Emergency/Disaster Preparedness

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Emergency/DisasterPreparedness

• Lisa Randall, RN, MSN, ACNS-BC
• RNSG 2432

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Objectives

• Compare and contrast interdisciplinary roles and
  responsibilities associated with emergency and
  disaster situations.
• Compare and contrast risk factors associated with
  need for emergency care.
• Analyze etiology, pathophysiology, and
  signs/symptoms of bioterrorism, chemical and
  radiation exposure, and other emergencies.
• Discuss nursing care and diagnoses associated
  with emergency care.

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Definitions

• Emergency
• MCI
• Bioterrorism
• Chemical and radiation exposure
• Primary survey
• Secondary survey

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Emergency and Mass Casualty Incident
Preparedness

• Emergency
• Any extraordinary event that requires a rapid
  and skilled response and can be managed by a
  communitys existing resources
• Mass casualty incident (MCI)
• Manmade or natural event or disaster that
  overwhelms communitys ability to respond with
  existing resources

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Emergency and Mass Casualty Incident Preparedness

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

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Emergency and Mass Casualty Incident Preparedness

• All health care providers have a role in
  emergency and MCI preparedness
• Know hospitals emergency response plan
• Participation in emergency/MCI preparedness
  drills is required

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Emergency and Mass Casualty Incident Preparedness

• Response to MCIs often requires the aid of a
  federal agency such as the National Disaster
  Medical System (NDMS)
• U.S. Department of Homeland Security
• responsible for the coordination of the federal
  medical response to MCIs

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Bioterrorism

• Anthrax
• Botulism
• Plague
• Tularemia
• Smallpox
• Typhoid fever
• Hemorrhagic fever

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Anthrax

• Bacillus anthracis
• Infected animals
• Skin, ingestion, inhalation
• Pulmonary
• Cutaneous
• GI
• Antibiotics
• Oral Fluoroquinolones
• Prevention
• Vaccination limited

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Botulism

• Clostridium botulinum
• Ingestion (12-36), inhalation (24-72)
• Neuropathies
• Blurred vision
• Weakness
• Respiratory dysfunction
• Vaccine investigational

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Plague

• Yersinia pestis
• Infected fleas (2-8d), aerosol (1-3)
• Lymphatic (bubonic)
• Blood (septicemia)
• Airborne
• Pulmonary variant
• Fever
• Cough
• Hemoptysis
• Antibiotics
• Doxycycline
• Vaccine
• Bubonic

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Smallpox

• Variola virus
• Airborne
• 7-17d incubation
• Flu-like symptoms
• Rash
• Vaccine

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Chemical Exposure

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

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Chemical Exposure

• Categorized by target organ or effect
• Sarin
• Neurotoxin
• Death within minutes of exposure
• Enters body through eyes and skin
• Paralyzes respiratory muscles
• Antidotes
• Atropine
• Pralidoxime chloride (2-PAM, Protopam given IV)

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Chemical Exposure

• Phosgene
• Colorless gas normally used in chemical
  manufacturing
• Severe respiratory distress, pulmonary edema, and
  death
• Mustard gas
• Yellow to brown in color with garlic-like odor
• Eyes
• Skin burns/blisters

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Radiation Exposure

• Ionizing radiation
• Nuclear bomb
• Radioactive material
• Serious threat to safety of casualties and
  environment
• MASS CASUALTY

• Decontamination procedures
• Acute radiation syndrome
• Substantial exposure
• Predictable pattern

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Acute Radiation Syndrome
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Management Radiation Exposure

• Exposure dependent
• 10-12 Gy fatal
• Vomiting
• Lymphopenia
• Cerebrovascular changes
• Fluid replacement
• Cytokines
• G-CSF, GM-CSF, filgrastim
• Antiobiotics
• Burns, wounds
• Abdominal trauma
• Thyroid protection
• KI
• OR
• Within 36hr or after 6wks

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Explosion

• Radiologic dispersal devices (RDDs)
• Mix of explosives and radioactive material
• Scatters radioactive dust, smoke, and other
  material into environment
• Main danger from RDDs Explosion

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Explosive Devices as Agents
of Terrorism

• Blast, crush, or penetrating
• Blast injuries
• Supersonic overpressurization shock wave that
  results from explosion
• Lungs
• Ear
• GI
• Fracture, lacerations, burns, blindness

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Other Emergencies/Disasters

• Earthquakes
• Floods
• Hurricanes
• Landslide/mudslide
• Tornadoes
• Tsunamis
• Volcanoes
• Wildfires
• Winter weather

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Emergency and Mass Casualty Incident Preparedness

• Level-1 DMAT - disaster medical assistance teams
• Deployed within 8 hours
• Self-sufficient for 72 hours with enough food,
  water, shelter, and medical supplies to treat
  about 250 patients per day
• Level-2 DMAT
• Replaces a Level-1 team
• Supplements the equipment left on site

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Emergency and Mass Casualty Incident Preparedness

• HAZMAT
• NRP
• First responders
• Police
• Emergency Medical Personnel
• Triage of casualties differs from usual ED triage
  and is conducted in lt15 seconds

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Emergency and Mass Casualty Incident Preparedness

• Colored tags
• Green
• minor injury
• walking wounded
• Yellow
• non-critical injury
• RPM
• R-resp. P-pulse M- mental status/response/comma
  nds
• Red
• life-threatening injury
• immediate intervention
• Black
• dead or expected to die
• catastrophically injured

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RPM assessment

• Step 1. Respiration (breathing)A. None, open
  airway, still no breathing, tag deceased -
  blackB. Respirations greater than 30/min. or
  less than 10/min. tag Red.C. Respiration between
  10-30 per minute. Go on to Step 2.Step 2.
  Perfusion check (radial pulse) or use a capillary
  blanch testA. Squeeze nail bed, palm of hand or
  pad of finger.B. If color regains in greater
  than two seconds, tag Red.C. If the color
  returns in less than two seconds go onto Step 3
  Mental status.D. In poor lighting, attempt to
  find the radial pulse. If radial pulse is present
  proceed to Step 3.Step 3. Mental statusA.
  Altered mental status is the inability to follow
  simple commands, tag Red.B. Able to follow
  simple commands, tag Yellow.C. Example of simple
  commands can you squeeze my hands? Can you
  open and close your eyes? D. All steps have
  been passed for patient to be tagged Yellow.

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Nursing concerns

• Triage
• Assessment
• Interventions
• Drug therapy
• Diet therapy
• Hypermetabolic states
• Surgical/medical interventions

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Triage Emergency Severity Index

• Short term hospital resource and staffing needs
• Illness severity
• Hospital resources
• 5 level
• ESI-1 highest priority
• Triage algorithm

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Definition ESI-1 ESI-2 ESI-3 ESI-4 ESI-5
Stability of vital functions Unstable Threatened Stable Stable Stable
Life /organ threat Obvious Likely but not always obvious Unlikely but possible No No
How soon patient should be seen by physician Immediately Minutes Up to 1 hour Could be delayed Could be delayed
Expected resource intensity High staff at bedside continuously mobilization of team response High multiple, complex diagnostic studies frequent consultation cont monitoring Medium/high multiple diagnostic studies or brief observation or complex procedure Low 1 simple diagnostic study or simple procedure Low examination only
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ESI Triage Algorithm
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ESI-1

• Cardiac arrest.
• Respiratory arrest.
• Severe respiratory distress.
• SpO2 lt 90.
• Critically injured trauma patient who presents
  unresponsive.
• Overdose with a respiratory rate of 6.
• Severe respiratory distress with agonal or
  gasping-type respirations.
• Severe bradycardia or tachycardia with signs of
  hypoperfusion.
• Hypotension with signs of hypoperfusion.
• Trauma patient who requires immediate crystalloid
  and colloid resuscitation.
• Chest pain, pale, diaphoretic, blood pressure
  70/palp.
• Weak and dizzy, heart rate 30.
• Anaphylactic reaction.
• Baby that is flaccid.
• Unresponsive with strong odor of ETOH.
• Hypoglycemia with a change in mental status.

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Triage

• ISOLATION PRECAUTIONS
• Basic triage principles
• 1. life threatening injuries
• 2. decontaminate
• 3. decongest area

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Triage the following (ESI)

• A 6 yo w T 103.2
• A 22 yo w asthma in acute resp distress
• An infant who has been vomiting for 2 days
• A 50 yo man w LBP/spasms
• A 32 yo woman unconcious following an MVA
• A 40 yo woman w rhinitis and cough
• A 58 yo man w midsternal chest pain
• A teenager w an angulated FA from sports

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Primary Survey

• Maintain airway
• Suction and/or remove foreign body
• Insert nasopharyngeal/oropharyngeal airway
• Endotracheal intubation
• Cricothyroidotomy or tracheostomy

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Primary Survey

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

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Primary Survey

• Breathing
• Assessment
• Administer high-flow O2 via a nonrebreather mask
• Bag-valve-mask (BVM) ventilation with 100 O2 and
  intubation for life-threatening conditions
• Monitor patient response

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Primary Survey

• Circulation
• Check central pulse
• Assess skin for color, temperature, moisture
• Assess mental status and capillary refill
• Aggressive fluid resuscitation
• Insert two large-bore IV catheters
• NS or LR

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Primary Survey

• Disability
• LOC
• AVPU
• A alert
• V responsive to voice
• P responsive to pain
• U unresponsive
• GCS
• Pupils

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Secondary Survey

• Exposure/Environmental control
• Remove clothing
• Provide temperature controlavoid hypothermia

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HPI

• Obtain history
• Location
• Duration
• Activity
• Occupation
• affected

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Secondary Survey

• VS
• BP
• HR
• RR
• Temperature

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Secondary Survey

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

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Assessment

• S/S nonspecific
• VS
• LOC
• Neuro
• GI
• Skin

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Secondary Survey

• Five interventions
• ECG
• Pulse oximetry
• Catheterize
• NGT
• Labs

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Labs

• Serial CBC
• Blood cultures
• Chromosomal aberration
• 24 hr urine/stool

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Drug therapy

• Volume expanders
• Inotropes
• Vasopressors
• Opiods
• Vasocnstrictors
• Immunizations, vaccines, immune globulin
• Antibiotics and antivirals
• Antidotes such as atropine

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Nursing Diagnosis

• Ineffective airway
• Ineffective tissue perfusion
• Risk for infection
• Impaired physical mobility
• Spiritual distress
• Risk for post-trauma syndrome

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Emergency and Mass Casualty Incident Preparedness

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

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Question

• The nurse performing a primary survey in the ED
  is assessing
• a. the acuity of the patients condition to
  determine priority of care
• b. the status of airway, breathing, circulation,
  or presence of deformity.
• c. whether the patient is responsive enough to
  provide needed information
• d. whether the resources of the ED are adequate
  to treat the patient.

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Question

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

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Question

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

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Heat StrokePathophysiology

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

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Heat Stroke

• Development is directly related to
• Amount of time the body temperature is elevated
• What are some common causes?

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Heat Stroke

• Strenuous activity in hot/humid environment
• High fevers
• Clothing that interferes with perspiration
• Working in closed areas/prolonged exposure to
  heat
• Drinking alcohol in hot environment

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Heat StrokeManifestations Complications

• Core temp gt 104F
• AMS
• No perspiration
• Skin hot, ashen, dry
• Dec. BP
• Inc. HR
• S/S of what?

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Heat StrokePrognosis

• Related to
• Age
• Length of exposure
• Baseline health status
• Number of co-morbidities
• Which co-morbidities would predispose your
  patient to heat related emergencies?

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Heat StrokeTreatment Interventions

• Monitor for s/s of rhabdomyolysis
• What is this?
• How would you monitor for this?
• Monitor for s/s disseminated intravascular
  coagulation (DIC)
• What is this?
• How would you monitor for this?

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HypothermiaPathophysiology

• Definition
• Core temperature less than 95F (35C)
• Core temp lt86F - severe hypothermia
• Core temp lt78F - death
• Heat produced by the body cannot compensate for
  cold temps of environment
• 55-60 of all body heat is lost as radiant
  energy
• Head, thorax, lungs
• Dec body temp ? peripheral vasoconstriction ?
  shivering movement ? coma results lt78F

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HypothermiaCauses

• Exposure to cold temperatures
• Inadequate clothing, inexperience
• Physical exhaustion
• Wet clothes in cold temperatures
• Immersion in cold water/near drowning
• Age/current health status predispose
• What health issues would predispose a patient to
  hypothermia?

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HypothermiaManifestations Complications

• Vary dependent upon core temp
• Mild (93.2F - 96.8F)
• Lethargy, confusion, behavior changes, minor HR
  changes, vasoconstriction
• Moderate (86F 93.2F)
• Rigidity, dec HR, dec RR, dec BP, hypovolemia,
  metabolic resp acidosis, profound
  vasoconstriction, rhabdomyolysis
• Shivering usually disappears at 92F
• Profound/(Severe) (lt86F)
• Person appears dead attempt to re-warm to 90F
• Reflexes vitals very slow
• Profound bradycardia, asystole 64.4F, or Vfib
  71.6F

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HypothermiaTreatment Interventions

• Goal
• Rewarming to temp of _____F
• Correction of dehydration acidosis
• Treat cardiac dysrhythmias
• Attainment
• Passive active external rewarming
• Active core rewarming

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Submersion InjuryCauses Incidence

• 8000 submersion injuries
• per year
• 40 children under 5yrs
• Categorized as
• Drowning
• Near drowning
• Immersion syndrome
• Risk factors
• Inability to swim entanglement with objects in
  water
• ETOH or drug use
• Trauma
• Seizures
• Stroke

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Submersion Injury Pathophysiology

• Definition
• Drowning
• Death from suffocation after submersion in water
  or other fluid medium
• Near Drowning
• Survival from potential drowning
• Immersion syndrome
• Immersion in cold water ? stimulation of vagus
  nerve potentially fatal dysrhythmias
  (bradycardia)

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Submersion Injury Pathophysiology

• Death is caused by hypoxia
• secondary to aspiration swallowing of fluid
• Victims that aspirate
• Fluid aspirated into pulmonary tree ? PULMONARY
  EDEMA - HYPOXIA
• Victims that do not aspirate
• Bronchospasm airway obstruction ? dry
  drowning - HYPOXIA

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Submersion Injury

• http//www.youtube.com/watch?vroFGBt8xEisfeature
  relateddrowning

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Poisoning

• 1-800-POISON1
• Treatments
• Activated charcoal, gastric lavage, eye/skin
  irrigation, hemodialysis, hemoperfusion, urine
  alkalinization, chelating agents and antidotes
  acetylcysteine (Mucomyst)
• Contraindicated (charcoal gastric lavage)
• AMS, ileus, diminished bowel sounds, ingestion of
  substance poorly absorbed by charcoal (alkali,
  lithium, cyanide)

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Bites StingsPathophysiolgy

• Direct tissue damage is a product of
• Animal size
• Characteristics of animals teeth
• Strength of jaw
• Toxins released
• Death is due to
• Blood loss
• Allergic reactions
• Lethal toxins

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Bites Stings

• Hymenopteran stings
• Bees, yellow jackets, hornets, wasps, fire ants
• Mild to Anaphylactic
• What are some manifestations of each?
• What interventions would you implement to treat
  these manifestations?
• Treatment
• Remove stinger with scraping motion
• Tweezers why or why not?
• Maintain ABCs
• What meds might you give?

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Bites Stings

• Spider bites
• Black widow
• Venom is neurotoxic to humans
• Symptoms progress over time 15mins 3hrs
• Can cause systemic issues
• Treatment
• Cool area to slow movement of toxins
• Antivenin used in special at risk population
• Brown recluse
• Venom is cytotoxic to humans
• Symptoms progress over 6hrs 2weeks
• Can cause systemic issues
• Treatment
• Clean area, treat pain, antibiotics (why?)
• Surgical debridement with grafting may be
  necessary

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Black Widow
Brown Recluse
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Bites Stings

• Snakebites
• Pit viper, rattlesnakes, copperheads, water
  moccasins, coral snakes
• Pit viper hemolytic, coral neurotoxic
• Can cause systemic reaction
• Necrosis can occur
• Treatment
• IV access, fluids, labs (which ones?), analgesics
  as needed, circumference of site q30mins, tetanus
  prophylaxis
• Ice tourniquets not recommended
• Caffeine, alcohol smoking not recommended
• Remember "red on yellow kill a fellow"

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Question

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

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Question

• As a member of a volunteer disaster medical
  assistance team, the nurse would be expected to
• a. triage casualties of a tornado that hit the
  local community.
• b. assist with implementing the hospitals
  response plan.
• c. train citizens of communities how to respond
  to mass casualty incidents.
• d. deploy to local or other communities with
  disasters to provide medical assistance.

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Cardiopulmonary Resuscitation
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CPR

• http//www.hulu.com/watch/21873/saturday-night-liv
  e-cpr-class

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Case Study

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

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Case Study

• Subjective Data
• Wife states he has been working all week on the
  roof even though he has not felt well the last
  day or two
• Objective Data
• VS T 106 HR 124 and weak and thready RR 36 and
  shallow BP 8240
• Skin hot, dry, and pale

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Case Study continued

• 1. What factors in Mr. Ms history place him at
  risk for heat stroke?
• Advanced age and prolonged exposure to heat over
  several days

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Case Study continued

• 2. What laboratory tests would the nurse
  anticipate to be ordered, and what alterations in
  these tests would be indications of heat stroke?
• ABGsdecreased PaO2
• Electolytesdecreased Na, Cl-, K
• CBChemoconcentration with elevated HH, BUN/Cr,
  Glu
• PT/INRincreased
• LFTelevated
• UAelevated sp. Gr., protein, possible hematuria

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Case Study continued

• 3. How would cooling for Mr. M. be carried out?
• Clothing would be removed, fans, tepid mist, ice
  water bath
• Cold water peritoneal dialysis

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Case Study continued

• 4. What supportive treatment is indicated for Mr.
  M.?
• 100 O2, with intubation and mechanical
  ventilation
• IV crystalloid with CVC or PA catheter
• Cooling methods
• Indwelling catheter, IO
• Thorazine (shivering)

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Case Study continued

• 5. What should Mrs. M. be told about Mr. Ms
  condition?
• Mrs. M. should be told that Mr. M. is very
  seriously ill and that there is a chance he might
  not recover
• High morbidity and mortality rate
• She should be kept informed of the treatment he
  is receiving and his response to treatment
• Emotional support

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Case Study continued

• 6. Based on the assessment data presented, write
  one or more appropriate nursing diagnoses. Are
  there any collaborative problems?
• Hyperthermia r/t environmental exposure
• Decreased CO r/t hypermetabolic process
• Deficient fluid volume r/t fluid loss excessive
  to intake
• Altered protection r/t ams
• Risk for injury r/t seizure activity
• Risk for impaired skin integrity r/t immobility
• Collaborative hypovolemic shock cerebral edema
  seizures hypoxia electrolyte imbalance renal
  failure

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References

• Lewis, S., Heitkemper, M., OBrien, P., Bucher,
  L. (2007). Medical-Surgical Nursin.g Assessment
  of Management of Medical Problems. Mosby
  Elsevier, St. Louis, Missouri.
• Emergency Preparedness and Response. Centers for
  disease control and prevention. Retrieved
  2/21/2011, from http//www.bt.cdc.gov.