Environmental Emergencies Flashcards by Kelly Linskey

Which statement regarding decompression sickness (the “bends”) is not true?

A. A diver at great depths for long periods may experience decompression sickness if he ascends rapidly.
B. The gas that is the problem in decompression sickness is oxygen.
C. Extremes of water temperature and poor physical condition are factors that increase the severity of this condition.
D. The treatment of choice for decompression sickness is recompression

B. The gas that is the problem in decompression sickness is oxygen.

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A high school football player is starting practice in midsummer. He is instructed to run the track, along with other players for 10 laps. On lap 6, he becomes dizzy and nauseated. Upon arrival, he is pale, with moist skin. Vital signs are BP 90/50, HR 154, RR 44/min and temp 99oF. You suspect:

A. Heat cramps
B. Heat exhaustion
C. Heat stroke
D. Heat intolerance

C. Heat stroke

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Which laboratory finding would the nurse expect for a patient with heatstroke?

A. Elevated serum glucose
B. Low serum blood urea nitrogen
C. Respiratory acidosis
D. Elevated hematocrit

D. Elevated hematocrit

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Heat _____:

Assessment:
* Muscle cramps
* Nausea
* Tachycardia
* Pallor
* Diaphoresis
* Cool skin
* Slightly elevated temp
* Low serum Na+

Management:
-Remove from heat
* Rest
* Oral or IV balanced electrolyte replacement
* Gentle massage to muscles
* Rest for 1-2 days
* Education

Heat Cramps

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Heat _______:

Assessment:
* Headache
* Vomiting
* Malaise
* Extreme thirst
* Tachycardia
* Hypotension
* Syncope/collapse
* Warm, moist skin
* Mild to severe temp elevation 98.6-104oF (37-40oC)

Management:
-Cool environment
* Remove constricting clothing
* Fluid and electrolyte replacement
* Cardiac monitoring
* Education

Heat Exhaustion

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Heat _______:

Assessment:
-Headache
* Vomiting
* Malaise
* Extreme thirst
* Tachycardia
* Hypotension
* Syncope/collapse
* Warm, moist skin
* Mild to severe temp elevation 98.6-104o F (37-40oC)

Management:
* Cool environment
* Remove constricting clothing
* Fluid and electrolyte replacement
* Cardiac monitoring
* Education

Heat Exhaustion

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Heat ______:

Assessment
* Core temp > 105o F (40.5oC)
* Anxiety
* Visual disturbances
* Confusion, hallucinations
* Loss of muscle coordination
* Nausea
* Hot, dry skin
* Rapid irregular pulse
* Loss of perspiration

Management
* Rapid cooling measures
* Cooling blankets
* Pack in ice
* Infusion with cool fluids
* Iced gastric lavage
* Fluid and electrolyte replacement
* Thorazine for shivering
* Cardiac monitoring
* Watch for rhabdomyolysis

Heat Stroke

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What is mild hypothermia? Moderate? Severe?

Mild: 93-95F (34-35C)
Moderate: 86-93F (30-34C)
Severe: <86F (<30C)

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Type of hypothermia:

Assessment:
-Decreased mentation
* Tachycardia
* Tachypnea
* Cold to touch
* Shivering

Management:
-Passive external warming
* Prevent further heat loss
* Remove wet clothing
* Warm blankets
* Warm PO fluids

Mild

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Type of hypothermia:

Assessment:
* Hypotension
* Shivering slows
* Hyperglycemia
* Slurred speech
* Bradycardia
* Decreased RR
* Dilated pupils
* Atrial dysrhythmias (osborn wave)

Management:
-Active external warming
* Rewarm truncal areas 1F/ hour
* Radiant heat lamps
* Hot water bottles
* Convection Blanket/Bair Hugger

Moderate

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Type of hypothermia:

Assessment:
-Unconsciousness
* Hypoventilation
* Shivering stops
* Decreased cardiac output
* Lactic acidosis
* Absent DTR’s
* Ventricular dysrhythmias

Management:
-Active core rewarming:
* Warmed IVF and Oxygen
* Peritoneal lavage
* GI lavage
* Cardiopulmonary bypass
* Hemodialysis
* Continuous arteriovenous rewarming (CAVR)
-Active external rewarming

Severe

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A positive deflection seen at the J point in precordial and true limb leads. It is most commonly associated with hypothermia <90F (32C)

Osborn Wave

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Type of frostbite:

Usually involves ears, fingertips, toes, & cheeks
Tingling, numbness
Pain with thawing
Burning sensation
Whitish, waxy color, no blanching
Skin cool to touch

Superficial

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Type of frostbite:

-Involves muscles, bones, and tendons
* White or yellow-white
* Hard and cool
* Insensitive to touch
* Blisters appear 1-7 days after injury
* Gray-black mottling progressing to gangrene

Deep

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How do we treat frostbite: (8)

*Rapidly rewarm body part in warm water
*Do not rub extremity
*Remove wet clothing
*Debride blisters
* Elevate
*Narcotic analgesics
* Tetanus prophylaxis
*Consider escharotomy with severe frostbite

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Try of submersion injury caused by intense laryngeal spasm; no aspiration of water. Death is secondary to airway obstruction (10-20% of cases)

Dry-drowning

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Type of submersion injury caused by aspiration of water (80-90% of cases)

Wet-drowning

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Type of submersion injury that occurs up to 72 hours after the initial insult due to the inflammatory response in the lungs and damage to the alveolar capillary membrane and altered surfactant function

Secondary drowning

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Submersion injury in this type of water:
-Water is absorbed across the alveolar-capillary membrane
* Hypervolemia develops
* Lysis of RBC as water is absorbed and leads to
hemoglobinuria
* Dilutional electrolyte problems (decreased Na+)
* Decreased surfactant activity

Freshwater

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Submersion injury in this type of water:
* Hypovolemia 2/2 hypertonicity of water in lungs
* Plasma pulled into lungs
* Hemoconcentration
* Electrolyte abnormalities

Saltwater

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What are 8 assessment findings with submersion injuries: How do we manage it (6)?

Assessment:
* Stridor
* Wheezing
* Frothy sputum
* Seizures from hypoxia
* Chest pain
* Altered LOC
* Hypothermia
* Hypoxia

Management:
-ABC’s
* C-spine stabilization
* Continuously monitor respiratory status & hemodynamic status
* Correct hypothermia
* Decompress abdomen
* Correct electrolyte imbalances

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Type of thermal injury: most common, caused by exposure to hot liquids

Scald burn

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Type of thermal injury: 2nd most common, caused by careless smoking, MVCs, clothing ignoted by stoves or space heaters

Flame burns

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Type of thermal injury: 3rd most common, caused by explosion of natural gas/propane/gasoline/other flammable liquids, intense heat for a brief period of time, often cause partial thickness burns and associated with significant upper airway damage

Flash burns

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Type of thermal injury: small areas of full thickness burn from contact with hot metal/plastic/glass

Contact burn

This is the leading cause of death in burn patients. Results in upper and/or lower airway edema causing airway obstruction, hypoxia and cellular damage to alveolar-capillary membrane

Inhalation injuries

With these burns we want to identify agent if possible but do not delay treatment. STAFF SAFETY and decontamination are essential. Irrigation with water is usually safe and effective.

Chemical Burns

What kind of chemical burns are more severe due to deeper penetration?

Alkaline

Tretament for this kind of exposure requires topical and IV calcium

Hydrofluoric acid

These burns are difficult to determine the extent of burn injury. Nerves and blood vessels most susceptible (least resistant). Monitor for cardiac dysrhythmias.

Electrical Burns

Cardiovascular effects of this cause inflammatory response develops from the release of mediators from damaged tissue, results in massive vasodilation and increased capillary permeability, loss of fluid and electrolytes resulting in hypovolemic shock

Burns

Depth of burn injury: -Only Epidermis involved *Skin red, dry, blanches -painful! * Treat with moisturizers -heals in 3-5 days

Superficial

Depth of burn injury: -Epidermis and all of dermis involved *May be mottled, dry or moist in appearance, blisters may be present (white to red skin) *Usually very painful * Treat with topical antibacterial agents or biologic dressings, may require debridement and grafting

Partial thickness

Depth of burn injury: -Loss of epidermis, dermis and extension of burn into muscle, tendons, and even bone *No pain (nerve endings are destroyed) but will have pain at periphery of burn *Appears white, black or charred, may have dry leathery appearance. No blisters -Skin hard to touch *Healing is prolonged and may never heal. -Requires debridement and grafting or possibly amputation of extremity

Full thickness

How do we assess burn injuries? (14)

*Assess LOC *Airway * Burns to face * Singed nasal hair * Singed facial hair * Soot or carbonaceous sputum * Cyanosis * Stridor *Coughing *Wheezing *Retractions *Hypotension * Tachycardia *Assess for other injuries

First 2 steps in burn management

-ABCs -Remove all clothes and jewelry

Treatment for thermal burns (3)

* Dry, clean dressings * Topical agents (Silvadene or Bacitracin) for small areas * Elevation

Treatment for chemical burns (2)

-Brush dry chemicals off patient’s body * Copious irrigation with water or saline

Treatment for tar and asphalt burns (3)

-Cool Tar * Mineral oil or petroleum jelly to remove tar * Treat as thermal burn

Treatment for electrical burns (5)

-Look for both entrance and exit wounds * Monitor for compartment syndrome – may need fasciotomies * Check urine for myoglobin * Monitor for cardiac dysrhythmias * Base resuscitation on perfusion and urine output

What is the fluid resuscitation formula (consesus guidelines) for burns? * _____ml/kg x % TBSA burned * ______ml/kg in peds *Administer ½ of fluid in first ______ hours after injury *Remaining fluid is administered over the next _______ hours *Keep urine output ___-_____ml/hr (adults), ______ml/kg/hr (peds)

* 2ml/kg x % TBSA burned * 3ml/kg in peds *Administer ½ of fluid in first 8 hours after injury *Remaining fluid is administered over the next 16 hours *Keep urine output 30-50ml/hr (adults), 1ml/kg/hr (peds)

Treat this by ensuring Airway, Breathing, and Circulation; Decontamination procedure; Remove any patient clothing and jewelry and place in sealed container marked “radioactive waste”; clean skin with soap and water, repeat until dosimeter readings are acceptable

Radiation Exposure

An acute illness caused by radiation of the whole body. Four phases: * Prodromal – loss of appetite, fatigue, nausea/vomiting/diarrhea, fever, and respiratory distress for several days * Latent period – symptoms subside * Overt illness – infection, electrolyte imbalances, N/V/D, bleeding, cardiovascular collapse, & mental status changes * Recovery or death

Acute radiation syndrome

Acute radiation syndrome phase: loss of appetite, fatigue, nausea/vomiting/diarrhea, fever, and respiratory distress for several days

Prodromal

Acute radiation syndrome phase: symptoms subside

Latent period

Acute radiation syndrome phase: infection, electrolyte imbalances, N/V/D, bleeding, cardiovascular collapse, & mental status changes

Overt illness

Acute radiation syndrome phase: final phase

Recovery or death

Symptoms of acute radiation syndrome: -Hematopoietic (3) -GI (5) -CNS (2) -Skin (1)

Hematopoietic: Bleeding, Anemias, Immunodeficiency GI: N/V/D, hypovolemia and electrolyte imbalances CNS: Mental Status Changes, Seizures Skin: burns

Treatment for acute radiation syndrome (5)

-use Serotonin (5-HT3) receptor antagonists (Zofran) for vomiting *Consider tissue & blood typing *Consider consultation with hematologist and radiation experts *Blood and platelet transfusions *Growth factors to stimulate hematopoiesis

*Odorless, colorless, tasteless gas *Produced by combustion of organic materials *Higher affinity for Hgb than O2 (>250x) *Causes severe tissue hypoxia

Carbon Monoxide (CO) Poisoning

9 symptoms of acute carbon monoxide (CO) exposure 3 symptoms of chronic carbon monoxide (CO) exposure (symptoms are severe upon awaking and improve after leaving the home)

Acute: * Headache -Nausea/vomiting * Decreasing LOC – Decreased RR * Bradycardia – Seizures -Dysrhythmias -twitching * Cherry red color to skin Chronic: symptoms are severe upon awaking and improve after leaving the home * Dizziness * Recurring headaches * Nausea

How do we treat carbon monoxide poisoning?

-100% O2 via mask -hyperbaric oxygen therapy is levels >20%, unconscious/seizures, ischemic changes on EKG, pregnant

A patient is transported to your ED after being involved in an industrial explosion. He has singed nasal and facial hair. He was intubated at the scene for airway protection by prehospital personnel. On arrival to the ED, you determine he has sustained a 60% TBSA burn. His weight is determined to be 80kg. How much fluid should this patient receive? A. Total of 9600ml with ¼ given in the first 8 hours since burn event B. Total of 4800ml given in the first 8 hours since burn event C. Total of 5600ml with all the fluid given in 24 hours D. Total of 4800ml with ½ given in the first 10 hours since burn event

B. Total of 4800ml given in the first 8 hours since burn event

In infants, the head and neck represent what percent of the body surface area? A. 14% B. 36% C. 9% D. 18%

D. 18%

A construction worker is brought to the ED by the rescue squad after having sustained an electrical shock of 10,000 volts. On arrival, he is alert and oriented, complaining of tingling in his left foot. His V/S are BP 120/70, HR 100, RR 18. All of the following factors determine the nature and severity of electrical injuries except: A. Age of the patient B. Amperage of the current C. Type of current D. Duration of contact with the current

A. Age of the patient

During the initial evaluation of a patient with an electrical injury, the emergency nurse should assess for: A. Fractures of lower extremities B. Entrance and exit wounds C. Injuries to his eyes D. Amnesia and psychosis

B. Entrance and exit wounds

The tissue in the body with the least resistance to current flow is: A. Bone tissue B. Muscle tissue C. Nerve tissue D. Cardiac tissue

C. Nerve tissue

All the following are early signs of a lightning strike except: A. Ruptured tympanic membranes B. Cataracts C. Vaporized rainwater on the skin D. Featherly skin burns

B. Cataracts

What is a major complication of snake bites?

Envenomation

Type of venomous snakes in the US that cause hemotoxin

Crotalidae = Pit vipers (rattlesnakes, copperheads, cottonmouths (water moccasins)

Type of venomous snakes in the US that caise neurotoxin

Elapidae = North American coral snakes

Most common venomous snake in eastern US, non-aggressive, bites are rarely fatal

Copperhead

Aquatic snake, extremely aggressive, ehite cotton lining of mouth shown when in striking position

Cottonmouth

Various distinct species of this snake, most commonly seen in southwest, rattle provides warning

Rattlesnake

Brightly colored snake (yellow/red/yellow/black), mimics Scarlet King snake (black/red/black/yellow), bites are uncommon / Shy snakes, patients may present with delayed symptom onset *“Red on Yellow – Kill a Fella, Red on Black, Venom Lack

North American Coral Snake

Symptoms of pit viper envenomation Localized (5) Systemic (6)

*Localized: * Erythema * Edema *Pain * Ecchymosis *Blisters *Systemic: *N/V/D *Weakness *Metallic taste * Fasciculations * Seizures *Numbness & tingling around the mouth

Snake bites can cause massive tissue edema leading to what?

Compartment syndrome

3 symptoms of pit viper bites?

-Hypotension -Coagulopathy (DIC) -Rhabdomyolysis

Worse complication of a coral snake bite?

Respiratory failure

What do we do to limbs with snake bites?

*Immobilize the limb at or below the heart *NO tourniquet or ice (this will cause more localized tissue damage)

Enhances venom elimination but has no effect on tissue injury, dosing varies (FabAV (ovine) is 4-6 vials initially, followed by maintenance doses, Fab2AV (equine) is 10 vials initially, maintenance usually not needed), best if administered within 4-6 hours of bite, less effective after 12 hours. *Monitor coagulation studies

Crotalidae Antivenin

How do we remove ticks?

Pull directly out with forceps or tweezers *Do Not crush or squeeze *No evidence to support the use of Vaseline, Nail polish, or Matches

Characteristic "bull's-eye" rash (erythema migrans), nonspecific symptoms - fever, malaise, fatigue, headache, myalgia, and arthralgia

Lyme disease

Caused by Rickettsia rickettsii * Often seen in South Atlantic & South Central regions * Long incubation period up to 14 days * Causes direct injury to blood vessels * Signs & Symptoms: * sudden onset fever, petechial rash (blanching) to extremities and progresses to pink macular rash to palm, wrist, sole and ankles

Rocky Mountain Spotted Fever

A patient presents to the emergency department with a suspected tick bite. Assessment findings may include all of the following except: A. Diarrhea B. Fever and chills C. Fatigue D. Muscle and joint pain

A. Diarrhea

How are tick borne illnesses managed? A. Antibiotic treatment with doxycycline for 10 days B. Antibiotic treatment with erythromycin for 7 days C. There is no treatment for the disease D. Antibiotic therapy with amoxicillin for 3 weeks

A. Antibiotic treatment with doxycycline for 10 days

A boy arrives in the ED stating that he was bitten on the foot while playing outside. He is screaming with pain at the bite mark, nauseated and weak. He describes severe abdominal pain and spasms in his leg. You suspect that he has been bitten/stung by a: A. Tick B. Black widow spider C. Wasp D. Brown recluse spider

B. Black widow spider Injects neurotoxin, almost immediately causes muscle spasm

A patient who was stacking wood 2 days ago presents to the ED complaining of painful ulceration on his hand. He has no other complaints. Based on this history, the most likely thing that may have bitten/stung him is: A. A black widow spider B. A blue scorpion C. A brown recluse spider D. A wolf spider

C. A brown recluse spider injects cytotoxin, causes ulceration in ~2 days - more like dead/necrotic tissue

Immediate treatment for a skier presenting to the ED with suspected frostbite to the foot would include: A. Removing the boot and rubbing the foot and ankle B. Opening the blisters and applying antibiotic cream to the entire area C. Application of warm soaks to the extremity D. Placing the foot in immobilization lower than the heart

C. Application of warm soaks to the extremity (at level of heart) Removing the boot and rubbing the foot and ankle will cause more tissue damage

Which of the following bites has the highest rate of infection? A. Cat B. Dog C. Snake D. Human

D. Human

*A viral disease that causes acute encephalitis – Lyssavirus *Usually transmitted by bats, raccoons, foxes, skunks, groundhogs, coyotes; rare from domesticated cats and dogs *Usually transmitted by bites, but can be by contact with contaminated saliva or tissue *Symptoms usually appear in 3-7weeks after exposure

Rabies

13 symptoms of rabies

-flu like sx at first -slight or partial paralysis -anxiety -insomnia -confusion -agitation -abnormal behavior -paranoia -terror -hallucinations -progressing to delirium -The production of large quantities of saliva and tears and inability to speak or swallow occurs during the later stages -Death usually occurs within 7 days after the first onset of symptoms

Highly successful if initiated within 6 days of infection. Patients receive one dose of immunoglobulin (RIG) and four doses of rabies vaccine. At least half the dose of RIG is injected in the region of the bite, if possible, with the remainder injected IM in gluteal region. The vaccine is given IM on days 0, 3, 7, 14 in deltoid. The patient who has been previously vaccinated only needs the vaccine on days 0 and 3, and no RIG.

Rabies Post-Exposure Prophylaxis

Which of the following is the highest priority for a neardrowning victim brought to the ED? A. Hypoxemia B. Pneumonia C. Cardiac dysrhythmias D. Hypothermia

A. Hypoxemia

A patient arrives in the ED 10 minutes after having been pulled from a frozen pond. The patient is pulseless, apneic, and unresponsive and has a temperature of 77oF (25oC). The cardiac monitor indicates ventricular fibrillation. Which of the following combinations of modes of care is most appropriate? A. Defibrillate at 200, 300, & 360 joules and begin CPR B. Begin CPR and warming C. Begin CPR, start an IV, give epinephrine, followed by defibrillation at 360 joules D. Begin CPR and insert a NG tube

B. Begin CPR and warming Drugs/electricity is not helpful until body is 86degrees to must warm first

*Jellyfish are the most common source *The nematocyte is the structure that attaches and injects the toxin *There is immediate onset of pain after injection

Aquatic stings

How do we treat aquatic stings? (5)

-Rinse area with saline *Apply 5% acetic acid for 15-30 minutes to the wound *Remove the nematocytes *Local anesthetics, analgesia, antihistamines, topical and systemic corticosteroids, and muscle relaxants *Antivenom is available for severe cases