Emergency, Terrorism, and Disaster Nursing Flashcards
Triage assessment questions
Is the patient dying?
Is this a patient who should not wait to be seen?
Put these patients ESI 1 or 2
Normal VS for ESI 3 or below;
Primary survey “A”
ABCDE
Airway: with Cspine stabilization or immobilization
-seizures, near-drowning, anaphylaxis, foreign body obstruction, or cardiopulmonary arrest; open airway using jaw-thrust maneuver->suction->insert airway–>intubate. Vent pt using 100% oxygen before intubation
rapid sequence intubation
is the preferred prpcedure for securing an unprotected airway in the ED. It involves the use of sedation (midazolam [Versed]) or anesthesia (etomidate [Amidate]) and paralysis (succinylcholine [Anectine]) apply cricoid pressure
Airway Emergency Assessment and Interventions
clear and open airway assess for obstructed airway assess for respiratory distress check for loose teeth or foreign objects assess for bleeding, vomitus, or edema
suction
jaw thrust maneuver
artificial airway
c spine immobilization
Primary Survey “B”
fractured ribs, pneumothorax, penetrating injury, allergic reactions, pulmonary emboli, and asthma attacks. Watch for dyspnea (PE), paradoxic or asymmetric chest wall mvmt (flail chest), decreased or absent breath sounds on the affected side (pneumothorax), visible wound to chest wall (penetrating injury), cyanosis (asthma), tachycardia and hypotension
Breathing Assessment and Interventions
Assess ventilation look for paradoxic mvmt of chest wall note use of accessory muscles listen for air bein expired through nose and mouth feel for air being expelled observe and count RR note color of nail beds, MM, skin auscultate lungs assess JVD and position of trachea
Give O2 (often 100% via non-rebreather)
vent with bag-valve-mask with 100% o2 if respirations are inadequate or absent.
prepare to intubate if respiratory arrest
have suction available
if absent breath sounds, prepare for needle thoracostomy and chest tube insertion
What do you do as an ED nurse if breath sounds are absent?
think about mechanically venting, or preparing for needle thoracostomy and chest tube insertion
Primary Survey “C”
Circulation: Heart, intact blood vessels and adequate blood volume. ** Altered Mental Status and delayed cap refill (>3sec) are the most significant signs of circulatory shock.
Circulation Assessment and Interventions
check carotid and femoral pulse palpate pulse for quality and rate assess color, temp, and moisture of skin check cap refill assess for external bleeding measure BP
if no pulse, initiate CPR
If shock symptoms or if pt is hypotensive, start two large-bore (14-16 gauge) IVs and initiate infusions of NS or LR
Control bleedings with direct pressure and sterile dressing
administer PRBC’s (warmed if rapid infusion, and don’t forget to replenish clotting factors too!)
consider use of a pneumatic antishock garment or pelvic splint in the presence of pelvic fracture with hypotension.
Obtain blood samples for type and crossmatch
Primary Survey “D”
DIsability: conduct a brief neuro exam–> pt’s LOC determines the degree of disability. GCS
assess pupils for size, shape, equality, and reactivity.
Inspect extremities for any obvious deformities and splint them if found.
Assess pain (PQRST)
Primary Survey “E”
Exposure/Environmental Control
Remove all trauma patient’s clothing to preform a thorough physical assessment. Once the patient is exposed, it is important to limit heat loss, prevent hypothermia, and maintain privacy by using warming blankets, overhead warmers, and warmed IV fluids
Life Threatening Conditions Identified During Primary Survey related to AIRWAY
inhalation injury
obstruction (partial or complete) from foreign bodies, vomitus, or tongue
penetrating wounds and/or trauma to upper airway structures
Life Threatening Conditions Identified During Primary Survey related to BREATHING
anaphylaxis
flail chest with pulmonary contusion
hemothorax
pneumothorax
Life Threatening Conditions Identified During Primary Survey related to CIRCULATION
MI pericardial tamponade shock (massive burns, hypovolemia) uncontrolled external hemorrhage hypothermia
Life Threatening Conditions Identified During Primary Survey related to DISABILITY
head injury
stroke
Secondary survey
the secondary survey begins after addressing each step of the primary survey and initiating any lifesaving interventions. The secondary survey is a brief, systematic process that aims to id ALL injuries.
Secondary Survey Steps: “FFFGHI”
Full set of VS Focused Adjuncts Facilitate family presence Give comfort measures History and Head to toe Assessment Inspect posterior surfaces
What are the actions to take during the Focused Adjuncts aspect of the secondary survey?
determine HR and rhythm. Initiate ECG, O2 sat, and end-tidal CO2 monitoring foley gastric tube obtain blood for labs arrange for diagnostic studies provide tetanus prophylaxis
What is the mnemonic to use during the History and Head to Toe assessment aspect of the secondary survey?
AMPLE
Allergies, Med Hx, Past Health HX, Last Meal, and Events/Environment preceding illness or injury
Post-cardiac arrest hypothermia
Therapeutic hypothermia for 24 hours following resuscitation improves mortality and neurologic outcomes in many patients. It should be considered for all patients who are comatose or who do not follow commands after resuscitation.
Therapeutic hypothermia
three phases: induction, maintenance, and rewarming
Induction phase of therapeutic hypothermia
goal core temp is 89.6-93.2. Achieve this through infusion of cold NS and cooling devices (Arctic Sun, Blanketrol). Patients require invasive monitoring (arterial and central pressures) and continuous assessment while receiving this therapy.
non-heart-beating donation
corneas, heart valves, skin, bone, and kidneys can be harvested from patients after death.
So you are cooling a person with heat stroke and they start to shiver. What do you do?
Administer Chlorapromazine (Thorazine) IV. Shivering increases core temp due to associated heated generated by muscle activity, so you should stop the shivering with meds. Antipyretics are not appropriate in this situation because the elevated temp is not due to infection.
Monitor for rhabdomyolysis (the muscle breakdown leads to myoglobinuria which places the kidneys at risk of acute failiure). Watch for tea-colored urine.
What happens physiologically if a person is hypothermic?
As core temp drops, BMR decreases two or three times. The cold myocardium is irritable and vulnerable to dysrhythmias. Decreased renal blood flow decreases GFR, which reduces water reabsorption, leading to dehydration. Hct increases as vascular volume decreases-cold, thick blood forms thrombuses–>risk for stroke, MI, PE, renal emboli
Shivering stops at core temps below 86. BMR, HR, and RR may be so slow that they are difficult to detect. reflexes are absent and pupils are fixed and dilated. The cause of death is typically refractory vfib.
Interventions for hypothermia
remove pt from cold environment
manage and maintain ABC’s
Provide high flow O2 via non-rebreather mask or BVM
rewarm patient (warming blanket, warm iv fluids, heated, humidified O2, warmed lavage)
**Warm central trunk first to limit rewarming shock
Immersion syndrome
occurs with immersion in cold water. This leads to stimulation of the vagus nerve and potentially fatal dysrhythmias (bradycardia and cardiac arrest)
What happens if a patient aspirates freshwater?
freshwater is typically hypotonic, and is rapidly absorbed into the circulatory system through the alveoli. Freshwater is often contaminated with chlorine, mud, and/or algae. This causes breakdown of lung surfactant, fluid seepage, and pulmonary edema. Body tries to compensate by shunting blood to the lungs. This only increases pressure in the lungs and further deteriorates respiratory status as the blood cannot be properly oxygenated and hypoxemia worsens–>ARDS
What happens if a patient aspirates saltwater?
Salt water is hypertonic. The hypertonic salt water draws fluid from the vascular space into the alveoli, impairing alveolar ventilation and resulting in hypoxia. This causes pulmonary edema. Body tries to compensate by shunting blood to the lungs. This only increases pressure in the lungs and further deteriorates respiratory status as the blood cannot be properly oxygenated and hypoxemia worsens–>ARDS
Secondary drowning
refers to delayed death from drowning due to pulmonary complications. Consequently, all near-drowning victims are observed in a hospital setting for a minimum of 23 hours.
Stings
remove the stinger using a scraping motion with a fingernail, knife, or needle–DONT use tweezers as they may squeeze the stinger and release more venom
flu like symptoms and a bulls eye rash
think Lyme disease and anticipate doxycycline as tx; later stages of Lyme disease are treated with Rocephin
a pink, macular rash on the palms, wrists, soles, feet, and ankles within 10 days of exposure; fever, chills, malaise, myalgies, and HA.
Rocky Mountain Spotted Fever
Tx doxycycline
flaccid ascending paralysis which develops over 1-2 days
tick paralysis; without tick removal, pt will die when respiratory muscles become paralyzed. Once the tick is removed, return of muscle movement occurs with 48-72 hours
What is gastric lavage
Gastric lavage involves oral insertion of a large-diameter (36-42F) gastric tube for irrigation of copious amounts of saline. Elevate the HOB or place pt on the side to prevent aspiration. Patients with an altered LOC or diminished gag reflex are intubated prior to gastric lavage. Patients who ingest caustic agents, co-ingest sharp objects, and ingest nontoxic substances should not receive gastric lavage. Perform gastric lavage within one hour of ingestion of most poisons to be effective. Problems associated with lavage include esophageal perforation and aspiration.
How does activated charcoal function to help a poisoned patient?
Administration of activated charcoal orally or via a gastric tube within one hour of poison ingestion is helpful bc toxins will bind to charcoal and pass through the GI tract rather than be absorbed into the circulation. Activated charcoal does NOT absorb ethanol, hydrocarbons, alkali, iron, boric acid, lithium, methanol, or cyanide. Adults receive 50-100g of charcoal. Contraindications to charcoal: diminished bowel sounds, ileus, and ingestion of substance poorly absorbed by charcoal. Charcoal may absorb and neutralize antidotes-space out administration.
malaise, diaphoreses, N/V, RUQ pain, hypoglycemia, increased LFTs
tylenol poisoning: activated charcoal or N-acetylcysteine [Mucomyst]
excess salivation, dysphagia, epigastric pain, burns of mouth, esophagus, and stomach
acids and alkalis: immediate dilution with water or milk; corticosteriods for alkali burns
tachypnea, tachycardia, hyperthermia, seizures, pulmonary edema, occult bleeding/hemorrhage, metabolic acidosis
aspirin poisoning: activated charcoal, gastric lavage, urine alkalinization, hemodialysis for severe acute ingestion, intubation and mechanical vent, supportive care
irritation of lips, mouth, and eyes, superficial injury to esophagus, chemical pneumonia and pulmonary edema
bleach poisoning: wash exposed skin and eyes; dilute with water or milk, gastric lavage, prevention of vomiting and aspiration
dyspnea, HA, tachypnea, confusion, impaired judgement, cyanosis, respiratory depression
carbon monoxide poisoning: remove from source, administer 100% O2 via non-rebreather, BVM, or intubation and mechanical vent. consider hyperbaric oxygen therapy
almond odor to breath, HA, dizzy, nausea, confusion, hypertension, bradycardia followed by hypotension and tachycardia, tachypnea followed by bradypnea and respiratory arrest
cyanide poisoning: amyl nitrate (nasally), IV sodium nitrate, IV sodium thiosulfate, supportive care
sweet aromatic odor to breath, n/v, slurred speech, ataxia, lethargy, respiratory depression
ethylene glycol: activated charcoal, gastric lavage, supportive care
bloody vomit, bloody diarrhea, fever, hyperglycemia, lethargy, hypotension, seizures, coma
iron poisoning: gastric lavage, chelation therapy [Desferal]
sorbitol
cathartic often given with activated charcoal in the event of a poisoning and acts to stimulate intestinal motility and increase elimination
What is added to IV fluids to enhance excretion of amphetamines and quinidine?
Vit C
What poisoning event is sodium bicarb benefical?
sodim bicarb raises pH which is helpful for phenobarbital and salicylate poisonings
Which bioligical agents of terrorism can be treated with antibiotics?
anthrax, plague, and tularemia
The placement of a nasogastric tube is contraindicated during emergency care when the patient has a possible
a. inhalation injury
b. head or facial trauma
c. intraabdominal bleed
d. ceervical spine fracture
B. head or facial trauma as the NG tube may enter the brain!
no established treatment for most forms
hemorrhagic fever
the septicemic form is most lethcal
plague
toxins cause hemorrhage and destruction of lung tissue (inhaled form)
Anthrax
neurotoxins that cause paralysis and respiratory failure
botulism
spread by flea bites
plague
hemorrhage of tissues with organ failure
hemorrhagic fever
lesions are pustular vesicles
smallpox
skin lesions are most common form
anthrax
primarily an infection of rabbits
tularemia
disease was eradicated in 1980
smallpox
death may occur within 24 hours of exposure
botulism
A victim of a sublethal dose (
b. nausea and vomiting
Ionizing radiation exposure in a sublethal dose will cause nausea and vomiting within 2-4 hours of exposure, hair loss in 2 days to 2 weeks, and coagulopathies in 2 days to 2 weeks.
What treatment should a nurse anticipate if a worker is exposed to anthrax?
cipro: antibiotics are effective to prevent systemic manifestations if treatment is begun early. Cipro is the treatment of choice for anthrax. Typically a 2 month antibiotic regimen
How to do treat Botulism?
induce vomiting and administer antitoxin
how do you treat hemorrhagic fever
isolation to prevent spread of virus
how do you treat smallpox?
vaccinia immune globulin (VIG) is used for smallpox
how do you treat frostbite?
immersion of extremities in water bath (102-108 degrees)
what is active core rewarming?
administration of warmed IV fluids for moderate to severe hypothermia.
when do you use passive of active external rewarming techniques?
mild hypothermia (warming blanket or radiant heat lamps)
