Lisa Randall, RN, MSN, ACNS-BCRNSG 2432

Compare and contrast interdisciplinary roles and responsibilities associated with emergency and disaster situations.

Compare and contrast risk factors associated with need for emergency care.

Analyze etiology, pathophysiology, and signs/symptoms of bioterrorism, chemical and radiation exposure, and other emergencies.

Discuss nursing care and diagnoses associated with emergency care.

EmergencyMCIBioterrorismChemical and radiation exposurePrimary surveySecondary survey

Emergency Any extraordinary event that

requires a rapid and skilled response and can be managed by a community’s existing resources

Mass casualty incident (MCI)▪ Manmade or natural event or disaster

that overwhelms community’s ability to respond with existing resources

Total number of casualties a hospital can expect is estimated by doubling number of casualties that arrive in first hour 30% admission to hospital▪ half will need surgery within 8 hours

All health care providers have a role in emergency and MCI preparedness

Know hospital’s emergency response plan

Participation in emergency/MCI preparedness drills is required

Response to MCIs often requires the aid of a federal agency such as the National Disaster Medical System (NDMS) U.S. Department of Homeland

Security▪ responsible for the coordination of the

federal medical response to MCIs

Anthrax Botulism Plague Tularemia Smallpox Typhoid fever Hemorrhagic fever

Bacillus anthracis Infected animalsSkin, ingestion, inhalationPulmonaryCutaneousGIAntibiotics

Oral FluoroquinolonesPrevention

Vaccination limited

Clostridium botulinum Ingestion (12-36), inhalation (24-72)NeuropathiesBlurred visionWeaknessRespiratory dysfunctionVaccine investigational

Yersinia pestis Infected fleas (2-8d), aerosol (1-3) Lymphatic (bubonic) Blood (septicemia) Airborne Pulmonary variant

Fever Cough Hemoptysis

Antibiotics Doxycycline

Vaccine Bubonic

Variola virusAirborne 7-17d incubationFlu-like symptomsRashVaccine

A-Z Biotoxins Blood agents Caustics (acids) Incapacitating agents Metals Nerve agents Pulmonary agents Riot control agents Toxic alcohols Vesicants

Categorized by target organ or effect Sarin: ▪ Neurotoxin▪ Death within minutes of exposure ▪ Enters body through eyes and skin▪ Paralyzes respiratory muscles

Antidotes ▪ Atropine▪ Pralidoxime chloride (2-PAM, Protopam given

IV)

Phosgene▪ Colorless gas normally used in chemical

manufacturing ▪ Severe respiratory distress, pulmonary

edema, and death Mustard gas▪ Yellow to brown in color with garlic-like odor

▪ Eyes▪ Skin burns/blisters

Ionizing radiation Nuclear bomb Radioactive

material Serious threat to

safety of casualties and environment ▪ MASS CASUALTY

Decontamination procedures

Acute radiation syndrome ▪ Substantial exposure ▪ Predictable pattern

Exposure dependent 10-12 Gy fatal▪ Vomiting▪ Lymphopenia▪ Cerebrovascular changes

Fluid replacement Cytokines

G-CSF, GM-CSF, filgrastim Antiobiotics

Burns, wounds Abdominal trauma

Thyroid protection KI

OR Within 36hr or after 6wks

Radiologic dispersal devices (RDDs) Mix of explosives and radioactive

material Scatters radioactive dust, smoke, and

other material into environment Main danger from RDDs: Explosion

Blast, crush, or penetrating Blast injuries▪ Supersonic overpressurization shock

wave that results from explosion

▪Lungs▪Ear▪GI ▪Fracture, lacerations, burns, blindness

EarthquakesFloodsHurricanesLandslide/mudslideTornadoesTsunamisVolcanoesWildfiresWinter weather

Level-1 DMAT - disaster medical assistance teams ▪Deployed within 8 hours ▪ Self-sufficient for 72 hours with enough food, water, shelter, and medical supplies to treat about 250 patients per day

Level-2 DMAT▪ Replaces a Level-1 team▪ Supplements the equipment left on site

HAZMAT NRP

First responders Police Emergency Medical Personnel▪ Triage of casualties differs from usual

ED triage and is conducted in <15 seconds

Colored tags ▪ Green▪ minor injury▪ walking wounded

▪ Yellow ▪ non-critical injury▪ RPM

*R-resp. P-pulse M- mental status/response/commands

▪ Red ▪ life-threatening injury▪ immediate intervention

▪ BlackBlack▪ dead or expected to die▪ catastrophically injured

Step 1. Respiration (breathing)A. None, open airway, still no breathing, tag deceased - blackB. Respiration’s greater than 30/min. or less than 10/min. tag Red.C. Respiration between 10-30 per minute. Go on to Step 2.

Step 2. Perfusion check (radial pulse) or use a capillary blanch testA. Squeeze nail bed, palm of hand or pad of finger.B. If color regains in greater than two seconds, tag Red.C. If the color returns in less than two seconds go onto Step 3 – Mental status.D. In poor lighting, attempt to find the radial pulse. If radial pulse is present proceed to Step 3.

Step 3. Mental statusA. Altered mental status is the inability to follow simple commands, tag Red.B. Able to follow simple commands, tag Yellow.C. Example of simple commands: “can you squeeze my hands?” “Can you open and close your eyes?” D. All steps have been passed for patient to be tagged Yellow.

TriageAssessment Interventions

Drug therapy Diet therapy▪ Hypermetabolic states

Surgical/medical interventions

Short term hospital resource and staffing needs Illness severity Hospital resources

5 level ESI-1 highest priority Triage algorithm

Definition ESI-1 ESI-2 ESI-3 ESI-4 ESI-5

Stability of vital functions

Unstable Threatened Stable Stable Stable

Life /organ threat

Obvious Likely but not always obvious

Unlikely but possible

No No

How soon patient should be seen by physician

Immediately

Minutes Up to 1 hour

Could be delayed

Could be delayed

Expected resource intensity

High; staff at bedside continuously; mobilization of team response

High; multiple, complex diagnostic studies; frequent consultation; cont monitoring

Medium/high; multiple diagnostic studies or brief observation; or complex procedure

Low; 1 simple diagnostic study; or simple procedure

Low; examination only

Cardiac arrest. Respiratory arrest. Severe respiratory distress. SpO2 < 90. Critically injured trauma patient who presents unresponsive. Overdose with a respiratory rate of 6. Severe respiratory distress with agonal or gasping-type

respirations. Severe bradycardia or tachycardia with signs of

hypoperfusion. Hypotension with signs of hypoperfusion. Trauma patient who requires immediate crystalloid and

colloid resuscitation. Chest pain, pale, diaphoretic, blood pressure 70/palp. Weak and dizzy, heart rate = 30. Anaphylactic reaction. Baby that is flaccid. Unresponsive with strong odor of ETOH. Hypoglycemia with a change in mental status.

ISOLATION PRECAUTIONSBasic triage principles

1. life threatening injuries 2. decontaminate 3. decongest area

A 6 yo w T 103.2 A 22 yo w asthma in acute resp distress An infant who has been vomiting for 2

days A 50 yo man w LBP/spasms A 32 yo woman unconcious following an

MVA A 40 yo woman w rhinitis and cough A 58 yo man w midsternal chest pain A teenager w an angulated FA from sports

Maintain airway Suction and/or remove foreign body Insert nasopharyngeal/oropharyngeal

airway Endotracheal intubation Cricothyroidotomy or tracheostomy

Stabilize/immobilize cervical spine Collar Spinal precautions▪ Flat bedrest▪ Log roll

Breathing Assessment 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

Circulation Check central pulse Assess skin for color, temperature,

moisture Assess mental status and capillary

refill Aggressive fluid resuscitation ▪ Insert two large-bore IV catheters ▪ NS or LR

Disability LOC AVPU▪ A = alert▪ V = responsive to voice▪ P = responsive to pain▪ U = unresponsive

GCS Pupils

Exposure/Environmental control Remove clothing Provide temperature control—

avoid hypothermia

Obtain history Location Duration Activity Occupation # affected

VS BP

HR RR Temperature

Head-to-toe assessment Head and spine Chest Listen to abdomen first Pelvis Perineum Limbs – reduce fractures

S/S nonspecificVSLOCNeuroGISkin

Five interventions ECG Pulse oximetry Catheterize NGT Labs

Serial CBCBlood culturesChromosomal aberration24 hr urine/stool

Volume expanders InotropesVasopressorsOpiodsVasocnstrictors Immunizations, vaccines, immune

globulinAntibiotics and antiviralsAntidotes such as atropine

Ineffective airway Ineffective tissue perfusionRisk for infection Impaired physical mobilitySpiritual distressRisk for post-trauma syndrome

Many hospitals and DMATs have a Critical Incident Stress Management unit Group discussions Facilitates psychologic recovery

The nurse performing a primary survey in the ED is assessing a. the acuity of the patient’s condition to

determine priority of care b. the status of airway, breathing,

circulation, or presence of deformity. c. whether the patient is responsive

enough to provide needed information d. whether the resources of the ED are

adequate to treat the patient.

A homeless man is brought to the ED in profound hypothermia with a temperature of 85 degrees F. On initial assessment, the nurse would expect to find a. shivering and lethargy b. fixed and dilated pupils c. respirations of 6-8 per minute d. BP obtainable only by doppler

A victim of a sublethal dose of whole-body ionizing radiation exposure is admitted to the ED several hours after exposure. On assessment the nurse would expect the patient to report a. hair loss. b. nausea and vomiting. c. bleeding from the gums and nose. d. bruises on skin not covered by clothing.

•Definition▫ Failure of the hypothalamic regulatory process▫ Increased diopherisis▫ Vasodilatation▫ Increased RR ▫ Sweat glands stop working ▫ Core temp rises▫ Circulatory collapse

Development is directly related to Amount of time the body temperature is

elevated

What are some common causes?

Strenuous activity in hot/humid environment

High feversClothing that interferes with

perspirationWorking in closed areas/prolonged

exposure to heatDrinking alcohol in hot environment

Core temp > 104˚FAMSNo perspirationSkin hot, ashen, dryDec. BP Inc. HR

S/S of what?

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

patient to heat related emergencies?

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?

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

Exposure to cold temperatures Inadequate clothing, inexperience Physical exhaustion

Wet clothes in cold temperatures Immersion in cold water/near

drowningAge/current health status predispose

What health issues would predispose a patient to hypothermia?

Vary 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 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

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

•Attainment:▫Passive & active external rewarming▫Active core rewarming

• 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

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)

Death is caused by hypoxiasecondary to aspiration & swallowing of

fluid Victims that aspirate

Fluid aspirated into pulmonary tree PULMONARY EDEMA - HYPOXIA

Victims that do not aspirate Bronchospasm & airway obstruction “dry

drowning” - HYPOXIA

http://www.youtube.com/watch?v=roFGBt8xEis&feature=relateddrowning

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)

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

Hymenopteran stings 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 – why or why not?▪ Maintain ABCs

▪ What meds might you give?

• Spider bites▫Black widow

Venom is neurotoxic to humans Symptoms progress over time 15mins – 3hrs Can cause systemic issues Treatment

Cool area to slow movement of toxins Antivenin used in special at risk population

▫Brown recluse Venom is cytotoxic to humans Symptoms progress over 6hrs – 2weeks Can cause systemic issues Treatment

Clean area, treat pain, antibiotics (why?) Surgical debridement with grafting may be necessary

Black Widow

Brown Recluse

Snakebites Pit viper, rattlesnakes, copperheads,

water moccasins, coral snakes Pit viper: hemolytic, coral: 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 recommendedRemember: "red on yellow kill a fellow"

The priority of management of the near-drowning patient is a. correction of hypoxia b. correction of acidosis c. maintenance of fluid balance d. prevention of cerebral edema

As a member of a volunteer disaster medical assistance team, the nurse would be expected to a. triage casualties of a tornado that hit the

local community. b. assist with implementing the hospital’s

response plan. c. train citizens of communities how to respond

to mass casualty incidents. d. deploy to local or other communities with

disasters to provide medical assistance.

http://www.hulu.com/watch/21873/saturday-night-live-cpr-class

Mr. M., 72yo, was taking a short break from nailing new shingles on his roof during the summer when he lost conciousness and collapsed in his yard. Accompanied by his wife, he was brought by ambulance to the emergency department.

Subjective Data Wife states he has been working all

week on the roof even though he has not felt well the last day or two

Objective Data VS: T 106; HR 124 and weak and

thready; RR 36 and shallow; BP 8240 Skin hot, dry, and pale

1. What factors in Mr. M’s history place him at risk for heat stroke? Advanced age and prolonged exposure

to heat over several days

2. What laboratory tests would the nurse anticipate to be ordered, and what alterations in these tests would be indications of heat stroke? ABGs—decreased PaO2 Electolytes—decreased Na+, Cl-, K+ CBC—hemoconcentration with elevated H&H,

BUN/Cr, & Glu PT/INR—increased LFT—elevated UA—elevated sp. Gr., protein, possible

hematuria

3. How would cooling for Mr. M. be carried out? Clothing would be removed, fans, tepid

mist, ice water bath▪ Cold water peritoneal dialysis

4. What supportive treatment is indicated for Mr. M.? 100% O2, with intubation and

mechanical ventilation IV crystalloid with CVC or PA catheter Cooling methods Indwelling catheter, I&O Thorazine (shivering)

5. What should Mrs. M. be told about Mr. M’s condition? Mrs. M. should be told that Mr. M. is very

seriously ill and that there is a chance he might not recover ▪ High morbidity and mortality rate

She should be kept informed of the treatment he is receiving and his response to treatment

Emotional support

6. Based on the assessment data presented, write one or more appropriate nursing diagnoses. Are there any collaborative problems? Hyperthermia r/t environmental exposure Decreased CO r/t hypermetabolic process Deficient fluid volume r/t fluid loss excessive to

intake Altered protection r/t ams Risk for injury r/t seizure activity Risk for impaired skin integrity r/t immobility Collaborative: hypovolemic shock; cerebral edema;

seizures; hypoxia; electrolyte imbalance; renal failure

Lewis, S., Heitkemper, M., O’Brien, P., Bucher, L. (2007). Medical-Surgical Nursin.g Assessment of Management of Medical Problems. Mosby Elsevier, St. Louis, Missouri.

Emergency Preparedness and Response. Centers for disease control and

prevention. Retrieved 2/21/2011, from http://www.bt.cdc.gov.