EMERGENCY / TRAUMA/ MASS CASUALTY/ BIOTERRORISM

1. EMERGENCY / TRAUMA/ MASS CASUALTY/ BIOTERRORISM By: Diana Blum MSN MCC NURSING 2150

2. Care is episodic and involves primary secondary and tertiary care that is acute or critical in nature” PG: 2080 EMERGENCY

3. Place client in hospital gown • Ensure privacy • Med administration as ordered • Assist with procedures • Reprioritize and reassess as needed Care of Client

4. Rapid change • Noisy • Unpredictable Environment of Care

5. Multiple specialties • Increasing visits to 123.8 million in 2011 • Avg age of patient is 35.7 yrs old • 75 + years old highest visit rate • Common reasons for healthcare seeking: • A. • B. • C. • D. CHART 66-1 Demographic

6. 6 months to 1 year acute care/ICU training • Some ERs will hire new grads using intern program ER Nursing

7. 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 Priority Emergency Measures for All Patients

8. 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

9. Multitasking • Assist with: • Wound closure • Foreign body removal • Central line insertion • Transvenous pacemaker insertion • Lumbar puncture • Pelvic exam • Chest tube insertion • Lavage • Fracture management Technical Skills http://www.youtube.com/watch?v=n5Zw4ZARvNg

10. Core Competencies

11. Broad based • Multi disease process/insects/snakes/animals • Mandatory reporting for sexual assault, abuse • BLS, ACLS, PALS Knowledge of ER Care

12. Rapid recognition of abnormal findings • Must be aware of comorbidites • Act Quickly Assessment

13. Complex barriers • Use professional language • Protect HIPPA related information Communication

14. Means: to sort: ED triage differs from disaster triage in that patients who are the most critically ill receive the most resources, regardless of potential outcome • Across-the-room assessment • starts with visual contact, general appearance, work of breathing, skin color • Determine chief complaint 3. Focused assessment • (Subjective data) demographics, onset of symptoms, past medical history, LMP, current meds, allergies • (Objective data) inspection, palpation, auscultation, obtain vital signs Triage

15. Triage Nurse has 2-3 minutes to decide how long each patient should wait for medical care and assign a corresponding Triage Category

16. Assign acuity level • Emergent: immediate threat to life or limb • CODE, Respiratory Failure, Chest pain, hemorrhage • Urgent: treat quickly but life no immediate threat present at this time • Pneumonia, abd pain, fractures • Non-Urgent: can wait for several hours if needed • Strains, sprains, toothaches, cold, some rashes Basic Elements

17. urgency based on vital signs, complaints, appearance, and history • Coming by ambulance think of the following • Code 1 did not need ambulance • Code 2 minor injuries • Code 3 serious injury • Code blue =coding

18. Level 1- immediate life saving interventions, many resources • Level 2- high risk, many resources • Level 3- urgent, two or more resources, wait 30 min • Level 4- non-urgent one resource, wait up to 1 hour • Level 5-no resources, wait up to 2 hours 5 Level Triage (chart 66-11)

19. Level 1- CPR, intubation required • Level 2- chest pain, dyspnea, suicidal with plan or attempt, stroke, pregnant with active bleeding • Level 3-abdominal pain, closed fractures, dislocations • Level 4- sore throat, strains, sprains, URI, • Level 5- suture removal, medication refill, certain rashes Examples

20. Labs IV fluids • XRAY Consults • EKG Simple procedure • CT/MRI Complex procedure • IV/IM medications Resources

21. A:Airway • patency, stridor, inability to speak, rise and fall of chest • B: Breathing • rate and depth, breath sounds, chest expansion, skin color, spontaneous breathing • C: Circulation • heart rate, pulses, blood pressure, skin, cap refill D:Disability Alertness, Responsive toVoice, Responsive to pain, Unresponsiveness E:Exposure Remove clothing, keep pt warm Primary Survey

22. Identifies other injuries or medical issues that needs to be managed 2nd ary Survey

23. Use a team approach • Determine the extent of injuries and establish priorities of treatment • Assume cervical spine injury-log roll protect spine • Assign highest priority to injuries interfering with vital physiologic function Priorities of Care for the Patient With Multiple Trauma

24. Admitted or discharged is the question • What is the nurses role? Disposition

25. Nurse case managers intervene when necessary to assist in making follow up and referral arrangements especially with elderly and homeless, and abused clients Case Management

26. review D/C instructions • Reinforce safety (sealtbelt wearing) • Discuss home safety (detectors, fall prevention) • teach new procedures that will continue at home Teaching

27. Trauma Nursing By: Diana Blum RN MSN Metropolitan Community College

28. Common Trauma • Heat • Bites • Cold • Electrical • Altitude • Near drowning • Spinal • Head • Musculoskeletal • Stab/gunshot wounds • rape

29. Acute Medical Emergency • Failure of heat regulating mechanisms • Elderly and young at risk • Exceptional heat exhaustion • Stems from heavy perspiration • Need to stay hydrated! • Causes thermal injury at cellular level Hyperthermia

30. Mental status…Seizure may occur • Monitor vitals frequently • Renal status • Monitor temp continuously • EKG, Neuro status • Hypermetabolism due to increased body temp • Increases 02 demand • Hyperthermia may recur in 3 to 4 hours; avoid hypothermia Assessment

31. Lower temp as quickly as possible(102 and lower) How can this be done? • ABC’s • Give 02, Start large bore IV • Insert foley • Labs: • Lytes, CBC, myoglobin. Cardiac enzymes Treatment

32. Heat Exhaustion Stroke

33. Heat Exhaustion • Caused by dehydration • Stems from heavy perspiration • Poor electrolyte consumption • Signs/Symptoms • Normal mental status • Flu like • Headache • Weakness • N/V • Orthostatic hypotension • Tachycardia

34. Heat Exhaustion • Treatment • Outside hospital • Stop activity • Move to cool place • Cold packs • Remove constrictive clothing • Re-hydrate (water, sports drinks) • If remains call 911 • In hospital • IV 0.9% saline • Frequent vitals • Draw serum electrolyte level

35. Heat Stroke • Leads to organ failure and death • Mortality rate up to 80% • 2 types: • Exertional • Sudden onset • Too heavy clothes • Classic • Occurs over period of time • Chronic exposure to heat • Example (no air conditioning)

36. Heat Stroke • Assessment • Monitor mental status • Monitor vitals • Monitor renal status • Treatment • At site • ensure patent airway • Move to cool environment • Pour water on scalp and body • Fan the client • Ice the client • Call 911 • At hospital • O2 • Start IV • Administer normal saline • Use cooling blanket • DO NOT give ASA • Monitor rectal temp q15 minutes • Insert foley to monitor I/Os closely and measure specific gravity of urine • Check CBC, Cardiac enzymes, serum electrolytes, liver enzymes ASAP • Assess ABGs • Monitor vitals q 15 minutes • Administer muscle relaxants if the client shivers • Slow interventions when core temp is 102 degrees or less

37. Management of Patients With Heat Stroke • Remember ABCs (decrease temp to 39° C as quickly as possible • Cooling methods • Cooling blankets, cool sheets, towels, or sponging with cool water • Apply ice to neck, groin, chest, and axillae • Iced lavage of the stomach or colon • Immersion in cold water bath • Monitor temp, VS, ECG, CVP, LOC, urine output • Use IVs to replace fluid losses • Hyperthermia may recur in 3 to 4 hours; avoid hypothermia

38. Ensure adequate fluid and foods intake • Prevent overexposure to sun • Use sunscreen with at least SPF 30 • Rest frequently when in hot environment • Gradually expose self to heat • Wear light weight, light colored, loose clothing • Pay attention to personal limitations: modify accordingly Patient teaching

39. HYPOTHERMIA

40. COLD • Most common • Hypothermia • Frostbite • Synthetic clothing is best because it wicks away moisture and dries fast • “cotton kills” it holds moisture and promotes frostbite • A hat is essential to prevent heat loss though head • Keep water, extra clothing, and food in car in case of break down

41. 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

42. Apathy, drowsiness, pulmonary edema, coagulopathies • Weak HR and BP • Hypoxemia • Continuous temperature and EKG • Watch for dysrhythmias Assessment

43. Warm fluids, blankets • Cardiopulmonary bypass • Warm lavage Rewarming

46. Inadequate insulation is the culprit 3 stages Superficial (frost nip) Mild Severe Frostnip produces mild pain, numbness,pallor of affected skin Graded like burns-partial thick or full thick 1st degree- hyperemia, edema 2nd degree- fluid blisters with partial thick necrosis 3rd degree- dark fluid blisters, sub cutaneous necrosis 4th degree- no blisters, no edema, necrosis to muscle and bone Frost Bite

47. Snake Bites • Most species non venomous and harmless • Poisonous snakes found in each state except Maine, Alaska, and Hawaii • Fatalities are few • Children 1-9 yrs old victims during daylight hours • AWARENESS is KEY • 2 main types in North America are • 1. • 2.

48. Snake Bites • Pit Vipers • Depression between eye and nostril • Triangular head indicative of venom • Venom function is to immbolize, kill and aid in digestion of prey (systemic effects happen with in 8 hours of puncture) • impairs blood clotting • Breaks down tissue protein • Alters membrane integrity • Necrosis of tissues • Swelling • Hypovolemic shock • Pulmonary edema, renal failure • DIC • 2 retractable curved fangs with canals • Rattlers have horny rings in tail that vibrates as a warning

49. Snake Bites • Treatment • At site • Move person to safe area • Encourage rest to decrease venom circulation • Remove jewelry and restrictive clothing • Splint limb below level of heart • Be calm and reassuring • No alcohol or caffeine 2nd to speed of venom absorption • At hospital • Constrict extremity but not to tight • Do NOT incise or suck wound • Do NOT apply ice • Use Sawyer extractor if available if used within 3 minutes of bite and leave for 30 minutes in place • O2 • 2 large bore IV sites • Crystalloid fluids (NS or LR) • Continuous tele and bp monitoring • Opiod pain management • Tetanus shot • Broad spectrum antibx • Lab draw (coagulation studies, CBC, creatinine kinase, T and C, UA) • ECG • Obtain history of wound and pre-hospital tx • measure circumference of bite every 15-30 minutes • Possibly give antivenom if ordered (see page 177) • Monitor for anaphylaxis • Notify poison control

50. Snake Bites • Coral Snakes • Corals burrow in the ground • Bands of black, red, yellow • “red on yellow can kill a fellow” • “red on black venom lack” • Are generally non aggressive • Ability to inject venom is less efficient • Maxillary fangs are small and fixed • Use chewing motion to inject • Venom is neurotoxic and myotoxic • Enough in adult coral to kill human