hyperbaric pressure • Monitor patient continuously Management of Patients With Chemical Burns • Severity of the injury depends upon the mechanism of action of the substance, the penetrating strength and concentration, and the amount of skin exposed to the agent • Immediately flush the skin with running water from a shower, hose, or faucet – Lye or white phosphorus must be brushed off the skin dry
• Protect health care personnel from the substance • Determine the substance • Some substances may require prolonged flushing/irrigation • Follow-up care includes reexamination of the area at 24 hours, 72 hours, and 7 days Management of Patients With Substance Abuse • Acute alcohol intoxication: a multisystem toxin – Alcohol poisoning may result in death – Maintain airway and observe for CNS depression and hypotension – Rule out other potential causes of the behaviors before it is assumed the patient is intoxicated – Use a nonjudgmental, calm manner – Patient may need sedation if noisy or belligerent – Examine for withdrawal delirium, injuries, and evidence of other disorders Crisis Intervention—Rape Victims • How the patient is received and treated in the ED is important to his or her psychological well-being • Crisis intervention begins as soon as the patient enters the facility; the patient should be seen immediately • Goals are to provide support, reduce emotional trauma, and gather evidence for possible legal proceedings • Patient reaction; rape trauma syndrome • History taking and documentation • Physical examination and collection of forensic evidence • Role of the sexual assault nurse examiner (SANE) Psychiatric Emergencies • Overactive, underactive, violent, and depressed or suicidal patients • Management – Maintain the safety of all persons and gain control of the situation – Determine if the patient is at risk for injuring himself or others – Maintain the person’s self-esteem while providing care – Determine if the person has a psychiatric history or is currently under care to contact the therapist • Crisis intervention • Interventions specific to each of the conditions
Terrorism, Mass Casualty, and Disaster Nursing Emergency Operations Plan (EOP) • Health care facilities are required by the Joint Commission on Accreditation of Healthcare Organizations to create a plan for emergency preparedness and to practice this plan twice a year • Essential components of the plan: – An activation response – An internal/external communication plan – A plan for coordinated patient care – Security plans – Identification of external resources – A plan for people management and traffic flow • Essential components of the plan: – A data management strategy – Deactivation response – Post-incident response – A plan for practice drills – Anticipated resources – Mass casualty incident planning – An education for all of the above Managing Short- and Long-Term Psychological Effects After a Disaster • Provide active listening and emotional support • Provide information as appropriate • Refer to therapist or other resources • Discourage repeated exposure to media regarding the event • Encourage return to normal activities and social roles • Critical incident stress management (CISM) • Programs that include education, field support, defusing, debriefing, demobilization, and follow-up components • Persons with ongoing stress reactions should be referred to mental health specialists
Roles and Function of the Nurse in Emergency and Disaster Nursing • Educator • Counselor • Team member • Facilitator (include triaging) • Advocate • Researcher
Personal Protective Equipment (PPE) • Purpose: to shield the health care provider from chemical, physical, biological, and radiologic hazards that may exist when caring for contaminated patients • Categories of protective equipment: – Level A: self-contained breathing apparatus (SCBA) and vapor-tight chemical-resistant suit, gloves, and boots – Level B: high level of respiratory protection (SCBA) but lesser skin and eye protection; chemicalresistant suit – Level C: air-purified respirator, coverall with splash hood, and chemical-resistant gloves and boots – Level D: typical work uniform Isolation Precautions for Biological Terrorism Agents • Biological agents may be delivered or spread in a number of ways • Due to 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 upon the infecting agent • Always use Standard Precautions • Some agents require Transmission-Based Precautions • Terminal disinfection and disposal of wastes depends on the infecting agent Chemical Weapons • Chemical substances that quickly cause injury and/or death and cause panic and social disruption • Agents – Nerve agents – Blood agents – Vesicants – Pulmonary agents • Agents vary in volatility, persistence, toxicity, and period of latency • Limitation of exposure is essential with evacuation and decontamination as soon possible and as close to the scene of the incident as possible Nerve Agents • Sarin and soman organophosphates • Inhibit cholinesterase-causing cholinergic symptoms progressing to loss of consciousness, seizures, copious secretions, apnea, and death • Treatment: supportive care, atropine, benzodiazepine, and pralidoxime • Decontaminate with copious amounts of soap and water or saline for at least 20 minutes • Blot; do not wipe off • Plastic equipment will absorb sarin gas Vesicants • Lewisite, sulfur mustard, nitrogen mustard, and phosgene • Cause blistering and burning • Respiratory effects can be serious and cause death • Decontaminate with soap and water; do not scrub or use hypochlorite solutions • Eye exposure requires copious irrigation • Treatment for lewisite exposure: dimercaprol IV or topically Radiation Exposure • Radiation exposure may occur due to nuclear weapons, nuclear reactor incidents, or exposure to radioactive samples • Exposure to radiation is affected by time, distance, and shielding • Types of radiation exposure: – External radiation: all or part of the body is exposed to radiation; as decontamination is not necessary, it is not a medical emergency – Contamination: exposure to radioactive gases liquids or solids; requires immediate medical management to prevent incorporation – Incorporation: uptake of the radioactive material
into the body Radiation Decontamination • Triage outside the hospital • Cover floor and use strict isolation precautions to prevent the tracking of contaminants • Seal air ducts and vents • Waste is double bagged and put in a container labeled radiation waste • Staff protection – Water-resistant gowns, 2 pairs of gloves, caps, goggles, masks, and booties – Dosimetry devices • Patients are surveyed for radiation and directed to the decontamination area • Each patient is decontaminated with a shower outside the ED • Water, tarps, towels, soap, gowns, all the patient’s belongings, etc., must be collected and contained • Patients are surveyed and showered again as necessary • Showering should be performed so as not to contaminate clean areas with runoff from the showering • Biologic samples: nasal and throat swabs; blood • Internal contamination requires additional treatment: catharsis and gastric lavage with chelating agents Radiation Injuries • Acute radiation syndrome (ARS): dose of radiation determines if ARS will develop • All body systems are affected by ARS • Presenting signs and symptoms determine predicted survival • Probable survivors have no initial symptoms or only minimal symptoms • Possible survivors present with nausea and vomiting that persists for 24 to 48 hours • Improbable survivors are acutely ill with nausea, vomiting, diarrhea, and shock; neurologic symptoms suggest lethal dose; and survival time is variable
