Nursing Care & Interdisciplinary Roles with Adult Clients in the Emergency/Disaster Environment Kelle Howard, MSN, RN, CNE Revised Fall 2012

Nursing Care & Interdisciplinary Roles with Adult Clients in the Emergency/Disaster

Environment

Kelle Howard, MSN, RN, CNERevised Fall 2012

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

Heat Stoke:s/s of electrolyte depletion

• Hypernatremia

• Hyponatremia

• Hypokalemia

Heat Stroke:Causes

• Development is directly related to – Amount of time the body temperature is elevated

– What are some common causes?

Heat Stroke: Causes• Strenuous activity in hot/humid environment• High fevers• Clothing that interferes with perspiration• Working in closed areas/prolonged exposure to heat• Infants left in cars• Drinking alcohol in hot environment

Heat Stroke:Manifestations & Complications

• What will your patient look like?

Heat Stroke:Manifestations & Complications

• Core temp > 104˚F• AMS• No perspiration• Skin hot, ashen, dry• Coma• Seizure• Dec. BP• Inc. HR

– S/S of what?

Heat Stroke:Prognosis

• Related to:– Age– Length of exposure– Baseline health status– Number of co-morbidities• Which co-morbidities would predispose your patient to

heat related emergencies?

Heat Stroke:Treatment & Interventions

• ABC’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?


• Assessments/Interventions:– What are the initial ones?

• Goal:– Decrease the core temperature

• To what temperature?– Prevent shivering

• Attainment:– Remove clothes, wet sheets, large fan (evaporative), ICE water bath

(conductive), cool IV fluids

– Would you use antipyretics?


• Monitor for s/s of rhabdomyolysis

• Monitor for s/s disseminated intravascular coagulation (DIC)

Heat Stroke:Interdisciplinary Roles

• Who would be involved in this client’s care?– RN– MD – RT– SW– ?

Hypothermia:Pathophysiology

• Definition– Core 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:Causes

• What are some common causes?

Hypothermia:Causes

• Exposure to cold temperatures– Inadequate clothing, inexperience– Physical exhaustion

• Wet clothes in cold temperatures• Immersion in cold water/near drowning• Age/current health status predispose

Hypothermia:Manifestations & Complications


Hypothermia:Manifestations & Complications

• Varies: dependent upon core temp– Mild (93.2˚F - 96.8˚F)

• Lethargy, confusion, behavior changes, minor HR changes, vasoconstriction

– Moderate (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

Hypothermia: ModerateManifestations & Complications

• Hematologic – HCT inc. as volume dec

• Neuro– Stroke

• Cardiac– Irritable myocardium

• Respiratory– PE– Acidosis

• Renal– Dec blood flow, dehydration, rhabdomyolysis

Hypothermia:Prognosis

• Dependant upon– Core body temperature– Co-morbidities

Hypothermia:Treatment & Interventions

• ABC’s – must stabilize– What interventions will you perform initially?




• Goal:– Rewarming to temp of _____˚F– Correction of dehydration & acidosis– Treat cardiac dysrhythmias

• Attainment:– Passive & active external rewarming

– Active core rewarming


• Monitor– Core temp– for marked vasodilatation & hypotension– After drop

• Teach– Warm clothes & hats, layers, high calorie foods,

planning

Hypothermia:Interdisciplinary Management

• Who would be involved in this client’s care?– RN– MD– PT/OT– SW– CM– RT

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

Submersion Injury :Pathophysiology

• Definition– Drowning• Death from suffocation after submersion in water or

other fluid medium

– Near Drowning• Survival from potential drowning

– Immersion syndrome• Immersion in cold water stimulation of vagus nerve

& potentially fatal dysrhythmias (bradycardia)

Submersion Injury :Pathophysiology

• Death is caused by hypoxia

• Victims that aspirate– secondary to aspiration & swallowing of fluid– fluid aspirated into pulmonary tree pulmonary edema

• Victims that do not aspirate– bronchospasm & airway obstruction “dry drowning”

Submersion Injury :Manifestations & Complications


Submersion Injury :Manifestations & Complications

• Dependant upon length of time & amount of aspirate:– Pulmonary

– Cardiac

– Neuro

Submersion Injury :Treatment & Interventions

• ABC’s – must stabilize– What interventions will you perform initially?



Submersion Injury :Treatment & Interventions

• Goal:– Correct

• hypoxia• acid/base balance• fluid imbalances• correct dysrhythmias

• Attainment:– Anticipate intubation– 100% O2 via non-rebreather– IV access

Submersion Injury :Interdisciplinary Management

• Who would be involved in this client’s care?– RN– MD– RT– SW– Who else?

Bites & Stings:Pathophysiolgy

• Direct tissue damage is a product of – Animal size– Characteristics of animal’s teeth– Strength of jaw– Toxins released

• Death is due to – Blood loss– Allergic reactions– Lethal toxins

Bites & Stings

• Hymenopteran stings– Bees, yellow jackets, hornets, wasps, fire ants– Mild to Anaphylactic • Know s/s & treatments

– Treatment:• Remove stinger with scraping motion• Tweezers – why or why not?• Maintain ABCs

Bites & Stings:

• Spider bites– Black Widow– Brown Recluse

Black Widow– Black widow

• Characteristic hourglass marking– Southern black widow

• Venom is neurotoxic to humans• Symptoms progress over time 15mins – 3hrs• Dx often missed – bite usually not prominent

– Symptoms dependant on where bitten:» Upper part of body: » Lower part of body:

• Can cause systemic issues• Treatment

– Antivenin used in special at risk population

Where do you usually find them?

Brown Recluse– Brown recluse

• Characteristic violin batter on base head• Venom is cytoxic humans• Symptoms progress over hrs –weeks• Often unnoticed – painless bite• Can cause systemic issues

– Like what?

• Treatment – Clean area, treat pain, antibiotics – Surgical debridement with grafting may be necessary

Black Widow

Brown Recluse

Bites & Stings•Snakebites▫Pit viper (rattlesnakes, copperheads, water moccasins)

& coral snakes▫Pit viper: hemolytic▫Coral snake: neurotoxic▫Can cause systemic reaction▫Necrosis can occur▫Treatment

IV access, fluids, labs (which ones?), analgesics as needed, circumference of site q30mins, tetanus prophylaxis

Ice & tourniquets not recommended Caffeine, alcohol & smoking not recommended

Bites & Stings

• Antivenin– Do you know how it is made?

• Do we have enough?

Bites & StingsTick bites

• Lyme Disease (mimics other diseases)

– Caused by spirochete borrelia burgdorferi (tick)– Inflammatory disorder– 3 stages

• Initial rash (bull’s eye)**• Disseminated (arthritic like symptoms)• Late (chronic arthritis &neurologic symptoms)

• Diagnosis– Culture (difficult)– Antibody detection– EM lesion– ELISA & western blot

Treatment: antibiotics vibramycin (doxycycline) & amoxicillin

NSAID

Prevention**

long, light colored clothing

insect repellant frequently

frequent tick checks

http://healthlinks.washington.edu/nwcphp/lyme/index.html

Bites & Stings:Interdisciplinary Management

• Who would be involved in this client’s care?– You name them!!!!

Poisoning:

1-800-POISON1

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

• Bioterrorism– Anthrax, plague, tularemia, smallpox, botulism,

Hemorrhagic fever

• Chemical terrorism– Sarin, phosgene, mustard gases

• Radiological/Nuclear terrorism

Agents of Terrorism:Bioterrorism

• Anthrax– Bacillus Anthracis - bacteria that forms spores

– 3 types• cutaneous, inhalation, gastrointestinal

– As a weapon:• 2001 Postal Service

– Treatment• 60 day course of antibiotics

– (streptomycin or gentamicin)

• Vaccination – not available to general public at this time


• Plague– Yersinia Pestis – bacteria found in rodents

– 2 types• Bubonic• Pneumonic

– As a weapon• Pneumonic plague can spread through the air• Infecting anyone who breaths it• Symptoms due not show for 1 to 6 days• Many easily infected

– Treatment• Antibiotics (streptomycin or gentamicin)


• Tularemia– Francisella Tularensis – bacteria found in rodents & rabbits

– Can be spread by:• Breathing in spores• Being bitten by carrier• Drinking contaminated water (not spread person to person)

– As a weapon• Would most likely be used as an aerosol• Could also contaminate water sources

– Treatment• antibiotics


– Smallpox• Variola virus • Treatment: no specific treatment

– disease has a very systematic progression• Prevention: ________

– Botulism• Clostridium Botulinum – toxin made by bacteria

– foodborne, infantile, wound

• S/S - _________• Treatment: _________

– Hemorrhagic fever• Treatment: no established treatment

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

Agents of Terrorism:

• 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:

• Radiologic/Nuclear Terrorism– Radiologic 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

http://images.google.com/imgres?imgurl=http://s4.hubimg.com/u/1192927_f260.jpg&imgrefurl=http://hubpages.com/hub/Acute-Radiation-Syndrome&usg=__2V5IOnris_27Z3erTvtWVfVDaZM=&h=228&w=260&sz=7&hl=en&start=56&sig2=CLchk5HUZmKvyVv89UAn_w&um=1&itbs=1&tbnid=CTUGfToSXVBpCM:&tbnh=98&tbnw=112&prev=/images?q=acute+radiation+syndrome&start=54&um=1&hl=en&sa=N&ndsp=18&tbs=isch:1&ei=EwrOS6i2Ep64tQOAnaWvDg

Bioterrorism:Interdisciplinary Management

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

Case Study: Mike Jones http://www.firefighter-emt.com/archives/case-study-anaphylactic-shock-from-bee-stings.php

• 29 year old male – working outside on a construction site

• Beehive found at construction site and the man was stung several times by an unknown number of bees

• Immediately after stings – complaints of:– Pain at sting site– Generalized malaise –lightheadedness, weakness & nausea

Case Study: M. Jones

• Question:– What are your concerns at this time?– What questions would you ask?– What would you suggest the man do?


• Co-workers convince man to go to the hospital – 5 miles away – they transport him.

• During transport – complaints of:– Increased nausea– Some difficulty breathing– Audible wheezing

What would you suggest the coworkers do at this time?


• Co-workers stop at local convenience store and call 9-1-1

• While in the parking lot– M. Jones becomes unresponsive– Periods of apnea– No apparent pulse

• What should the co-workers do at this time?


• There was a severe thunder and lightening storm occurring, so the co-workers left the man inside the truck – thinking the outside conditions would be hazardous

• The man is found still in the vehicle when EMS arrived


• What would you anticipate EMS to do when they arrive on the scene? (Prioritize)


• EMS interventions:– Assess ABC’s

• man was pulseless & apenic– Remove pt from vehicle– CPR initiated– Assess cardiac rhythm

• asystole– Epinephrine given– Intubation– Recheck rhythm

• VFib– Defibrilliate

• 200J– CPR continued & transported to hospital


• What are some things you have to worry about in a situation like this, with regard to airway?


• In route to hospital – Crew noted:– No rash– Minimal facial and airway swelling

• At facility – Multiple doses of Epi given– Palpable carotid pulse developed– Within 20mins

• BP 100/60• HR 110• Epinephrine gtt @ 4 micrograms/min


• Yea!!!!! They saved him.

• Or did they?

• What other assessments do you want before you start celebrating?

Case Study: M. Jones Outcome

• No neurological response after 3 days in ICU• Decision to discontinue life support• Family provides history+• What will happen before life support d/cd?• What happened to this patient (diagnosis)? • How could it have been prevented? • What would you do differently?

• Case study found at JEMS.com

Case Study: Sally Smith

• 24 year old, healthy female, driving SUV on sunny day in February in Austin TX.

• Air was calm, ambient temperature of 67˚F• Loses control of car near a park- car

submerges into man made pond – 6 feet deep• Witnesses were at the scene• Water temperature was 42˚F

Case Study: S. Smith

• Witnesses call 911• Witness reports reveal– One witness attempted to enter the water but the

water was too frigid and he had to turn back– After 2 minutes in the water, woman was able to

break the back window of the SUV and escape– Woman was yelling for help and struggling to

swim


• EMS and Fire Rescue arrive on the scene approximately 15 minutes after woman initially went in to the water

• 2 firefighters attempted to enter the water but, again, were forced to turn back before they were able to reach the woman

• By the time the rescue team made it to the woman, she had been in the water for approx 25 minutes• The woman was face down, lifeless and pulseless

Case Study: S. Smith• At this point, what interventions would you complete?– A. CPR– B. Shake the patient, if necessary, to prevent loss of consciousness– C. Rub the patients’ extremities to keep promote rewarming– D. Cover with blankets– E. Remove wet garments– F. Elevate to patients head– G. Avoid rough movements if possible

• Why would this not apply to this person?

At the scene• Vitals & Neuro assessments completed• CPR initiated• Airway secured• Transfer to ER

Case Study: S. Smith• Upon arrival to ER – approximately 25mins

after being pulled from the water– Assessment:

• Initial vitals: Core body temp 92.1˚F ; HR 84; decreased drive to breath, BP 120/75; O2Sats 86% RA

• Assumptions: she may have swallowed a large amount of pond water


• What level of hypothermia would this patient be classified as:– A. Mild– B. Moderate– C. Profound


• What other assessment information do you want?

• LABS:– Na 144 K 5.0 Cl 102– Glucose 238 BUN 17 Creat 1.9 Ca 10.2– CBC normal/ex. WBC 25– ABG – pH 7.32 pCO2 50 HCO3 21What concerns do you have regarding these labs?What is this patient’s metabolic status?


• CXR– Mixed interstitial and alveolar infiltrates bilaterally

• EKG– Afib

• Which interventions are appropriate at this time?– A. Observation– B. Electrical cardioversion– C. Anticoagulation– D. Pharmacological cardioversion


• Admitted to ICU– DX: _____________ & _____________

• What orders/interventions would you expect?

• What is therapeutic hypothermia?

Case Study: S. SmithTherapeutic Hypothermia

• Insert Cool-Guard endovascular cooling catheter in femoral vein

• Goal temp is 89.6-93.2 F– Ms. Smith – by the time catheter is placed, her

temp dropped to 87.08 – she was initially warmed to target temp of 93.2 F.• Why did her temperature drop so low?

• 20 hours of active cooling then passively re-warmed

Case Study: S. SmithOutcome

• Average temp for 24hrs – 93.4• Acidosis corrected in 1st 8hrs• Pupils responded to light in 8hrs• Seizure on day 2 – dilantin started• GCS improved by day 3 with spontaneous eye movements

and obeying commands• Day 4 transferred to dependant unit with GCS 15• Eventually transferred to rehab – 3 months post injury –

independent with ADLs expected to discharge home

Case Study: Johnny Williamsadapted from http://www.vhct.org/case699/begin_the_case.htm

• 5 year old boy, 48 lbs, camping with family at Inks Lake

• Unaccounted for for about 15 mins while on a nature hike

• Body found floating in lake, face down• Immediately pulled from water and CPR

started by his father

Case Study: J. Williams

You are a nurse in the ED where Johnny will be arriving. What would you do to prepare for arrival?


• On arrival to ED– Assessment• Cyanotic• Pulseless• Apneic• Fixed and dilated pupils• Core body temp 89˚F• CPR continued

• With this information, what will you anticipate?


• After airway established and other assessments complete, rewarming begins.– How would you rewarm this patient?

– What do we worry about with regard to CPR, hypothermia, and cardiac dysrhythmias?

– What do you have to watch for during the rewarming process?


• 20 mins after intubation/mechanical ventilation,– spontaneous HR returns– adequate BP of 103/65– core temp of 95˚F

– What happens next?

Case Study: J. WilliamsOutcome

• 5 days in PICU – ventilated• Eventually weaned off of ventilator• 5 more days on medical unit• Recovery anticipated, with deficits

Case Study: Extra InfoChildren’s Health Encyclopedia

• 0-4 years old --- pools implicated in 60-90% of drowning– also bathtubs

• Teen boys --- natural bodies of water• Roughly 4 out of 5 drowning victims are male• Death or permanent neurological damage is very likely when patients arrive at the

emergency room comatose or without a heartbeat. • Of these patients, 35 to 60 percent die in the emergency department• Almost all of those who survive have permanent disabilities. • Early rescue of near-drowning victims (within five minutes of submersion) and

prompt CPR (within less than ten minutes of submersion) seem to be the best guarantees of a complete recovery

• Extremely cold water (less than 41°F or 5°C) seems to protect individuals from some of the neurological damage that occurs with near drowning. Some hypothermic near-drowning victims have been revived after they appeared dead and have experienced few permanent disabilities.

Documents

Nursing Care & Interdisciplinary Roles with Adult Clients in the Emergency/Disaster Environment Kelle Howard, MSN, RN, CNE Revised Fall 2012