Interdisciplinary Roles with Adult Clients in the Emergency/Disaster Environment

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Interdisciplinary Roles with Adult Clients in
the Emergency/Disaster Environment
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Objectives

• Discuss
• Heat Stroke
• Cold Related Emergencies
• Drowning
• Bites/Stings
• Poisoning
• Agents of Terrorism
• Review with regard to each of the said topics
• pathophysiology
• causes
• manifestations potential complications
• treatment interventions
• interdisciplinary management
• Evaluation of Learning
• Case studies

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Heat StrokePathophysiology

• Definition
• Failure of the hypothalamic regulatory process
• Inc. sweating ? vasodilatation ? Inc. RR ? sweat
  glands stop working ? core temp inc.? circulatory
  collapse

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Heat StrokeCauses

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

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Heat StrokeCauses

• 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

• What will your patient look like?

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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

• ABCs must stabilize
• What interventions will you perform initially?
• What do you think the goal of treatment is?
• How would you achieve this goal?
• Would you use antipyretics?

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Heat StrokeTreatment Interventions

• Goal
• Decrease the core temperature
• To what temperature?
• Prevent shivering
• Attainment
• Remove clothes, wet sheets, large fan
  (evaporative), ICE water bath (conductive), cool
  IV fluids

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Heat StrokeTreatment Interventions

• Monitor for s/s of rhabdomyolysis
• Monitor for s/s disseminated intravascular
  coagulation (DIC)

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Heat StrokeInterdisciplinary Roles

• Who would be involved in this clients care?
• RN
• MD (physician's assistant, nurse practitioner)
• RT
• SW

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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

• What are some common causes?

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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

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HypothermiaManifestations Complications

• What will your patient look like?

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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
• What about each system?
• 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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HypothermiaPrognosis

• Dependant upon
• Core body temperature
• Co-morbidities

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HypothermiaTreatment Interventions

• ABCs must stabilize
• What interventions will you perform initially?
• What do you think the goal of treatment is?
• How would you achieve this goal?

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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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HypothermiaTreatment Interventions

• Monitor
• Core temp
• for marked vasodilatation hypotension
• After drop
• Teach
• Warm clothes hats, layers, high calorie foods,
  planning

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HypothermiaInterdisciplinary Management

• Who would be involved in this clients care?
• RN
• MD
• PT/OT
• SW
• CM
• RT

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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 Manifestations Complications

• What will your patient look like?

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Submersion Injury Manifestations Complications

• Dependant upon length of time amount of
  aspirate
• Pulmonary
• Ineffective breathing, dyspnea, distress, arrest,
  crackles rhonchi, pink frothy sputum with
  cough, cyanosis
• Cardiac
• Inc./dec. HR, dysrhythmia, dec. BP, cardiac
  arrest
• Neuro
• Panic, exhaustion, coma

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Submersion Injury Treatment Interventions

• ABCs must stabilize
• What interventions will you perform initially?
• What do you think the goal of treatment is?
• How would you achieve this goal?

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Submersion Injury Treatment Interventions

• Goal
• Correct
• hypoxia
• acid/base balance
• fluid imbalances
• Attainment
• Anticipate intubation
• 100 O2 via non-rebreather
• IV access

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Submersion Injury Interdisciplinary Management

• Who would be involved in this clients care?
• RN
• MD
• RT
• SW
• Chaplain

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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
• Treatment
• Remove stinger with scraping motion
• Tweezers why or why not?
• Maintain ABCs

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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

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Bites StingsTick bites

• Lyme Disease
• (mimics other diseases)
• Caused by
• spirochete borrelia burgdorferi (tick)
• Inflammatory disorder
• 3 stages
• Initial rash (bulls eye)
• Disseminated
• (arthritic like symptoms)
• Late
• (chronic arthritis
• neurologic symptoms)
• Diagnosis
• Culture (difficult)
• Antibody detection
• EM lesion
• ELISA western blot

Treatment antibiotics vibramycin (doxycycline)
amoxicillin NSAID Prevention long, light
colored clothing insect repellant frequently
frequent tick checks
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Bites StingsInterdisciplinary Management

• Who would be involved in this clients care?
• RN
• MD
• RT

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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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Agents of TerrorismTypes

• Bioterrorism
• Anthrax, plague, tularemia, smallpox, botulism,
  Hemorrhagic fever
• Chemical terrorism
• Sarin, phosgene, mustard gases
• Radiological/Nuclear terrorism

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Tularemia
Plague
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Agents of TerrorismTreatment

• Bioterrorism
• Anthrax, Plague ,Tularemia
• Treatment antibiotics (streptomycin or
  gentamicin)
• Smallpox
• Treatment vaccine
• Botulism
• Treatment antitoxin
• Hemorrhagic fever
• Treatment no established treatment
• Provided there is sufficient supply treatment
  occurs in a timely manner!!!!!!!

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Agents of TerrorismTreatments

• Chemical Terrorism
• Sarin gas
• Nerve gas (highly toxic)
• Can cause death within minutes of exposure
  paralyzing respiratory muscles
• Treatment antidote atropine 2-PAM chloride
• Phosgene gas
• Colorless gas
• Can cause respiratory distress, pulmonary edema
  death
• Treatment treat S/S, remove from exposure
• Mustard gas
• Yellow/brown in color , garlic like odor
• Can irritate eyes, burn skin and creates
  blisters, damage lungs if inhaled
• Treatment decontamination, treat symptoms

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Agents of TerrorismTreatments

• Radiologic/Nuclear Terrorism
• Radiologic dispersal devices (RDDs)
• Aka dirty bombs
• Made of explosives radioactive material
• When detonated smoke radioactive dust enter
  air
• Treatment limit contamination (cover mouth
  nose) decontamination (shower, proper disposal
  of clothing)
• Ionizing radiation (nuclear)
• Acute radiation syndrome (ARS)
• External radiation exposure

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BioterrorismInterdisciplinary Management

• Who would be involved in this clients care?
• EVERYONE

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Case Study Mike Jones

• 32 year old male working outside on a
  construction site
• Beehive found at construction site and the man
  was stung several times by an unknown number of
  bees.
• Immediately after stings complaints of
• Pain at sting site
• Generalized malaise lightheadedness, weakness
  nausea

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Case Study M. Jones

• Question
• What are your concerns at this time?
• What questions would you ask?
• What would you suggest the man do?

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Case Study M. Jones

• Co-workers convince man to go to the hospital 5
  miles away they transport him.
• During transport complaints of
• Increased nausea
• Some difficulty breathing
• What would you suggest the coworkers do at this
  time?

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Case Study M. Jones

• Co-workers stop at local convenience store and
  call 9-1-1
• While in the parking lot
• M. Jones becomes unresponsive
• Not breathing
• No pulse
• What should the co-workers do at this time?

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Case Study M. Jones

• There was a severe thunder and lightening storm
  occurring, so the co-workers left the man inside
  the truck thinking the outside conditions would
  be hazardous
• The man found still in the vehicle when EMS
  arrived.

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Case Study M. Jones

• What would you anticipate EMS to do when they
  arrive on the scene? (Prioritize)

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Case Study M. Jones

• EMS interventions
• Assess ABCs
• man was pulseless apenic
• Remove pt from vehicle
• CPR initiated
• Assess cardiac rhythm
• asystole
• Epinephrine Atropine given
• Intubation
• Recheck rhythm
• VFib
• Defibrilliate
• 200J
• CPR continued transported to hospital

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Case Study M. Jones

• What are some things you have to worry about in a
  situation like this, with regard to airway?

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Case Study M. Jones

• In route to hospital Crew noted
• No rash
• No facial or airway swelling
• At facility
• Multiple doses of Epi given
• Palpable carotid pulse developed
• Within 20mins
• BP 100/60
• HR 110
• Epinephrine gtt _at_ 4 micrograms/min

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Case Study M. Jones

• Yea!!!!! They saved him.
• Or did they?
• What other assessments do you want before you
  start celebrating?

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Case Study M. Jones Outcome

• No neurological response after 3 days in ICU
• Decision to discontinue life support
• Family provides history
• What will happen before life support d/cd?
• What happened to this patient (diagnosis)?
• How could it have been prevented?
• What would you do differently?
• Case study found at JEMS.com

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Case Study Sally Smith

• 24 year old, healthy female, driving SUV on sunny
  day in February in Austin TX.
• Air was calm, ambient temperature of 67F
• Loses control of car near a park- car submerges
  into man made pond 6 feet deep
• Witnesses were at the scene
• Water temperature was 42F

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Case Study S. Smith

• Witnesses call 911
• Witness reports reveal
• One witness attempted to enter the water but the
  water was too frigid and he had to turn back
• After 2 minutes in the water, woman was able to
  break the back window of the SUV and escape
• Woman was yelling for help and struggling to swim

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Case Study S. Smith

• EMS and Fire Rescue arrive on the scene
  approximately 15 minutes after women initially
  went in to the water
• 2 firefighters attempted to enter the water but,
  again, were forced to turn back before they were
  able to reach the women
• By the time the rescue team made
• it to the woman, she had been in
• the water for approx 25 minutes
• The woman was face down,
• slightly obtunded, but arousable

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Case Study S. Smith

• At this point, what interventions would you
  complete?
• A. Avoid rough movements
• B. Shake the patient, if necessary, to prevent
  loss
• of consciousness
• C. Rub the patients extremities to keep promote
• rewarming
• D. Cover with blankets
• E. Remove wet garments
• F. Elevate to patients head

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Case Study S. Smith

• Upon arrival to ER approximately 10mins later
• Assessment
• Remained slightly obtunded but arousable
• Complaints thirst, being cold
• Denies chest pain
• Assumptions she may have swallowed a large
  amount of pond water
• Shivering vigorously with occasional coughing
• Initial vitals Core body temp 92.6F pulse
  irregulary irregular, HR 125-145 bpm RR 29, BP
  82/58 O2Sats 86 RA

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Case Study S. Smith

• What level of hypothermia would this patient be
  classified as
• A. Mild
• B. Moderate
• C. Profound

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Case Study S. Smith

• What other assessment information do you want?
• LABS
• Na 144 K 5.0 Cl 102 CO2 15
• Glucose 238 BUN 17 Creat 1.9 Ca 10.2
• Alb 4.7 Liver wnl CBC normal/ex. WBC 25
• ABG pH 7.32 pCO2 50 HCO3 21
• What concerns do you have regarding these labs?
• What is this patients metabolic status?

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Case Study S. Smith

• CXR
• Mixed interstitial and alveolar infiltrates
  bilaterally
• EKG
• Afib
• Which interventions are appropriate at this time?
• A. Observation
• B. Electrical cardioversion
• C. Anticoagulation
• D. Pharmacological cardioversion
• E. Intubation

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Case Study S. SmithOutcome

• Admitted for observation monitoring
• Spontaneously converted to SR 2 days later
• Antibiotics given IV for 2 days then started on
  PO course
• Acidosis resolved, CXR improving over 2 days
• Uneventful stay --- LUCKY!!!!
• What were your primacy concerns for this patient?

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Case Study Johnny Williams

• 5 year old boy, 48 lbs, camping with family at
  Inks Lake
• Unaccounted for for about 15 mins while on a
  nature hike
• Body found floating in lake, face down
• Immediately pulled from water and CPR started

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Case Study J. Williams

• You are a nurse in the ED where Johnny will be
  arriving. What would you do to prepare for
  arrival?

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Case Study J. Williams

• On arrival to ED
• Assessment
• Cyanotic
• Pulseless
• Apneic
• Fixed and dilated pupils
• Core body temp 89F
• CPR continued
• With this information, what will you anticipate?

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Case Study J. Williams

• After airway established and other assessments
  complete, rewarming begins.
• How would you rewarm this patient?
• What do we worry about with regard to CPR,
  hypothermia, and cardiac dysrhythmias?
• What do you have to watch for during the
  rewarming process?

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Case Study J. Williams

• 20 mins after intubation/mechanical ventilation,
• spontaneous HR returns
• adequate BP of 103/65
• core temp of 95F
• What happens next?

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Case Study J. WilliamsOutcome

• 5 days in PICU ventilated
• Eventually weaned off of ventilator
• 5 more days on medical unit
• Recovery anticipated, with deficits

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Case Study Extra InfoChildrens Health
Encyclopedia

• 0-4 years old --- pools implicated in 60-90 of
  drowning
• also bathtubs
• Teen boys --- natural bodies of water
• Roughly 4 out of 5 drowning victims are male
• Death or permanent neurological damage is very
  likely when patients arrive at the emergency room
  comatose or without a heartbeat.
• Of these patients, 35 to 60 percent die in the
  emergency department
• Almost all of those who survive have permanent
  disabilities.
• Early rescue of near-drowning victims (within
  five minutes of submersion) and prompt CPR
  (within less than ten minutes of submersion) seem
  to be the best guarantees of a complete recovery
• Extremely cold water (less than 41F or 5C)
  seems to protect individuals from some of the
  neurological damage that occurs with near
  drowning. Some hypothermic near-drowning victims
  have been revived after they appeared dead and
  have experienced few permanent disabilities.