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

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Presentation on theme: "EMERGENCY / TRAUMA/ MASS CASUALTY/ BIOTERRORISM By: Diana Blum MSN MCC NURSING 2150."— Presentation transcript:

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

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

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

4 Environment of Care Rapid change NoisyUnpredictable

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

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

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

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 http://www.youtube.com/watch?v=n5Zw4ZARvNg

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

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

13 Communication Complex barriers Use professional language Protect HIPPA related information

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 1. Across-the-room assessment starts with visual contact, general appearance, work of breathing, skin color 2. 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

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

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 5 Level Triage (chart 66-11) 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

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

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

21 Primary Survey A: A irway patency, stridor, inability to speak, rise and fall of chest B: B reathing rate and depth, breath sounds, chest expansion, skin color, spontaneous breathing C: C irculation 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 2 nd ary Survey Identifies other injuries or medical issues that needs to be managed

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?

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

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

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

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

29 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

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

31 Treatment  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

32 Heat  Exhaustion  Stroke

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

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

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

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

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

38 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

39 HYPOTHERMIA

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

41 Hypothermia  Internal core temperate is 35° C or less  Elderly, infants, persons with concurrent illness, the homeless, and trauma victims are at risk  Alcohol ingestion increases susceptibility  Hypothermia may be seen with frostbite; treatment of hypothermia takes precedence  Physiologic changes in all organ systems  Monitor continuously

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

43 Rewarming  Warm fluids, blankets  Cardiopulmonary bypass  Warm lavage

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  1 st degree- hyperemia, edema  2 nd degree- fluid blisters with partial thick necrosis  3 rd degree- dark fluid blisters, sub cutaneous necrosis  4 th 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.

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

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

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

51 Snake Bites  Action of venom  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

52 Snake Bites  Coral Treatment  At site  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 http://www.expotv.com/videos/reviews/19/169/Coghlan27sSnakeBiteKit/ 156505

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.

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 http://www.videojug.com/film/how-to-treat-an-insect-bite

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

56  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 site  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

59  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  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

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

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

66  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 9- 30 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

69 treatment  At site  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

70 Patient Education  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

71 Lightning  Year round problem  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

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)

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

74 Interventions  At site  Spinal immobilization  Monitor ABCs  CPR  Sterile dressings for burns  Hospital care  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

75 Altitude related Illness  High altitude is elevations above 5000 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

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 Site Descent to lower altitude Monitor for symptom progression Rest O2 if available Altitude Illness Hospital Acetazolamide Acetazolamide Acts as bicarb diuretic Sulfa drug Take 24 hours before ascent and take for 1 st 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 Dexamethazone: 4mg – 8mg po or IM initially then 4mg q6hours during descent O2 O2 Monitor airway Monitor airway Lasix Lasix Critical care Critical care

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

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 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 Symptoms Symptoms can vary, but may include: Abdominal distention Abdominal distention Bluish skinBluish skin of the face, especially around the lips Bluish skin Cold skin and pale appearance Confusion CoughCough with pink, frothy sputum CoughIrritability Lethargy No breathing No breathing Restlessness Shallow or gasping respirations Chest pain Chest pain Unconsciousness Vomiting

82  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.CPR

83 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.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  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

87 Assessment Of SCI  1 st assess respiratory status  ET tube may be necessary if compromised  2 nd assess for intra- abdominal hemorrhage (hypotension, tachycardia, weak and thready pulse)  3 rd 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

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

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

90  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 Brain Injuries (TBI)

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

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

95  Battles sign  Raccoon eyes  Flail chest  Tension Pneumothorax  Hemothorax

96

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

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

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

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

102

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

104 Stages of healing  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

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

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

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

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

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  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

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

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  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  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 assessments

120

121  CAUSES  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. CRUSH SYNDROME

122  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 Complex regional pain syndrome

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

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)

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)

127  Defense Wound  Stab Wound w/ single edge blade

128 Gun shot wounds  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

129 Wound Care Treatment (at Site) Bleeding can usually be stopped by applying direct pressure to the wound. 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. 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. All wounds require immediate thorough cleansing with fresh tap water. Gently scrub the wound with soap and water to remove foreign material. Gently scrub the wound with soap and water to remove foreign material. Remove dead tissue from the wound with a sterile scissors or scalpel. 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. After cleaning the wound, a topical antibiotic ointment (bacitracin) should be applied 3 times per day. Wounded extremities should be immobilized and elevated. Wounded extremities should be immobilized and elevated. Puncture wounds are usually not sutured (stitched) unless they involve the face. 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 Stay Safe. Utilize universal precautions and wear personal protective equipment if available.universal precautionspersonal protective equipment 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. Control bleeding If not, try using pressure points. Tourniquets should be avoided unless medical care will be delayed for several hours.pressure pointsTourniquets Holes in the chest can lead to collapsed lungs.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.shortness of breath Once bleeding has been controlled, wash the puncture wound with warm water and mild soap. If bleeding starts again, repeat step two. In Hospital Treatment

132 Sexual Abuse 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) incest (Renvoizé 1982)incest (Renvoizé 1982) Different types of sexual abuse involve: Non-consensual, forced physical sexual behavior such as rape or sexual assault rapesexual assaultrapesexual assault Psychological forms of abuse, such as verbal sexual behavior or stalking. stalking The use of a position of trust for sexual purposes. position of trustposition of trust 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. 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 http://www.youtube.com/watch?v=PvXxzZUuIn 0 http://www.youtube.com/watch?v=PvXxzZUuIn 0

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

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)

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

138 Effects of rape  Unpredictable emotions  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

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

140 Mandatory reporting  If abuse suspected  Child  Domestic  Any type

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

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

144 Hospital Role Commander Triage officer Medical command physician

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

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 Planning Incident Commander Logistics Operations Finance Liaison Officer Safety and Security Officer Public Information Officer Medical or Technical Officer

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 TriageDescriptionColor 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 YELLO W 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

150 DISASTER and BIOTERRORISM NURSING

151 What is it?  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  http://www.youtube.com/ watch?v=2t_MsSO9qRk http://www.youtube.com/ watch?v=2t_MsSO9qRk http://www.youtube.com/ watch?v=2t_MsSO9qRk

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”

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

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

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

156 National Standards of Nursing Education  Pre-September 11, 2001 – considered unnecessary  Now Emergency and Disaster Preparedness Core Competencies for Nurses are standard and have been added to Education Curriculums  Core Competencies pg. 2061 Chart 65-2

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

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

159 Chart 65-5 pg 2065  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

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 History of Agents ChemicalBiologicalRadiologicalExplosive

162  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 Disaster Planning Assumptions versus Observations  Assumptions  Observations  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) Weapons of Mass Destruction (WMD) Because they cause massive destruction and injury Because they cause massive destruction and injury CBRNE (Department of Justice) – Chemical, Biological, Radiological, Nuclear and Explosive (includes Fire-causing) 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 Delivery of agent – spraying devices, packages, contaminating water and food, animals and the wind Identifying an event – 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

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

165 Biological  Documented use in the 6 th 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

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  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)

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 http://www.bt.cdc.gov/bioterrorism/factsheets.asp

170 Biological  Possible Treatment  Isolation  Vaccines  Antibiotics

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

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

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

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 http://usmilitary.about.com/library/milinfo/blchemical.htm

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

180 Vesicants  Lewisite, sulfur mustard, nitrogen mustard, and phosgene  Respiratory effects can be serious and cause death

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

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

184 BLOOD AGENTS  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

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

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

189 CHOKING AGENTS AmmoniaChlorinePhosgene

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

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

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

197 Radiation  Possible treatments  Burn unit  Possible anticoagulants  Antibiotics to prevent infection  Pain management  Corticosteroids  surgery  Pyschological support http://www.bt.cdc.gov/radiatio n/criphysicianfactsheet.asp http://www.bt.cdc.gov/radiatio n/criphysicianfactsheet.asp

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

199 RADIOLOGIC AGENTS Acute Radiation Syndrome  Four Phases 1. Prodromal Phase 2. Latent Phase (Transient Phase) 3. Illness Phase 4. Recovery or death

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 Levels of PPE  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

202 LEVEL A LEVEL B

203 LEVEL C LEVEL D

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

205 http://www.remm.nlm.gov/radtriage.htm#start

206 Decontamination

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

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 EXPLOSIVE AGENTS Nail Bomb or Jar Bomb 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

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

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

214 The point is to save as many as you can

215


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