Kelle Howard, RN, MSN Modified by:

Darlene M. Wilson, MSN, RN

Objectives• Discuss

▫ Heat Stroke▫ Cold Related Emergencies▫ Drowning▫ Bites/Stings▫ Poisoning ▫ Agents of Terrorism

• Review: with regard to each of the said topics– pathophysiology– causes– manifestations & potential complications– treatment & interventions – interdisciplinary management

• Evaluation of Learning▫ Case studies

Heat Stroke:Pathophysiology

• Definition▫ Failure of the hypothalamic regulatory process

▫ Inc. sweating vasodilatation Inc. RR sweat glands stop working core temp inc. circulatory collapse

What makes this temperature so dangerous?What happens to electrolytes? Which ones do you worry about?What are some signs/symptoms of these altered lytes?What are critical labs values for these lytes?

Heat Stroke:s/s of electrolyte depletionNa <120 critical

Change in mental status Combative, decreased LOC

HallucinationsLoss of motor controlCerebral edema & hemorrhage

K <2.8 criticalHypo-reflexia, muscle weaknessRespiratory depressionDiarrheaEKG changes

Heat Stroke:CausesDevelopment is directly related to

Amount of time the body temperature is elevated

What are some common causes?

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Heat Stroke:CausesStrenuous activity in hot/humid environmentHigh feversClothing that interferes with perspirationWorking in closed areas/prolonged exposure

to heatDrinking alcohol in hot environment

Heat Stroke:Manifestations & Complications

What will your patient look like?

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Heat Stroke:Manifestations & ComplicationsCore temp > 104˚FAMSNo perspirationSkin hot, ashen, dryDec. BPInc. HR

S/S of what?

Heat Stroke:PrognosisRelated to:

AgeLength of exposureBaseline health statusNumber of co-morbidities

Which co-morbidities would predispose your patient to heat related emergencies?

Heat Stroke:Treatment & InterventionsABC’s – must stabilize

What assessments/interventions will you perform initially?

What do you think the goal of treatment is?

How would you achieve this goal?

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Heat Stroke:Treatment & InterventionsGoal:

Decrease the core temperature To what temperature? 102

Prevent shivering Why? thorazine How? – what med is used? Antipsychotic, CNS depression

Attainment:Remove clothes, wet sheets, large fan (evaporative),

ICE water bath (conductive), cool IV fluids

Would you use antipyretics?

Heat Stroke:Treatment & InterventionsMonitor for s/s of rhabdomyolysis

What is this?How would you monitor for this?

Monitor for s/s disseminated intravascular coagulation (DIC)What is this?How would you monitor for this?

RhabdomyolysisSkeletal muscle breakdownMonitor: ARF – cpk, creatinine, urine

DICPathological activation of coagulation

mechanismsMonitor:

bleeding and bruising Coags & platelets ARF – what will you see?

Heat Stroke:Interdisciplinary Roles

Who would be involved in this client’s care?RNMD - which ones?RTSW – why?Anyone else?

Hypothermia:Pathophysiology

DefinitionCore temperature less than 95˚F (35˚C)

Core temp <86˚F - severe hypothermia Core temp <78˚F - death

Heat produced by the body cannot compensate for cold temps of environment

55%-60% of all body heat is lost as radiant energy Head, thorax, lungs

Dec body temp peripheral vasoconstriction shivering &movement coma results <78˚F

Hypothermia:CausesExposure to cold temperatures

Inadequate clothing, inexperiencePhysical exhaustion

Wet clothes in cold temperaturesImmersion in cold water/near drowningAge/current health status predispose

What health issues would predispose a patient to hypothermia?

Hypothermia:Manifestations & Complications

What will your patient look like?

Hypothermia:Manifestations & ComplicationsVary dependent upon core temp

Mild (93.2˚F - 96.8˚F) Lethargy, confusion, behavior changes, minor HR

changes, vasoconstrictionModerate (86˚F – 93.2˚F)

Rigidity, dec HR, dec RR, dec BP, hypovolemia, metabolic & resp acidosis, profound vasoconstriction, rhabdomyolysis

Shivering usually disappears at 92˚F **What about each system?

Profound/(Severe) (<86˚F) Person appears dead – attempt to re-warm to 90˚F Reflexes & vitals very slow Profound bradycardia, asystole 64.4˚F, or Vfib 71.6˚F

– usual cause of death?

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Hypothermia: ModerateManifestations & Complications

Hematologic HCT inc. as volume dec.

cold blood thickens, thrombus occurs Neuro

Stroke lack of blood flow due to vasoconstriction/thrombus

Cardiac Irritable myocardium

atrial & ventricular fibrillation, MI Respiratory

PE Acidosis

lactic acid builds up anaerobic metabolism metabolic acidosis

Renal Dec blood flow, dehydration, rhabdomyolysis

Acute Kidney Injury

Hypothermia:PrognosisDependant upon

Core body temperatureCo-morbidities

Hypothermia:Treatment & InterventionsABC’s – must stabilize

What interventions will you perform initially?

What do you think the goal of treatment is?

How would you achieve this goal?

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Hypothermia:Treatment & Interventions• Goal:

▫ Rewarming to temp of 95˚F▫ Correction of dehydration & acidosis▫ Treat cardiac dysrhythmias

• Attainment:▫ Passive & active external rewarming

What are some examples? Passive – move to warm place & dry place remove wet clothes, apply warm blankets Active -- body to body contact, fluid or air filled blankets,

▫ Active core rewarming warm IV fluids, heated humidified O2, peritoneal , gastric or colonic lavage

What should be warmed first – core or extremities? Why?

Hypothermia:Treatment & Interventions

MonitorCore tempfor marked vasodilatation & hypotensionAfter drop

What is this?

TeachWarm clothes & hats, layers, high calorie

foods, planning

Hypothermia:Interdisciplinary Management

Who would be involved in this client’s care?RNMDPT/OTSWCMRT

Submersion Injury:Causes & Incidence

• 8000 submersion injuries per year

▫ 40% children under 5yrs• Categorized as

▫ Drowning▫ Near drowning▫ Immersion syndrome

• Risk factors ▫ Inability to swim & entanglement with objects in water▫ ETOH or drug use▫ Trauma▫ Seizures▫ Stroke

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Submersion Injury :PathophysiologyDefinition

Drowning Death from suffocation after submersion in water or

other fluid mediumNear Drowning

Survival from potential drowningImmersion syndrome

Immersion in cold water stimulation of vagus nerve & potentially fatal dysrhythmias (bradycardia)

Submersion Injury :Pathophysiology

Death is caused by hypoxia

Victims that aspiratesecondary to aspiration & swallowing of fluidfluid aspirated into pulmonary tree PULMONARY

EDEMA - HYPOXIAVictims that do not aspirate

bronchospasm & airway obstruction “dry drowning” - HYPOXIA

Submersion Injury :Manifestations & Complications

What will your patient look like?PulmonaryCardiacNeuro

Submersion Injury :Manifestations & ComplicationsDependant upon length of time & amount of

aspiratePulmonary

Ineffective breathing, dyspnea, distress, arrest, crackles & rhonchi, pink frothy sputum with cough, cyanosis What interventions would you perform?

Cardiac Inc./dec. HR, dysrhythmia, dec. BP, cardiac arrest

Neuro Panic, exhaustion, coma

Submersion Injury :Treatment & InterventionsABC’s – must stabilize

What interventions will you perform initially?What should you assume with all victims?

What do you think the goal of treatment is?

How would you achieve this goal?

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Submersion Injury :Treatment & InterventionsGoal:

Correct hypoxia acid/base balance fluid imbalances correct dysrhythmias

Attainment:Anticipate intubation100% O2 via non-

rebreatherIV access

Near drowning victims:• Nursing assessment

•Pulmonary Edema•SPO2

Submersion Injury :Interdisciplinary ManagementWho would be involved in this client’s care?

RNMDRTSWChaplain

Real Life Drowning Victimhttp://www.youtube.com/watch?

v=roFGBt8xEis&feature=related

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Bites & Stings:PathophysiolgyDirect tissue damage is a product of

Animal sizeCharacteristics of animal’s teethStrength of jawToxins released

Death is due to Blood lossAllergic reactionsLethal toxins

Poisoning:

1-800-221-1212 Treatments:

Activated charcoal, gastric lavage, eye/skin irrigation, hemodialysis, hemoperfusion, urine alkalinization, chelating agents and antidotes – acetylcysteine (Mucomyst)

Contraindicated (charcoal & gastric lavage): AMS, ileus, diminished bowel sounds, ingestion

of substance poorly absorbed by charcoal (alkali, lithium, cyanide)

Agents of Terrorism:Types

BioterrorismAnthrax, plague, tularemia, smallpox, botulism,

hemorrhagic feverChemical terrorism

Sarin, phosgene, mustard gasesRadiological/Nuclear terrorism

Tularemia

Plague

Botulism: The good, the bad & the ugly

Agents of Terrorism:Treatment

BioterrorismAnthrax, Plague, Tularemia

Treatment: antibiotics (streptomycin or gentamicin)Smallpox

Treatment: vaccineBotulism

Treatment: antitoxinHemorrhagic fever

Treatment: no established treatment

Provided there is sufficient supply & treatment occurs in a timely manner!!!!!!!

Agents of Terrorism:Treatments Chemical Terrorism

Sarin gas Nerve gas (highly toxic) Can cause death within minutes of exposure – paralyzing respiratory

muscles Treatment: antidote – atropine & 2-PAM chloride

Phosgene gas Colorless gas Can cause respiratory distress, pulmonary edema & death Treatment: treat S/S, remove from exposure

Mustard gas Yellow/brown in color , garlic like odor Can irritate eyes, burn skin and creates blisters, damage lungs if

inhaled Treatment: decontamination, treat symptoms

Agents of Terrorism:Treatments

Radiologic/Nuclear TerrorismRadiologic dispersal devices (RDD’s)

Aka: dirty bombs Made of explosives & radioactive material When detonated: smoke & radioactive dust enter air Treatment: limit contamination (cover mouth & nose) &

decontamination (shower, proper disposal of clothing)

Ionizing radiation (nuclear) Acute radiation syndrome (ARS) External radiation exposure

Radiologic/Nuclear Terrorism(FYI)American Nuclear Society:

Extremity (arm, leg, etc) Xray: 1 mrem Dental Xray: 1 mrem Chest Xray: 6 mrem Nuclear Medicine (thyroid scan): 14 mrem Neck/Skull Xray: 20 mrem Pelvis/Huip Xray: 65 mrem CAT Scan: 110 mrem Upper GI Xray: 245 mrem Barium Enema: 405 mrem

A single dose of around 300,000-500,000 mrem is usually considered produce death in 50% of the cases.

Bioterrorism:Interdisciplinary Management

Who would be involved in this client’s care?EVERYONE

Emergency NursingTriage

Rapid assessment skill to determine acuity

Threat to life, vision, or limb are treated before other patients

Emergency Nursing-Primary Survey

Airway, breathing, circulation, and disability (ABCD)Identifies life-threatening conditions

Necessary interventions started immediately before proceed to next step of the survey

Primary SurveyAirway with cervical spine stabilization

and/or immobilization Signs/symptoms of compromised airway

DyspneaInability to vocalizePresence of foreign body in airwayTrauma to face or neck (See Notes below for Primary Survey)

Primary SurveyMaintain airway: Least to most

invasive method Open airway using the jaw-thrust

maneuver

Primary SurveyMaintain airway: Least to most

invasive method cont.Suction and/or remove foreign body

Insert nasopharyngeal/oropharyngeal airway

Endotracheal intubation

Cricothyroidotomy or tracheostomy

Primary SurveyStabilize/immobilize cervical spine:

Face, head, or neck trauma and/or significant upper torso injuries

* Remember* Cervical Spine Stabilization is always part of the primary survey!!!

Primary SurveyBreathing: Assess for dyspnea, cyanosis

paradoxic/asymmetric chest wall movement, decreased/absent breath sounds, tachycardia, hypotension

Administer high-flow O2 via a nonrebreather mask

Bag-valve-mask (BVM) ventilation with 100% O2 and intubation for life-threatening conditions

Monitor patient response

Primary SurveyCirculation: Check central pulse

(peripheral pulses may be absent because of injury or vasoconstriction)

Assess skin for color, temperature, moisture

Assess mental status and capillary refill Insert two large-bore IV catheters Initiate aggressive fluid resuscitation

using normal saline or lactated Ringer’s

Primary SurveyDisability: Measured by patient’s level

of consciousness AVPU

A = alert V = responsive to voice P = responsive to pain U = unresponsive

Glasgow Coma Scale: Assess arousal aspect of patient’s consciousness (EVM) **Note**

Pupils: Size, shape, response to light, equality

Secondary SurveyDefinition: Brief, systematic process

to identify all injuries after key life threats identified and treated

Exposure/Environmental controlRemove clothingProvide temperature control—avoid

hypothermia

Secondary Survey**Full set of vital signs **

Blood pressure (bilateral)Heart rateRespiratory rateTemperature (rectal)

Secondary Survey**Five interventions **

Initiate ECG/EKG monitoringInitiate pulse oximetryInsert indwelling catheterInsert orogastric/nasogastric tube Collect blood for laboratory studies

Secondary SurveyFacilitate Family presence Supported family members during invasive

procedures or resuscitation

Allow family in the room when resuscitation is happening. Have a staff member at their side explaining what is happening.

Give comfort measuresPain management measures

Secondary SurveyHistory and Head-to-toe assessment

Obtain history of event, illness, injury from patient, family, and emergency personnel

AMPLE Allergies, Meds, Past health, Last meal, & Events

Perform head-to-toe assessment to obtain information about all other body systems

Secondary SurveyHead-to-toe assessment

Gently palpate with palms & check Head and spine & look for blood/CSF - stabilize Chest Listen to abdomen first - OR Pelvis – (avoid rocking) Check perineum Limbs – reduce fractures

Secondary SurveyInspect the posterior surfaces

Logroll patient (while maintaining cervical spine immobilization) to inspect the posterior surfaces Ecchymoses, wounds, deformities, spine alignment,

pain, & rectal exam for tone and blood

Warm patient & warm IV fluids

Secondary SurveyEvaluate need for tetanus prophylaxisProvide ongoing monitoring and

evaluate patient’s response to interventions

Prepare to: Transport for diagnostic tests (e.g., x-ray)

*Admit to general unit, telemetry, or

intensive care unitTransfer to another facility