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

1. Nursing Care & Interdisciplinary Roles with Adult Patients in the Emergency/Disaster Environment by Kelle Howard, RN, MSN Modified by Chris Puglia, MSN, RN, CEN

2. 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

3. 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 lab values for these lytes?

4. Heat Stroke:s/s of electrolyte depletion • Na >155 critical • Change in mental status • Weakness • Irritability • Neuromuscular excitability • Na <120 critical • Change in mental status • Combative, decreased LOC • Hallucinations • Loss of motor control • Cerebral edema & hemorrhage • K <2.8 critical • Hypo-reflexia, muscle weakness • Respiratory depression • EKG changes

5. Heat Stroke:Causes • Development is directly related to • Amount of time the body temperature is elevated • What are some common causes? Next

6. 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

7. FYI: • During 1999--2003, a total of 3,442 deaths resulting from exposure to extreme heat were reported (annual mean: 688) • Children’s thermoregulatory systems are not as efficient as adults and warm at a rate of 3-5xs faster STATISTICS Total number of U.S. hyperthermia deaths of children left in cars:   2012: 29 2011: 33 2010: 49 Heat Stroke Deaths Children in Vehicles

8. FYI • 73 degrees outside • 100 degrees in 10 minutes inside a car • 120 degrees in 30 minutes inside a car • 90 degrees outside • 160 degrees in minutes inside a car

9. Heat Stroke:Manifestations & Complications • What will your patient look like? Next

10. Heat Stroke:Manifestations & Complications • Core temp > 104˚F • AMS - confusion, sluggishness, • No perspiration • Skin hot, ashen, dry • Seizure • Coma • BP • HR • S/S of what?

11. 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?

12. 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? Next

13. Heat Stroke:Treatment & Interventions • Assessments/Interventions: • ABC’s – RR, O2 sats, BP, pulse • EKG • Large bore IV • Goal: • Decrease the core temperature • To what temperature? • Prevent shivering • Why? • How? – what med is used? • Attainment: • Remove clothes, wet sheets, large fan (evaporative), ICE water bath (conductive), cool IV fluids • Would you use antipyretics?

14. Heat Stroke:Treatment & Interventions • Monitor 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? Next

15. Heat Stroke:Treatment & Interventions • Rhabdomyolysis • skeletal muscle breakdown • monitor: • AKI – what will you see (labs)? • DIC • Pathological activation of coagulation mechanisms • monitor: • bleeding and bruising • coags & platelets • AKI – what will you see?

16. Heat Stroke:Interdisciplinary Roles • Who would be involved in this Patient’s care? • RN • MD - which ones? • RT • SW – why? • Anyone else? • Let’s say your patient shows changes in LOC, who do you call?

17. 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 body temp  peripheral vasoconstriction  shivering &movement  coma results <78˚F

18. Hypothermia:Causes • What are some common causes? Next

19. 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 • What health issues would predispose a patient to hypothermia?

20. Hypothermia:Manifestations & Complications What will your patient look like?

21. Hypothermia:Manifestations & Complications • Varies: dependent upon core temp • Mild (93.2˚F - 96.8˚F) • Lethargy, confusion, behavior changes, minor HR changes, vasoconstriction • Intense shivering at higher temps – difficulty speaking – then shivering begins to decrease • Moderate (86˚F – 93.2˚F) • Rigidity, dec HR, dec RR, dec BP, hypovolemia, metabolic & resp acidosis, profound vasoconstriction, rhabdomyolysis • Shivering usually disappears around 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? do cardiac drugs/defibrillation work?

22. 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

23. Hypothermia:Prognosis • Dependant upon • Core body temperature • Co-morbidities

24. Hypothermia:Treatment & Interventions • ABC’s – must stabilize • What interventions will you perform initially? • What do you think the goal of treatment is? • How would you achieve this goal? Next

25. Hypothermia:Treatment & Interventions • Goal: • Rewarming to temp of _____˚F • Correction of dehydration & acidosis • Treat cardiac dysrhythmias • What about CPR? • 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?

26. Bair Hugger • http://www.arizant.com/us/bairhuggertherapy

27. Hypothermia:Treatment & Interventions • Monitor • Core temp How? • for marked vasodilatation & hypotension • After drop • What is this? • Teach • Warm clothes & hats, layers, high calorie foods, planning

28. Submersion Injury:Causes & Incidence • avg. 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 Next

29. 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)

30. Submersion Injury :Pathophysiology • Death is caused by hypoxia • Victims that aspirate • secondary to aspiration & swallowing of fluid • fluid aspirated into pulmonary tree  PULMONARY EDEMA - HYPOXIA • Victims that do not aspirate • bronchospasm & airway obstruction  “dry drowning” - HYPOXIA

31. Submersion Injury :Manifestations & Complications • What will your patient look like? • Pulmonary • Cardiac • Neuro

32. Submersion Injury :Manifestations & Complications • Dependant upon length of time & amount of aspirate: • Pulmonary • Ineffective breathing, dyspnea, distress, arrest, crackles & rhonchi, pink frothy sputum with cough, cyanosis • Cardiac • Inc./dec. HR, dysrhythmia, dec. BP, cardiac arrest • Neuro • Panic, exhaustion, coma

33. Submersion Injury :Treatment & Interventions • ABC’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? Next

34. Submersion Injury :Treatment & Interventions • Goal: • Correct • hypoxia • acid/base balance • fluid imbalances • correct dysrhythmias • Attainment: • Anticipate intubation • What about your “dry drowning victims?” • 100% O2 via non-rebreather • IV access

35. Real Life Drowning Victim • Near Drowning

36. 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

37. Bites & Stings • Hymenopteran stings (hī-mə-näp-tə-rən) • Bees, yellow jackets, hornets, wasps, fire ants • Mild to Anaphylactic • What are some manifestations of each? • What interventions would you implement to treat these manifestations? • Treatment: • Remove stinger with scraping motion • Tweezers • Maintain ABCs • What meds might you give?

38. Bites & Stings • Manifestations • Mild • Stinging, swelling, burning, redness • Anaphylactic • Airway constriction, wheezing, & CV collapse • Interventions • Remove rings, watches, etc. • Elevate the limb • Cool compress • Meds: • Topical, PO, IM, IV antihistamines --- Benadryl • Epi IM • Corticosteroids

39. Got any home remedies to share? • Meat tenderizer • Baking soda • Mud • Penny? • These are for site specific issues… these should not be considered if the person is having a systemic reaction.

40. 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 dependent on where bitten: • Upper part of body: shoulder, chest and back rigidity • Lower part of body: symptoms mimic appendicitis, pancreatitis, & abdominal emergencies • Can cause systemic issues • Treatment • Antivenin used in special at risk population Where do you usually find them?

41. Brown Recluse • Brown recluse • Characteristic violin pattern on base head • Venom is cytotoxic to humans • Symptoms progress over hrs –weeks • Often unnoticed – painless bite • Can cause systemic issues • Like what? • Treatment • Clean area, treat pain, antibiotics (why?) • Surgical debridement with grafting may be necessary

42. 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 • Why? • Caffeine, alcohol & smoking not recommended • Why? Remember: "red on yellow, kill a fellow" “red on black, friend of Jack”

43. Bites & Stings • Antivenin • Do you know how it is made? • Venom injected in animal  antibodies made  antibodies harvested • Do we have enough? • No • Coral snake bites • treat with intubation & mechanical ventilation • antivenin no longer made in US • what is left expired in 2009

44. 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

45. Poisoning: • 1-800-POISON1 (1-800-222-1222) • 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)

46. Agents of Terrorism:Types • Bioterrorism • Anthrax, plague, tularemia, smallpox, botulism, hemorrhagic fever • Chemical terrorism • Sarin, phosgene, mustard gases • Radiological/Nuclear terrorism

47. 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

48. Agents of Terrorism:Bioterrorism • Plague • Yersinia Pestis – bacteria found in rodents • 2 types • Bubonic – from rodent bites • Pneumonic – person to person • 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)

49. Agents of Terrorism:Bioterrorism • 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

50. Agents of Terrorism:Bioterrorism • Smallpox • Variola virus • Treatment: no specific treatment • disease has a very systematic progression • Prevention: vaccine • Botulism • Clostridium Botulinum – toxin made by bacteria • foodborne, infantile, wound • S/S – muscle paralyzing disease • Treatment: antitoxin • Hemorrhagic fever • Treatment: no established treatment