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EMERGENCY / TRAUMA/ MASS CASUALTY/ BIOTERRORISM

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Presentation on theme: "EMERGENCY / TRAUMA/ MASS CASUALTY/ BIOTERRORISM"— Presentation transcript:

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 Recognized in late 70s

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

4 Environment of Care Rapid change Noisy Unpredictable
It is a specialty area in nursing where things are constantly changing. The newest philosophy of the ER is that an emergency is whatever the pt/family perceive it to be.

5 Demographic Multiple specialties
Increasing visits to 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 Chest pain abd pain headache fever

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

7 Priority Emergency Measures for All Patients
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 Always be alert and aware.. Violence can happen anywhere—cafeteria, on floor remember fight at CUMC Prisoners are cuffed to bed and have officer with them

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 Technical Skills Multitasking Assist with: Wound closure
Foreign body removal Central line insertion Transvenous pacemaker insertion Lumbar puncture Pelvic exam Chest tube insertion Lavage Fracture management

10 Core Competencies

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

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

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

14 Triage 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 With the focused assessment think of the pneumonic CIAMPEDS: Chief complaint, immunizations, isolation.. Allergies, meds, parents view, events surrounding incident, diet…diapers(ouput), symptoms Objective assess pneumonic: MVIT: mechanism of injury, VS, Injury, Treatment Ample is history based: Allergies, meds, past medical history, last meal, everything related to chief complaint Before beginning Secondary survey Attach EKG leads, Pulse ox, C02 device to ETT, foley cath if not contraindicated, NG, radiographs -Full set of vital signs/Focused interventions FAST scan-focused assessment -Give comfort measures -History/Head to toe assessment Pre-hospital info AMPLE

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 Basic Elements 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) DO NOT CONFUSE THIS WITH DISASTER TRIAGE!!!

19 Examples 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 Resources Labs IV fluids XRAY Consults EKG Simple procedure
CT/MRI Complex procedure IV/IM medications Resources

21 Primary Survey 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 to Voice, Responsive to pain, Unresponsiveness E: Exposure Remove clothing, keep pt warm

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

23 Priorities of Care for the Patient With Multiple Trauma
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

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

27 By: Diana Blum RN MSN Metropolitan Community College
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 Common Trauma

29 Hyperthermia 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 Assessment 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 Mortality =duration of hyperthermia

32 Exhaustion Stroke Heat

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

34 Heat Exhaustion Treatment Outside hospital In 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 Heat Exhaustion

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) Heat Stroke

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 Heat Stroke

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 Patient teaching 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 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 COLD

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 Assessment 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

44

45

46 Frost Bite 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

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. Snake Bites Most bites between April and October Peak in July and August pit vipers (look for warm blooded prey) Water moccasins, copperheads, rattlesnakes Most of bites Coral snakes From North Carolina to Florida and in the Gulf states, Arizona, and Texas

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 Snake Bites

49 Snake Bites Treatment At site At hospital O2 2 large bore IV sites
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 minutes Possibly give antivenom if ordered (see page 177) Monitor for anaphylaxis Notify poison control Snake Bites

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 Snake Bites

51 Snake Bites Action of venom S/S
Blocks binding of acetylcholine at post synaptic junction S/S pain mild and transient Fang marks may be hard to see Effects may be delayed 12 hours but then act rapidly after N/V Headache Pallor, abd pain Late stage: parathesias, numbness, mental status change, crainal and peripheral nerve deficit , flaccid, difficulty speaking, swallowing, breathing elevated creatinine kinase Snake Bites

52 Snake Bites Coral Treatment At site At Hospital
Try to ID snake Same as pit viper without concern of necrosis At Hospital Continuous tele Continuous bp and pulse ox Provide airway management (possible ET tube) Provide antivenom treatment as ordered Monitor for anaphylaxis from antivenom Notify poison control Snake Bites

53 Patient teaching Avoid venomous snakes as pets
Be cautious in areas that harbour snakes like tall grass, rock piles, ledges, crevices, caaves, swamps Don protective attire like boots, heavy pants and leather gloves. Use a walking stick Inspect areas before placing hands or feet in them Do not harass snakes….striking distance is the length of the snake Snakes can bite even 20—60 minutes after death due to bite reflex Use caution when transporting snake with victim to hospital…make sure it is in a sealed container. Patient teaching

54 Arthropod Bites and Stings
Spiders: carnivorous Almost all are venomous Most not harmful to humans Brown recluse, black widow, and tarantula are dangerous for example Scorpions: not in Midwest or New England Sting with tail Bark scorpion is most dangerous Bees and Wasps Wide range of reactions African or killer bees are very aggressive found in southwest states Arthropod Bites and Stings

55 Brown recluse spider Bites result in ulcerative lesions
Cytotoxic effect to tissue Medium in size Light brown color with dark brown fiddle shaped mark from eyes Shy in nature..hide in boxes, closets, basements, sheds, garages, luggage, shoes, clothing, bedsheets, clothes Brown recluse spider

56 Surgery is often needed
Over 1-3 days lesion becomes dark and necrotic…eschar even forms, and sloughs Surgery is often needed Skin grafting Rare: Malaise, Joint pain, Petechaie, N/V Fever, Chills Pruritis Erythema Extreme: hemolytic, renal failure, death

57 Treatment At hospital At site Topical antiseptic
Cold compress initially and intermittentl y over 4 days (may limit necrosis) Rest Elevation of extremity NEVER use heat At hospital Topical antiseptic Sterile dressing changes Antibx Dapsone: polymorphonuclear leukocyte inhibitor: 50mg twice/day Monitor lab work closely Surgery consult Debridment and skin grafting

58 Black Widow Found in every state but Alaska
Prefers cool, damp, environment Black in color with red hourglass pattern on abd Male are smaller and lighter color that females Carry neurotoxic venom Bites to humans are defensive in nature Main prey other bugs, snakes, and lizards Bite is can be painful, local reactions Systemic reactions can happen in 1 hour and involve the neuromuscular system Black Widow

59 Venom causes neurotransmitters to release from nerve terminals s/s
Causes lactrodectism Venom causes neurotransmitters to release from nerve terminals s/s Abd pain Peritonitis like symptoms N/V Hypertension Muscle rigidity Muscle spasms Facial edema Pytosis Diaphoresis Weakness Increased salavation Priapism Respiratory difficulty Faciculations parathesias

60 At site At hospital Apply an ice pack Monitor for systemic involvement
ABCs At hospital Monitor vitals Pain meds Muscle relaxants Tentanus Monitor for seizures Antihypertensives Anti venom if needed Call poison control

61 Tarantulas Largest spider
Found mostly in tropical and subtropical parts of USA Some are in dry arid states like New Mexico and Arizona Can live 25 years Venom paralyzes prey and causes muscle necrosis Most human bites have local effects Have urticating hairs in dorsal abd area that can be launched for a defensive technique landing in skin and causing an inflammatory response Tarantulas

62 USA trantulas don’t produce systemic reactions
Worldly ones do S/S Pain at site Swelling Redness Numbness Lymphangitis Intense pruritis Severe ophthalmic reactions if hairs come in contact with eyes

63 Treatment Pain meds Immobolize extremity Elevate site
Remove hairs with sticky tape followed by irrigation For eyes: irrigation with saline Antihistamines and steroids for pruritis

64 Scorpions Found in many states
Not usual in midwest or new england unless pet, or transported in baggage Venom in stinger located on the tail s/s Localized pain Inflammation Mild symptoms Treatment: pain meds, wound care, supportive management Scorpions

65 Bark scorpion Deadly Has a fatal sting
Found in tress, wood piles, and around debris Humans stung when it gets in clothing, shoes, blankets, and items left on ground Solid yellow, brown, or tan in color Have thin pinchers, thin tail, and a tubercle Found in Arizona, New Mexico, Texas, Nevada, and California Has neurotoxic venom Bark scorpion

66 Symptoms begin immediately and reach maximum intensity in 5 hours
s/s Involve cranial nerves May be symptom free Pain Respiratory failure Pancreatitis Musculoskeletal dysfunction Gentle tap at possible sting site while client not looking greatly increases pain, and is confirmation of bite Symptoms begin immediately and reach maximum intensity in 5 hours Most symptoms resolve in hours Pain and parathesia can last 2 weeks

67 Treatment Monitor vitals May need intubation Supply O2 IV Fluids
Ice pack to sting site Pain meds and sedatives with caution in non intubated client Wound care Call poison control Atropine gtts to help with hypersalavation Antivenom if needed

68 Bees/Wasps Stings cause wide array of reactions S/S
Anaphylaxis most severe Respiratory failure Hypotension Decrease in LOC Dysrhythmias Cardiac arrest Pain Local reaction Swelling N/V Diarrhea Pruritis Urticaria Lip swelling Bees/Wasps

69 treatment At site In hospital Remove stinger Ice pack
Epipen if allergy to bees Call 911 if needed In hospital ABCs Check history for allergy Epinephrine Antihistamine O2 NS 0.9% corticosteroids treatment

70 Wear protective clothing when working in areas with known venomous athropods (bees, scorpions, wasps) Cover garbage cans Use screens in windows and doors Inspect clothing and, shoes and gear before putting on Shake out clothing and gear that is on ground Exterminate the exterior house Do not place hands where eyes can not see Do not keep insects as pets Epi pen if allergy to bee/wasp Patient Education

71 Lightning Year round problem Caused by electrical charge in cloud
Most common in summer Caused by electrical charge in cloud Large energy with small duration High voltage is 1000 volts Lighting is 1 million volts Cloud to ground is most dangerous Flash over phenomenon: force powerful enough to blow off or damage the victims clothing Injury is by: Direct strike Spashing or side flash off of near by structure Through the ground Lightning

72 Lightning Best remedy: AVOIDANCE Education Observe forecasts
Seek shelter when your hear thunder DO NOT stand under tree DO NOT stand in an open area Isolated sheds and caves are dangerous Leave water immediately Avoid metal objects If camping stay away from metal tent poles and wet walls Stay away from open doors, windows, fireplaces Turn off electrical equipment Stay off of telephone Move to valley area and huddle in ball if in open area (this minimizes target area) Lightning

73 Lightning Most lethal effect is asystole or Vfib
Most victims suffer cardiac injury S/S Mottled skin Cardiac arrest Respiratory arrest Decreased or absent peripheral pulses Temporary paralysis Loss of Consciousness Amnesia, confusion, disorientation Photophobia Seizures Fatigue and PTSD Ruptured tympanic membranes Blindness, cataracts, retinal detachment Skin burns Ferning marks: branching on the skin Lightning

74 Interventions Hospital care At site ACLS Telemetry ABC support
Ventilator prn Creatinine kinase level to determine muscle damage Monitor for kidney failure Monitor for rhabdomyolosis (muscle destruction) Burn precautions Tetanus Xfer to burn center At site Spinal immobilization Monitor ABCs CPR Sterile dressings for burns Interventions

75 Altitude related Illness
High altitude is elevations above feet  most ski resorts As altitude increasesbarametric pressure decrease This means less o2 the higher you go Oxygen is 21% of the barametric pressure Acclimatizationthe process of adapting to high altitudes Increased RR Decrease in CO2 Respiratory alkalosis Impaired REM Excess bicarb excretion through the kidneys Cerebral blood flow increases Altitude related Illness

76 3 most common altitude illnesses Acute Mountain Sickness (AMS)
Precursor for HACE/HAPE Throbbing headache, anorexia, N/V Chilled, irritable Similar symptoms to alcohol hangover VS variable DOE or at rest High altitude cerebral edema (HACE) Unable to perform ADLs Ataxia w/o focal signs (decreased motor coordination) Confusion, impaired judgment , seizures Stupor, Coma, Death from brain swelling Increased ICP over 1-3 days High altitude pulmonary edema (HAPE) Most frequent cause of death Poor exercise intolerance and recovery Fatigue and weakness Tachycardia and tachypnea, rales, pneumonia Increased pulmonary artery pressure

77 Altitude Illness Site Hospital Descent to lower altitude
Monitor for symptom progression Rest O2 if available Hospital Acetazolamide Acts as bicarb diuretic Sulfa drug Take 24 hours before ascent and take for 1st 2 days of the trip 125mg-250mg po BID or 500mg SR cap daily Dexamethazone: 4mg – 8mg po or IM initially then 4mg q6hours during descent O2 Monitor airway Lasix Critical care Altitude Illness

78 Altitude Education Plan a slow descent
Avoid overexertion and over exposure to cold Avoid alcohol and sleeping pills Stay hydrated and have adequate nutrition If symptoms develop descend immediately O2 if able Wear protective gear Wear sunscreen Altitude Education

79 Each day in the United States, nine people drown.
Drowning is the second leading cause of accidental injury-related death among children ages 1 to 14. Drowning is the leading cause of accidental injury-related death among children ages 1 to 4. Male children have a drowning rate more than two times that of female children. However, females having a bathtub drowning rate twice that of males. Among children ages 1 to 4 years, most drownings occur in residential swimming pools.

80 More than half of drownings among infants (under age 1) occur in bathtubs, buckets or toilets.
Nonfatal drownings can result in brain damage that may result in long-term disabilities including memory problems, learning disabilities, and permanent loss of basic functioning. Nineteen percent of child drowning fatalities take place in public pools with certified lifeguards on duty. Roughly 5,000 children 14 and under go to the hospital because of accidental drowning-related incidents each year; 15% die and about 20% suffer from permanent neurological disability. In nearly 9 out of 10 child-drowning deaths, a parent or caregiver claimed to be watching the child. Participation in formal swimming lessons can reduce the risk of drowning by 88% among children ages 1-4. 2011 Drowning Statistic Between Memorial Day June 28, 2011, there were 48 drownings and 75 near-drowning events in 35 states and territories.

81 Leaving small children unattended around bathtubs and pools
Symptoms Symptoms can vary, but may include: Abdominal distention Bluish skin of the face, especially around the lips Cold skin and pale appearance Confusion Cough with pink, frothy sputum Irritability Lethargy No breathing Restlessness Shallow or gasping respirations Chest pain Unconsciousness Vomiting Causes Leaving small children unattended around bathtubs and pools Drinking alcohol while boating or swimming Inability to swim or panic while swimming Falling through thin ice Blows to the head or seizures while in the water Attempted suicide

82 When someone is drowning:
First Aid When someone is drowning: Extend a long pole or branch to the person, or use a throw rope attached to a buoyant object, such as a life ring or life jacket. Toss it to the person, then pull him or her to shore. People who have fallen through ice may not be able to grasp objects within their reach or hold on while being pulled to safety. Do not place yourself in danger. Do NOT get into the water or go out onto ice unless your are absolutely sure it is safe. If you are trained in rescuing people, do so immediately if you are absolutely sure it will not cause you harm. If the victim's breathing has stopped, begin rescue breaths as soon as you can. This often means starting the breathing process while still in the water. Continue to breathe for the person every few seconds while moving them to dry land. Once on land, give CPR if needed. For step-by-step instructions on rescue breathing, see the article on CPR.

83 Follow these additional steps:
Always use caution when moving a drowning victim. Assume that the person may have a neck or spine injury, and avoid turning or bending the neck. Keep the head and neck very still during CPR and while moving the person. You can tape the head to a backboard or stretcher, or secure the neck by placing rolled towels or other objects around it. Follow these additional steps: Keep the person calm and still. Seek medical help immediately. Remove any cold, wet clothes from the person and cover with something warm, if possible. This will help prevent hypothermia. Give first aid for any other serious injuries. The person may cough and have difficulty breathing once breathing re-starts. Reassure the person until you get medical help.

84 DO NOT DO NOT go out on the ice to rescue a drowning person that you can reach with your arm or an extended object. DO NOT attempt a swimming rescue yourself unless you are trained in water rescue. DO NOT go into rough or turbulent water that may endanger you. When to Contact a Medical Professional If you cannot rescue the drowning person without endangering yourself, call for emergency medical assistance immediately. If you are trained and able to rescue the person, do so and then call for medical help. All near-drowning victims should be checked by a doctor. Even though victims may revive quickly at the scene, lung complications are common.

85 Prevention Avoid drinking alcohol whenever swimming or boating. Observe water safety rules. Take a water safety course. Never allow children to swim alone or unsupervised regardless of their ability to swim. Never leave children alone for any period of time, or let them leave your line of sight around any pool or body of water. Drowning can occur in any container of water. Do not leave any standing water (in empty basins, buckets, ice chests, kiddy pools, or bathtubs). Secure the toilet seat cover with a child safety device. Fence all pools and spas. Secure all the doors to the outside, and install pool and door alarms. If your child is missing, check the pool immediately.

86 Causes of SCI Primary Secondary
Hyperflexion (moved forward excessively) Hyperextension (MVA) Axial loading (blow at top of head causes shattering) Excessive rotation (turning beyond normal range) Penetrating (knife, bullet) Secondary Neurogenic shock Vascular insult Hemorrhage Ischemia Electrolyte imbalance Causes of SCI

87 Assessment Of SCI 1st assess respiratory status
ET tube may be necessary if compromised 2nd assess for intra- abdominal hemorrhage (hypotension, tachycardia, weak and thready pulse) 3rd assess motor function C4-5 apply downward pressure while the client shrugs C5-6 apply resistance while client pulls up arms C7 apply resistance while pt straightens flexed arms C8 check hand grasp L2-4 apply resistance while the client lifts legs from bed L5 apply resistance while client dorsiflexes feet S1 apply resistance while client plantar flexes feet Assessment Of SCI

88 Emergency Care of SCI Observe for signs of autonomic dysreflexia
Sever HTN, bradycardia, sever headache, nasal stuffiness, and flushing Caused by noxious stimuli like distended bladder or constipation Immediate interventions Place in sitting position Call doctor Loosen tight clothes Check foley tubing if present Check for impaction Check room temp Monitor BP q10-15 minutes Give nitrates or hydralazine per md order Emergency Care of SCI

89 Treatment of SCI Immobilize fx Proper body alignment
Traction is possible Monitor vs q4 hours or more Neuro checks q4 hours or more Monitor for neurogenic shock (hypotension and bradycardia) Prepare for possible surgery Teach skin care, ADLs, wound prevention techniques, bowel and bladder training, medications, and sexuality Treatment of SCI

90 Brain Injuries (TBI) Open- skull fx or when skull is pierced by penetrating object Linear fx- simple clean break Depressed fx- bone pressed in towards tissue Open fx-lacerated scalp that creates opening to brain tissue Comminuted fx- bone fragments and depresses into brain tissue Basilar- unique fx at base of skull with CSF leaking though the ear or nose Closed- blunt trauma Mild concussion-brief LOC Diffuse axonal injury- usually from MVA May go into coma Contusion-bruising of brain Site of impact (coupe) Opposite side of impact (contrecoupe) Laceration-tearing of cortical surface vessels that leads to hemorrhage edema and inflammation

91 Always assume c-spine injury
ABC highest priority Control bleeding right away

92 Motor Vehicle Collisions
Frontal Front of car stops and driver keeps going Injuries: Seatbelt, Steering wheel, TBI, cspine, flail chest, myocardial contusion Side Injuries: Cspine, flail chest, pneumothorax Rear Hyperextension, cspine Rollover Multiple injuries Motor Vehicle Collisions

93 Figure 74.2 Unrestrained frontal impact.

94 Other types of multiple injuries
Motorcyle Tib/fib, chest, abd, TBI, cspine, femur Pedestrian Femur, chest, lower extremities Falls Calcaneous, compression, wrist, TBI Other types of multiple injuries

95 Battles sign Raccoon eyes Flail chest Tension Pneumothorax Hemothorax

96

97 Acceleration-caused by external force contacting head
Deceleration- when head suddenly stops or hits a stationary object Blunt Trauma by Force

98

99 Increased ICP Normal ICP is 10- 15mmHg
Normal increases occur with coughing, sneezing, defecation Leading cause of death for head trauma As ICP increases cerebral perfusion decreases causing tissue hypoxia, decrease serum pH, and increase in CO2 Increased ICP

100 ICP continued 3 types of edema
Vasogenic: increase in brain tissue volume Cytotoxic: result of hypoxia Interstitial: occurs with brain swelling ICP continued

101 Hematoma Epidural- bleed b/w dura and inner table
Subdural-bleed below dura and above arachoid Intracerebral- accumulation of blood in brain tissue Hematoma

102

103 Interventions for musculoskeletal trauma
Displaced Non- displaced fragmented Fractures Open Closed Spontaneous Stress Compression Greenstick Spiral Oblique Impacted Interventions for musculoskeletal trauma

104 48-72 hours after injury hematoma forms at break site
Area of bone necrosis forms secondary to diminished blood flow Fibroblasts and osteoblasts come to site Fibrocartilage forms =new foundation Callus forms 2-6 weeks after initial break 3 weeks to 6 months later new bone is formed Stages of healing

105 Factors that affect healing
Age Severity of trauma Bone injured Inadequate immobilization Infection Avascular necrosis Factors that affect healing

106 Musculoskeletal assessment
Assess for life threatening complications Skin color and temp Movement Sensation Pulses especially distal to the injury Cap refill Pain Listen for crepitation-grating sound Look for ecchymosis Assess for subcutaneous emphysema-bubbles under skin (like bubble wrap when pushed) Assess clients feeling of situation Some fractures can causes internal injury-hemorrhage

107 diagnostics No special lab tests except maybe D- Dimer for clots
H/H could be low due to bleeding CT Bone scan MRI X-rays Affected extremity diagnostics

108 interventions Inspect fx site Palpate area lightly
Assess motor function Immobilize extremity Realignment Cast Traction Surgery open reduction with internal fixation interventions

109 education Provide education regarding medication
Instruct the client on s/s of infection (foul discharge, purulent drainage, fever, lethargy, etc) Instruct on dressing changes and importance of them Instruct about pressure ulcer prevention Instruct on use of crutches or walker if needed Instruct about HHC and other available resources education

110 Specific fractures

111 Fx of clavicle usually from a fall
Fx of scapula not common and caused by direct impact Fx of humerus common in older adult Fx of olecrenon usually from fall directly onto elbow Fx of radius and ulna usually Fx together Fx of wrist and hand most common site is the carpal scaphoid bone in young adult men..one of the most misdiagnosed Fx b/c of poor visibility on x-ray Fx of hip caused by falls Fx of femur caused from trauma Fx of patella result from direct impact Fx of tibia and fibula usually break together Fx of ankle and foot difficult to heal because of instability of ankle bone

112 Fx of ribs and sternum caused by chest trauma and potentially can puncture lungs, heart and arteries
Fx of pelvis can also cause major internal damage because of the vascular structure present Compression Fx of the spine usually caused by osteoporosis. This causes pain, deformity, neurologic compromise

113 Femur and Pelvic Fractures
High incidence of hemmorage Femur fx-cast, brace, splint, traction Fat embolism: fat from bone released into blood and into heart, lungs, etc Pelvic- girdle, assess for stability Large amount of force Rectal exam Femur and Pelvic Fractures

114 Figure 56.10 Vascular anatomy of the pelvis.

115 Dislocations Painful Needs to be reduced ASAP Can cause nerve damage
Avascular Necrosis Dislocation occludes blood supply Dislocations

116 Other surgeries Vertebroplasty Kyphoplasty Both are minimally invasive
Both use a bone cement to provide immediate relief of pain Other surgeries

117 complications Acute compartment syndrome: increase pressure compromises circulation to are. Most common in lower leg and forearm. Fat embolism: fat from bone released into blood and into heart, lungs, etc. Most common with long bone fx DVT PE INFECTION: from break or from implanted hardware..bone infection most common with open fx Fracture blisters: associated with twisting injury..fluid moves into vacant spaces..leads to infection Ischemic necrosis: blood flow to bone is disrupted Delayed union: unhealed after 6 months Nonunion:never completely heal Malunion: heal incorrectly

118 amputations Removal of part of the body Types Levels Complications
Surgical-example digit Traumatic- example digit Levels Lower extremity: digits, bka, aka, midfoot Upper extremity: hands, fingers, arms Complications Hemorrhage Infection Phantom limb pain: perceive pain in the amputated limb Immobility Neuroma: sensitive tumor consisting of nerve cells found at several nerve endings Contractures

119 assessments Skin color Temp Sensation Pulses Cap refill
Assess feelings r/t amputation Young: bitter, hostile, uncooperative, loss of job, loss of hobbies, altered self concept, feeling a loss of independence Assess families perceptions also Routine preop xrays done BP done in all extremities Angiography to look at layout of vessels

120

121 CRUSH SYNDROME CAUSES CHARACTERISTICS S/S TX Wringer type injuries
Natural disasters Work related injuries Drug or alcohol overdose CHARACTERISTICS Acute compartment syndrome Hyperkalemia Rhabdomyolosis – myoglobin released into blood S/S Hypovolemia, hyperkalemia, compartment syndrome TX IVF, diuretics, low dose dopamine, sodium bicarb, kayexelate, hemodialysis is possible.

122 Complex regional pain syndrome
s/s: debilitating pain, atrophy, autonomic dysfunction (excessive sweating, vascular changes), and motor impairment (muscle paresis) Caused by hyperactive sympathetic nervous system Results from trauma Common in feet and hands 3 stages: 1: lasts 1-3 months; local severe burning pain, edema, vasospasm, muscle spasms 2: 3-6 months; pain, edema, muscle atrophy, spotty osteoporosis 3: marked muscle atrophy, intractable pain, severely limited mobility, contractures, osteoporosis

123 Pain control PT OT ROM Gentle skin care Support groups, etc Tx

124 Sports related injuries
Tears Lock knee Torn ACL Tendon rupture Dislocation Subluxation Strains Sprains Torn rotator cuff

125 Interventions for musculoskeletal trauma
Casts Braces Splints Traction Surgery Reduction (realignment) Interventions for musculoskeletal trauma

126 Stab wounds 4 types of wounds
Incised = Sharp cut like injuries (knives, glass) Slash wounds= more longer than deep Stab wound= depth longer than length Defense wound= warding wounds (like on hand) Stab wounds

127 Defense Wound Stab Wound w/ single edge blade

128 4 types Close contact= illustrates a patternized abrasion around the wound Contact= barrel has contacted the skin and the gases have passed into SQ tissues faint abrasion ring and sone grey/black discoloration Intermediate wound= powder tatooing Exit wound= slit like exit wound…no powder or soot Gun shot wounds

129 Wound Care Treatment (at Site)
Bleeding can usually be stopped by applying direct pressure to the wound. Very large foreign objects stuck in a wound should be stabilized. Do not remove them. All wounds require immediate thorough cleansing with fresh tap water. Gently scrub the wound with soap and water to remove foreign material. Remove dead tissue from the wound with a sterile scissors or scalpel. After cleaning the wound, a topical antibiotic ointment (bacitracin) should be applied 3 times per day. Wounded extremities should be immobilized and elevated. Puncture wounds are usually not sutured (stitched) unless they involve the face.

130 If the wound is clean, the edges can be drawn together with tape.
(Do not cover wounds inflicted by animals or that occurred in seawater with tape.) Oral antibiotics are usually recommended to prevent infection. If infection develops, continue antibiotics for at least 5 days after all signs of infection have cleared. Inform the doctor of any drug allergy prior to starting any antibiotic. The doctor will prescribe the appropriate antibiotic. Some may cause sensitivity to the sun, so sunscreen (at least SPF 15) is mandatory while taking these antibiotics. Pain may be relieved with 1-2 acetaminophen (Tylenol) every 4 hours, 1-2 ibuprofen (Motrin, Advil) every 6-8 hours, or both. Call 911 or get to ER immediately if stab or gunshot wound.

131 In Hospital Treatment Stay Safe. Utilize universal precautions and wear personal protective equipment if available. Control bleeding before anything else. Putting pressure directly on the puncture wound while holding it above the level of the heart for 15 minutes should be enough to stop bleeding. If not, try using pressure points. Tourniquets should be avoided unless medical care will be delayed for several hours. Holes in the chest can lead to collapsed lungs. Deep puncture wounds to the chest should be immediately sealed by hand or with a dressing that does not allow air o flow. Victims may complain of shortness of breath. If the victim gets worse after sealing the chest puncture wound, unseal it. Once bleeding has been controlled, wash the puncture wound with warm water and mild soap . If bleeding starts again, repeat step two.

132 Sexual abuse (also referred to as molestation) is defined as the forcing of undesired sexual acts by one person to another. The term incest is defined as sexual abuse between family members, and the euphemism "bad touch" is sometimes used to describe such abuse. (Renvoizé 1982) Different types of sexual abuse involve: Non-consensual, forced physical sexual behavior such as rape or sexual assault Psychological forms of abuse, such as verbal sexual behavior or stalking. The use of a position of trust for sexual purposes. Acquaintance rape - forced sexual intercourse between individuals who know each other - is a crime that is widespread on many college and university campuses. Usually, both parties involved in acquaintance rape have been drinking - often to excess. Research has not yet explained how and why alcohol is related to aggression in general or to acquaintance rape in particular Sexual Abuse

133 Sexual Abuse Signs of sexual abuse
Unexplained injuries (especially to parts of the female body that can be covered by a two-piece swimsuit) Torn or stained clothing or underwear Pregnancy Sexually transmitted diseases (STDs) Unexplained behavioral problems Depression Self abuse and/or suicidal behavior Drug and/or alcohol abuse Sudden loss of interest in sexual activity Sudden increase of sexual behavior Sexual Abuse

134 The doctor in the emergency room will examine the victim for injuries and collect evidence.
The attacker may have left behind pieces of evidence such as clothing fibers, hairs, saliva or semen that may help identify him. In most hospitals, a "rape kit" is used to help collect evidence. A rape kit is a standard kit with little boxes, microscope slides and plastic bags for collecting and storing evidence. Samples of evidence may be used in court. Next, the doctor will need to do a blood test. Women will be checked for pregnancy and all rape victims are tested for diseases that can be passed through sex. Cultures of the cervix may be sent to a lab to check for disease, too. The results of these tests will come back in several days or a few weeks. It's important for the client to see their own doctor in 1 or 2 weeks to review the results of these tests. If any of the tests are positive, the victim will need to talk with your doctor about treatment.

135 The emergency room doctor can tell the victim about different treatments.
If a birth control pill or intrauterine device (IUD) the chance of pregnancy is small. If no birth control is taken the victim may consider pregnancy prevention treatment. Pregnancy prevention consists of taking 2 estrogen pills when you first get to the hospital and 2 more pills 12 hours later. This treatment reduces the risk of pregnancy by 60% to 90%. (The treatment may make you feel sick to your stomach.) The risk of getting a sexually transmitted disease during a rape is about 5% to 10%. Your doctor can prescribe medicine for chlamydia, gonorrhea and syphilis when the victim first gets to the hospital. If not already vaccinated for hepatitis B, the victim should get that vaccination when you first see the emergency room doctor. Then they’ll get another vaccination in 1 month and a third in 6 months. The doctor will also discuss human immunodeficiency virus (HIV) infection. Your chance of getting HIV from a rape is less than 1%, but if you want preventive treatment, you can take 2 medicines-- zidovudine (brand name: Retrovir) and lamivudine (brand name: Epivir) -- for 4 weeks.

136 Rape Classified as assault
Primary cause is an aggressive desire to dominate according to experts Difficult to prosecute b/c of lack of evidence Statistics Women by men: 90-91% most frequent Male by male: 9-10% less common Little to no research on women offenders Definition Intercourse , is attempted or happens without consent of one of the parties involved (penetration with penis or objects etc) Rape

137 Types of rape Gang Date Custodial Serial Marital Prison Acquaintance
Multiple offenders, one victim Date Custodial Serial Marital Prison Acquaintance Wartime Statuatory Types of rape

138 Effects of rape Unpredictable emotions PTSD can occur
Feeling numb and detached Memory problems Avoidance of things anxiety PTSD can occur Relive the rape over and over Disturbed sleeping patterns Eating habits affected Effects of rape

139 More stats If reported to police 50% chance an arrest will be made
If arrest made, 80% chance of prosecution If prosecuted, 58% chance of felony conviction If felony conviction, 69% chance of jail time More stats

140 If abuse suspected Child Domestic Any type Mandatory reporting

141 Mass Casualty

142 System Notification/Activation of Emergency Preparedness
Classified disaster earthquake, tornado, accident, Terrorist attack Notify by radio/pager Utilize telephone tree to call staff in INCIDENT COMMAND CENTER initiated System Notification/Activation of Emergency Preparedness

143 http://www.cnn.com/201 4/01/20/us/omaha- plant-fire/
Recent Omaha NEWS

144 Commander Triage officer Medical command physician Hospital Role

145 Debriefing Critical Incident Stress Debriefing 2 types
Critical Incident Stress Management Post Traumatic Stress Disorder Administrative Review Debriefing

146 Psychological Effects After a Disaster
Provide active listening and emotional support Provide information as appropriate Refer to therapist or other resources Discourage repeated exposure to media regarding the event Encourage return to normal activities and social roles

147 Incident Command Incident Commander Logistics Operations Planning
Finance Public Information Officer Liaison Officer Safety and Security Officer Medical or Technical Officer Part of Hospital preparedness adapted from NIMS (National Incident Management System) – Incident Command System Incident Commander (IC) – one person in charge of the entire operation. Giver overall direction for hospital operations. Breaks down into Four main areas (Operations, Planning, Finance, Logistics) and each of these have a chief or head over each area that report directly to the IC. In addition – a safety officer, Medical or technical officer, Liaison and Public Information Officer also are identified and report directly to the IC. Used to identify a clear chain of command and clear responsibilities with a common language and a common mission, prioritization of duties and documentation of the event. The Public Information Officer – in charge of communication with the media, relapses information that is pertinent and necessary only, helps with communication to the public – avoids panic and educates public on the incident The Safety and Security Officer monitors and has authority over the safety and rescue operations and hazardous conditions. Scene protection and security. The Liaison Officer functions as the contact person between outside agencies providing rescue and support (fire dept., police, assisting organizations to help in disaster relief) The Medical / Technical Officer – is a specialist on the type of disaster and provides expert advise for care and rescue and directly report to the IC too. Planning section – continuously evaluates the event and develops action plans and objectives to meet the incident needs most current needs and resources available, the planning section continuously provides data, keeps records and updates to the IC via the chief of planning frequently. Operations – covers much of the daily activities of delivering the medical care needed during the incident. Responsible for actual scene control, manages resources utilized, matching staff to patient needs, managing the treatment areas, decon areas, OR, ER, triage. Finance – provides funding for operations and assist with recovery costs. Manages the cost of the event, recording HR hours, injuries or damage claims, overall in control of cost analysis of incident. Logistics – responsible for providing materials, facilities, services needed to support the event. Includes communication equipment, medical supplies, food for the workers and patients, sleeping quarters, pharmaceutical supplies, etc.

148 (ID the walking wounded)
Green :minor injuries Yellow: injuries can be controlled or treated for limited time in field Red: respirations present but minimal, multiple injuries, decreased LOC, Black: dead or near dead…no respirations detected

149 ID ME Immediate Delayed Minor Expectant/ Deceased Triage Description
Color Immediate Respirations are present, very serious injury that can be fixed quick with out a lot of resources RED Delayed Can wait to be treated for hours to days, dislocations, minor fractures YELLOW Minor “walking Wounded”, cuts, minor wounds GREEN Expectant/ Deceased Not breathing, Massive Head trauma, would take massive resources away from many others to save one BLACK ID ME RED- Immediate – two or more systems affected, breathing with or without pulse and non or intact CNS Yellow – Delayed - One system involved Green – Minor – identify the walking wounded first. If you can get up and walk go to the green zone Black – deceased or impending death with no life extending care to be delivered (no pulse or no effective spontaneous respiratory effort after airway is repositioned

150 DISASTER and BIOTERRORISM NURSING

151 Deliberate release of viruses, bacteria, or other germ agents to cause illness and/or death in people, animals, plants The purpose is to disrupt daily life and cause terror and panic watch?v=2t_MsSO9qRk What is it?

152 Terrorism Disrupt Daily Life & Cause Terror and Panic
FBI – “the unlawful use of force or violence against person’s or property to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives” Terrorism

153 Terrorism International - Domestic - al Qaeda, Irish Republic Army
Klux Klux Klan, Greenpeace, and Individuals like Timothy McVeigh Terrorism

154 Targets Anything & Anywhere that causes large scale disruption
Large crowds/gatherings of people Nuclear/Chemical Plants Federal Systems Controversial businesses (Abortion Clinics) Targets

155 Purpose Attract Media Attention Increase support for Cause
Undermine the Government or Agency attacked Influence Policy Solely For Revenge Purpose

156 National Standards of Nursing Education
Pre-September 11, – considered unnecessary Now Emergency and Disaster Preparedness Core Competencies for Nurses are standard and have been added to Education Curriculums Core Competencies pg Chart 65-2 National Standards of Nursing Education

157 Identification of Events
Weapons of Mass Destruction (WMD) Because they cause massive destruction and injury Incident identification can be difficult especially if delayed onset from exposure (Especially with biological agents) Recognizing clusters- found usually by public health epidemiological methodology Identification of Events

158 Agent Route of Entry Vectors – means of spreading the agent
Entry to body: Ingestion Inhalation Injection Dermal Exposure Agent Route of Entry

159 Hot Zone – (red zone) – the area of highest contamination, waiting to be contaminated, triage area
Warm Zone – (yellow zone) – contamination reduction corridor, where decontamination process takes place Cold Zone – (green zone) – support zone – decontaminated Chart 65-5 pg 2065

160 Isolation Precautions for Biological Terrorism Agents
Due to modern travel, spread of infection may occur in areas thousands of miles apart Health care providers need to be aware of potential signs of biological weapon s signs and symptoms are similar to those of common disease process Isolation practices depend upon the infecting agent Always use Standard Precautions Some agents require Transmission-Based Precautions Terminal disinfection and disposal of wastes depends on the infecting agent

161 Chemical Biological Radiological Explosive
History of Agents Chemical Agents -Chinese in 1000 BC used arsenic smoke -WWW I the Germans released 150 tons of chlorine gas –because chlorine gas is heavy and hugs the ground it settled into the trenches of the allied forces -Sulfur mustard was also used caused around 20,000 causalities, Iraq used against Iran and Kurdish citizens that killed 5,000 Sarin Gas was released in a Tokyo Subway Biological agents -6th Century BC – 1st documented use -The Asyrians poisoned enemy water wells with rye erot , a fungus that causes cardiac problems and hallucinations -French and Indian War – blankets and handkerchiefs infected with smallpox were delivered to the Indians who were sympathetic to the French. -Korean war by US, the Vietcong used pungi sticks – sharpened sticks placed in rice paddies contaminated with human waste to make big infected sores. Radiological – Hiroshima and Nagasaki during WWII atom bomb Explosive agents -Oklahoma City Federal Building Bombing -World Trade Center Bombings -World Trade Center Attack 9/11/2001 – used airplanes as a bomb

162 Disaster Planning Assumptions versus Observations
Dispatchers will send emergency response units once notified Trained Emergency personnel will carry out field search and rescue Trained EMS personnel will carry out triage, first aid, medically stabilize and decontaminate before transport Casualties will be transported via ambulance to the appropriate facility or hospital in an appropriate amount that the facility or hospital can accommodate Hospitals will be properly notified Most serious casualties will arrive first Emergency Response Units will self dispatch (local and distant) Initial search and rescue is carried out by the survivors themselves Casualties are likely to bypass on-the-site triage, first aid and decontamination stations and go directly to hospitals Most casualties are not transported by ambulance. Most go by private vehicles, police vehicles, buses or on foot. Most casualties will go to the nearest hospital or the most familiar hospital. Hospitals most often are notified by arriving victims and/or by news media The least serious casualties often arrive first

163 Types of Events Identification and Delivery
Weapons of Mass Destruction (WMD) Because they cause massive destruction and injury CBRNE (Department of Justice) – Chemical, Biological, Radiological, Nuclear and Explosive (includes Fire-causing) Delivery of agent – spraying devices, packages, contaminating water and food, animals and the wind Identifying an event – Biological – Delayed onset, epidemiology, public health Chemical – symptoms suggestive of chemical agent used Radiological – clustering of symptoms resembling radiological exposure (could be delayed) Explosive – boom! Trauma causalities Types of Events Identification and Delivery Biological - events are hard to identify due to delayed onset from exposure (incubation period) Recognizing clusters-found usually by public health epidemiological methodology (Today any small pox incident will be treated as a Bioterrorism event) Chemical – identifying symptoms suggestive of a chemical agent identification of clustering symptom, type and delivery of radiation numerous traumatic injuries not related to an accident, usually caused by an explosive device

164 Types 3 major types 3 minor types Biological Chemical Radiation
Eco terrorism Narcotic trafficking to fund terror Cyber-attacks civilians to draw notoriety to cause Types

165 Biological Documented use in the 6th century
Ex: Asyrians poisoned enemy water wells with rye ergot (a fungus that grows on rye) causing hallucinations and cardiac problems WW2: shigella and others French and Indian War: Smallpox Russia 1979: Anthrax Biological Vectors – fleas (plague) , ticks, mosquitoes (WNV), rats, mice, etc. Illness from the 1918 flu pandemic, also known as the Spanish flu, came on quickly. Some people felt fine in the morning but died by nightfall. People who caught the Spanish Flu but did not die from it often died from complications caused by bacteria, such as pneumonia. During the 1918 pandemic: Approximately 20% to 40% of the worldwide population became ill An estimated 50 million people died Nearly 675,000 people died in the United States

166 BIOLOGICAL AGENTS Bacteria - Anthrax, Brucellosis (Black Death), Cholera, Glanders, Plague, Q Fever, Rickettsia, Tularemia, Typhus Viruses - Dengue Fever, Ebola, Rift Valley Fever, Small Pox, Venezuelan Equine, Encephalitis (VEE) Virus, Viral Hemorrhagic Fever (VHF) Toxins - Botulinum, Ricin, Saxitoxin, Staphylococcal Enterotoxin B (SEB), Trichothecene Mycotoxinx

167 BIOLOGICAL AGENTS Bacteria: Anthrax, Brucellosis, Plague, Q Fever, Tularemia Viral: Small Pox, Venezuelan equine encephalitis (VEE), Viral hemorrhagic fevers Toxins: Botulinim, Staphylococcal enterotoxin B (SEB), Ricin, Trichothecene (T-2) mycotoxins

168 Biological 3 categories A: high priority B: second highest priority
easy to spread person to person High death rate Require special action (anthrax, botulism, plague, smallpox, hemorrhagic fever, tularemia) B: second highest priority Moderately easy to spread Moderate illness Low death (Salmonella, e coli, Q fever, Ricin toxin, etc) C: third highest priority Easy available Easy produced Potential for high death and major health impact (hantavirus) Biological Priority is based on how easily it is spread from person to person, thus increasing morbidity- VIRULENCE – THE DEGREE TO WHICH A MICROORGANISM OR PATHOGEN CAN CAUSE DISEASE – PERSON TO PERSON HIGHEST

169 Biological Signs/Symptoms
Vary upon agent (example: hantavirus causes a resistent TB) Death is result of respiratory failure, paralysis, hypovolemic shock, multi organ failure, etc Biological

170 Possible Treatment Isolation Vaccines Antibiotics Biological

171 Isolation Precautions for Biological Terrorism
Due to modern travel, spread of infection may occur in areas thousands of miles apart Health care providers need to be aware of potential signs of biological weapons signs and symptoms are similar to those of the disease Isolation practices depend upon the infecting agent Always use Standard Precautions Some agents require Transmission-Based Precautions Terminal disinfection and disposal of wastes depends on the infecting agent

172 Chemical Hazardous chemical released Many are industrial
Some created by military Some found in nature Chemical

173 Chemical Weapons Chemical substances that quickly cause injury and/or death and cause panic and social disruption Agents: Nerve agents Blood agents Vesicants Pulmonary agents Agents vary in toxicity Limitation of exposure is essential with evacuation and decontamination as soon possible and as close to the scene of the incident as possible

174 Chemical Types Biotoxins ( poison from plant or animal)
Blister agents (lewisite, sulfar mustard, nitrogen mustard, etc) Blood agents (hydrogen cyanide, cyanide chloride) Caustics (acid) Choking agents (chlorine, phosgene, etc) Incapacitating agents Long acting anticoagulants Metals Nerve agents (VG, VM, sarin, soman, etc) Organic solvents Riot control agents (tear gas) Toxic alcohols Vomitting agents Chemical

175 Chemical Signs/Symptoms Variable depending on agent
Examples include: cardiac arrest, seizures, death Chemical

176 Chemical Possible treatment
Give antidote if available and if known agent Administer O2 CPR Flush eyes DO NOT induce vomitting Take off clothes and wash skin immediately Chemical

177 Nerve Agents Inhibit cholinesterase-causing cholinergic symptoms
Decontaminate with copious amounts of soap and water or saline for at least 20 minutes Blot; do not wipe off Plastic equipment will absorb sarin gas

178 NERVE AGENTS Signs and Symptoms
SLUDGEM: salivation, lacrimation, urination, defecation, gastric upset, emesis, and miosis Dim vision Cardiac dysrhythmias, confusion and convulsions, along with unconsciousness Runny nose and shortness of breath Pinpoint pupils and muscle fasciculations (muscle twitching)

179 NERVE AGENTS - Treatment
Oxime reversal agents: Protopam chloride (2-PAM chloride) MARK I kit: atropine and protopam Diazepam (Convulsions and muscle twitching) Full decontamination of body and clothing Hydration: electrolyte and fluid replacement as needed Reassure patient, to decrease anxiety and promote rest Do not induce vomiting if ingested NERVE AGENTS - Treatment Atropine - anticholinergic Pralidoxime chloride is a cholinesterase reactivator – due to the nerve agent exposure that inactivated cholinesterase

180 Vesicants Lewisite, sulfur mustard, nitrogen mustard, and phosgene
Respiratory effects can be serious and cause death Lewisite – asymptomatic period of hours following exposure. Damage is being done to the tissue exposed, but overt signs are delayed

181 Are blistering agents that cause burning, conjunctivitis, bronchitis, pneumonia, hematopoietic (stem cell) suppression and death. Inhalation, Topical (skin damage irreversible but seldom fatal) VESICANT AGENTS

182 VESICANT AGENTS Signs and symptoms
Eyes: irritation, conjunctivitis, corneal burns, blindness Skin: erythema, itching, areas of increased pigmentation, blisters Mucosal sloughing and airway obstruction Bone marrow suppression Respiratory effects: irritation/burning of nares, sinus pain or irritation, nosebleeds, and irritation of the pharynx, dyspnea and increased sputum production Damage to the trachea and upper airways, laryngitis Headache, nausea, vomiting, and diarrhea Blood-stained emesis and feces

183 VESICANT AGENTS Treatment
Supportive Treat skin – wound care, burn care Treat respiratory – O2 support, Airway support, mechanical ventilation if necessary Support bone marrow and immune response Antibacterial for secondary infections Treat symptoms Decontaminate with soap and water Eye irrigations VESICANT AGENTS Treatment

184 Effects cellular metabolism and hemoglobin – results in lactic acidosis and reduced intracellular ATP Primary route of entry – Inhalation Liquid forms may be absorbed though dermal routes, eyes and oral mucosa. Liquid exposure – requires decontamination High exposures – death results in 3-8 minutes BLOOD AGENTS

185 BLOOD AGENTS Gases: Hydrogen cyanide Cyanogen chloride Crystals: Sodium Cyanide Potassium Cyanide

186 BLOOD AGENTS Signs and Symptoms
Initial transient rapid respiratory rate Apprehension, anxiety, agitation, and vertigo Feeling of general weakness, nausea with or without vomiting, and muscular trembling Slowing respirations, loss of consciousness, convulsions, and apnea with cardiac standstill

187 BLOOD AGENTS Treatment
100% oxygen administration Amyl nitrate by inhalation or sodium nitrate by intravenous injection Sodium thiosulfate Hyperbaric oxygen treatment Supportive therapy: IV bicarbonate for severe acidosis, vasopressors, valium -amyl nitrite , sodium nitrate induces the formation of methemoglobin. -methemoglobin combines with the cyanide to form nontoxic cyanmethemoglobin. -Sodium thiosulfate – converts cyanide to thiocynate – excreted in urine -vasopressors needed to treat shock plus nitrates are vasodilators -Valium to treat muscle spasms, etc.

188 CHOKING AGENTS Destroys the pulmonary membrane that separates the alveolus from the capillary bed Results in fluid filled alveoli Inhaled

189 Ammonia Chlorine Phosgene
CHOKING AGENTS

190 CHOKING AGENTS Signs and Symptoms
Irritation of the nasopharynx, causing sneezing, pain, and erythema Dysphagia, cough Hoarseness, stridor, and coarse rhonchi, lacrimation and rhinorrhea, swelling of the throat and bronchi Pulmonary edema - large amounts of white to pink frothy sputum Chemical pneumonitis and lung hemorrhage

191 CHOKING AGENTS Treatment
Supportive Oxygen, ventilation support, bronchodilators Bed rest Steroids (anti- inflammatory) and ibuprofen CHOKING AGENTS Treatment

192 IRRITANTS Commonly known as – “riot controlling agents”
Produces transient discomfort – to render an opponent incapable of resistance or fighting back Examples Mace Tear gas Pepper spray Signs and symptoms Pain, eye and nasal burning, lacrimation, or discomfort on exposure to mucous membranes Treatment is fresh air, washing away the irritant

193 Radiation Types Dirty bombs Contaminating food water sources
Explosion or meltdown at nuclear plant Radiation Radiation that can be used as a weapon RDD - Radiological Dispersion Device or “Dirty Bomb” – an explosive device that releases radioactive material into the environment Creates trauma from the explosion, complicates evacuation and care of victims due to the contamination Causes wide spread panic and terror Blast Injuries Thermal Burns Nuclear Radiation will cause radiation syndrome

194 RADIOLOGIC AGENTS Nuclear explosion –
Trauma from the blast thermal burns from the heat and light acute radiation syndrome from exposure to the nuclear radiation Exposure to radiation Is affected by time, distance, and shielding

195 RADIOLOGIC AGENTS Nonionizing - low energy and non-harmful
Ionizing – Alpha, Beta and Gamma Alpha – poorly penetrates skin, travel 1- 2 inches, very harmful to kidneys lungs and skeletal system if introduced through broken skin or ingested Blocked by clothing or paper Beta – can penetrate skin at short distances causing burns, travels up to 10 ft., can be harmful if ingested or inhaled Blocked by heavy clothing, walls, or thin metals Gamma – emitted during nuclear detonation and are present in fall out, travel several 100 ft., are penetrating through tissue to deep organs. Blocked by dense materials – lead, concrete, and steel

196 Radiation Signs/Symptoms Cancer Death to those near site
Itching and erythema Edema Feel heat Ulcers/necrosis Radiation

197 Radiation Possible treatments Burn unit Possible anticoagulants
Antibiotics to prevent infection Pain management Corticosteroids surgery Pyschological support n/criphysicianfactsheet.asp Radiation

198 RADIOLOGIC AGENTS Acute Radiation Syndrome
An acute illness that occurs when the entire body (or most of it) receives or is exposed to a high dose of radiation. Generates highly reactive free radicals, damages messenger RNA (mRNA) and DNA and interferes with cell growth, or even causes cell death. Severity varies with the amount of exposure, age and overall heath of an individual RADIOLOGIC AGENTS Acute Radiation Syndrome

199 RADIOLOGIC AGENTS Acute Radiation Syndrome
Four Phases Prodromal Phase Latent Phase (Transient Phase) Illness Phase Recovery or death RADIOLOGIC AGENTS Acute Radiation Syndrome Prodromal Phase – onset minutes to hours last from hours to days rapid onset of nausea/vomiting, malaise. May have fever, hypotension, diarrhea (at high levels of exposure). Onset of symptoms w/in 30 minutes most likely a lethal dose. Latent/Transient phase – follows prodromal phase, relatively symptom free, last up to two weeks Illness phase/Manifest – overt illness Hematopoietic system – drop in all cell counts due to bone marrow destruction -Fever, sepsis, hemorrhage -recovery depends on the bone marrow recovery – may need transfusions, stem cell transplant GI – N/V, Diarrhea (bloody) - damage to epithelial cells lining the small intestine, F/E imbalances, septicemia treatment of symptoms, anti-emetics, fluid electrolyte replacement, sedatives CNS – At very high doses CNS is effected… Disorientation, seizures mostly related to F/E imbalances and ICP. Treatment – sedative, anti seizure meds, analgesics, anti-anxiety Recovery/Death – Mortality is directly related to amount of exposure, mostly from opportunistic infections as a direct result of bone marrow destruction. Large exposures will usually die w/in few months. Recovery of survivors may last for several months to years.

200 Radiation Decontamination
Triage outside the hospital Cover floor and use strict isolation precautions to prevent the tracking of contaminants Seal air ducts and vents Waste is double bagged and put in a container labeled radiation waste Staff protection Water-resistant gowns, 2 pairs of gloves, caps, goggles, masks, and booties

201 A: highest level for skin, eyes, mucous membranes, and respiratory system
B: Chemical protective clothing used instead of the fully encapsulated suit C: Full face piece with air purifier and chemical resistant clothing D: regular clothes Levels of PPE

202 LEVEL B LEVEL A

203 LEVEL D LEVEL C

204 Decontamination Removal of contaminating material Areas:
Hot Zone: highest contamination Warm Zone: contamination reduction corridor Cold Zone: support zone Steps: disrobe completely, step in shower, lather completely including creases, dry off, then dress in hospital gown and go to cold zone Decontamination

205

206 Decontamination

207 Blast Injuries Most severe injuries are to lungs
Other things include ear drum perforation, bowel perforation, lacerations Blast Injuries

208 EXPLOSIVE AGENTS High Order Explosive (nitroglycerin) and Low Order Explosives (pyrotechnics, gunpowder) High Order Explosive Injuries are classified into Primary, Secondary and Tertiary.

209 Blast Injuries from High Order Explosives
Primary – Impact of the over- pressurization wave with body surfaces – lungs, ears, GI, TBI (most) Secondary – Flying debris and bomb fragments Tertiary – Injuries incurred from being thrown by the blast. Quaternary – explosion related injuries that are complication of the previous injuries Nail Bomb or Jar Bomb EXPLOSIVE AGENTS

210 Clothing and personal items sent to FBI for evidence

211 Psychological Effects After a Disaster
Provide active listening and emotional support Provide information as appropriate Refer to therapist or other resources Discourage repeated exposure to media regarding the event Encourage return to normal activities and social roles

212 National Resources (was national pharmaceutical stock pile)
Strategic National Stock Pile Push Packs-shipped within 12 hours of the decision to deploy 4% of the stockpile Antibiotic agents IV/IM medications Bulk Supplies-First Aid Analgesics Other Emergency Medications National Resources (was national pharmaceutical stock pile) Push packs consists of 100 containers weighting approx. 50 tons containers are designed to fill a 747 cargo jet The receiving site must have at least 12,000 square feet of space for storage. IV/IM Antibiotic agents, Vaccines, anti-virals, antitoxins, antidotes, analgesics, other emergency meds Bulk Supplies-First Aid (Contents are added based on incident) 2700 Ventilators have been added in 2003 to the stock pile

213 DMAT/DMORTS Disaster Management Assistance Teams/Disaster Management Mortuary Teams Health care providers, nurses, EMT’s, Technical Staff, and other health care professionals. DMORTS – management and identification of the dead Medical Reserve Corps Nebraska Emergency Response Red Cross OMMRS (Omaha Metro Medical Response System) Military – National Guard

214 The point is to save as many as you can

215


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