Interdisciplinary Roles with Adult Clients in the Emergency/Disaster Environment

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

Heat Stroke:Pathophysiology•Definition

▫Failure of the hypothalamic regulatory process

▫Inc. sweating vasodilatation Inc. RR sweat glands stop working core temp inc. circulatory collapse

What makes this temperature so dangerous?What happens to electrolytes? Which ones do you worry about?What are some signs/symptoms of these altered lytes?

Heat Stroke:Causes•Development is directly related to

▫Amount of time the body temperature is elevated

▫What are some common causes?

Heat Stroke:Causes•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

Heat Stroke:Manifestations & Complications

•What will your patient look like?

Heat Stroke:Manifestations & Complications•Core temp > 104˚F•AMS•No perspiration•Skin hot, ashen, dry•Dec. BP•Inc. HR

• S/S of what?

Heat Stroke:Prognosis•Related to:

▫Age▫Length of exposure▫Baseline health status▫Number of co-morbidities

Which co-morbidities would predispose your patient to heat related emergencies?

Heat Stroke:Treatment & Interventions•ABC’s – 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?

Heat Stroke:Treatment & Interventions•Goal:

▫Decrease the core temperature To what temperature?

▫Prevent shivering Why? How?

•Attainment:▫Remove clothes, wet sheets, large fan

(evaporative), ICE water bath (conductive), cool IV fluids

Heat Stroke:Treatment & Interventions•Monitor for s/s of rhabdomyolysis

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

Heat Stroke:Interdisciplinary Roles•Who would be involved in this client’s

care?▫RN▫MD (physician's assistant, nurse

practitioner)▫RT▫SW

Hypothermia:Pathophysiology

•Definition▫Core temperature less than 95˚F (35˚C)

Core temp <86˚F - severe hypothermia Core temp <78˚F - 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 <78˚F

Hypothermia:Causes

•What are some common causes?

Hypothermia:Causes•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?

Hypothermia:Manifestations & Complications

•What will your patient look like?

Hypothermia:Manifestations & Complications• Vary dependent upon core temp

▫ Mild (93.2˚F - 96.8˚F) Lethargy, confusion, behavior changes, minor HR

changes, vasoconstriction▫ Moderate (86˚F – 93.2˚F)

Rigidity, dec HR, dec RR, dec BP, hypovolemia, metabolic & resp acidosis, profound vasoconstriction, rhabdomyolysis

Shivering usually disappears at 92˚F **What about each system?

▫ Profound/(Severe) (<86˚F) Person appears dead – attempt to re-warm to 90˚F Reflexes & vitals very slow Profound bradycardia, asystole 64.4˚F, or Vfib 71.6˚F

– usual cause of death?

Hypothermia:Prognosis•Dependant upon

▫Core body temperature▫Co-morbidities

Hypothermia:Treatment & Interventions•ABC’s – must stabilize

▫What interventions will you perform initially?

•What do you think the goal of treatment is?

•How would you achieve this goal?

Hypothermia:Treatment & Interventions•Goal:

▫Rewarming to temp of _____˚F▫Correction of dehydration & acidosis▫Treat cardiac dysrhythmias

•Attainment:▫Passive & active external rewarming

What are some examples?▫Active core rewarming

Hypothermia:Treatment & Interventions•Monitor

▫Core temp▫for marked vasodilatation & hypotension▫After drop

•Teach▫Warm clothes & hats, layers, high calorie

foods, planning

Hypothermia:Interdisciplinary Management•Who would be involved in this client’s

care?▫RN▫MD▫PT/OT▫SW▫CM▫RT

Submersion Injury:Causes & 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

Submersion Injury :Pathophysiology•Definition

▫Drowning Death from suffocation after submersion in

water or other fluid medium▫Near Drowning

Survival from potential drowning▫Immersions syndrome

Immersion in cold water stimulation of vagus nerve & potentially fatal dysrhythmias (bradycardia)

Drowning:Pathophysiology• Death is caused by hypoxia

secondary to aspiration & swallowing of fluid• Victims that aspirate

▫Fluid aspirated into pulmonary tree PULMONARY EDEMA

• Victims that do not aspirate▫Bronchospasm & airway obstruction “dry

drowning” - HYPOXIA

Drowning:Manifestations & Complications•What will your patient look like?

Drowning: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

Drowning:Treatment & Interventions•ABC’s – must stabilize

▫What interventions will you perform initially?

•What do you think the goal of treatment is?

•How would you achieve this goal?

Drowning:Treatment & Interventions•Goal:

▫Correct hypoxia acid/base balance fluid imbalances

•Attainment:▫Anticipate intubation▫100% O2 via non-rebreather▫IV access

Drowning:Interdisciplinary Management•Who would be involved in this client’s

care?▫RN▫MD▫RT▫SW▫Chaplain

Bites & Stings:Pathophysiolgy•Direct tissue damage is a product of

▫Animal size▫Characteristics of animal’s teeth▫Strength of jaw▫Toxins released

•Death is due to ▫Blood loss▫Allergic reactions▫Lethal toxins

Bites & Stings•Hymenopteran stings

▫Bees, yellow jackets, hornets, wasps, fire ants

▫Mild to Anaphylactic What are some manifestations of each?

▫Treatment: Remove stinger with scraping motion Tweezers – why or why not? Maintain ABCs

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

Black Widow

Brown Recluse

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

Bites & StingsTick bites

• Lyme Disease (mimics other diseases)

▫ Caused by spirochete borrelia

burgdorferi (tick)▫ Inflammatory disorder▫ 3 stages

Initial rash (bull’s 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

Bites & Stings:Interdisciplinary Management•Who would be involved in this client’s

care?▫RN▫MD▫RT

Poisoning:1-800-POISON1 Treatments:

Activated charcoal, gastric lavage, eye/skin irrigation, hemodialysis, hemoperfusion, urine alkalinization, chelating agents and antidotes – acetylcysteine (Mucomyst)

Contraindicated: AMS, ileus, diminished bowel sounds,

ingestion of substance poorly absorbed by charcoal (alkali, lithium, cyanide)

Agents of Terrorism:Types•Bioterrorism

▫Anthrax, plague, tularemia, smallpox, botulism, Hemorrhagic fever

•Chemical terrorism▫Sarin, phosgene, mustard gases

•Radiological/Nuclear terrorism

Tularemia

Plague

Agents of Terrorism:Treatment

•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!!!!!!!

Agents of Terrorism:Treatments •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

Agents of Terrorism:Treatments

•Radiologic/Nuclear Terrorism▫Radiologic dispersal devices (RDD’s)

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

Bioterrorism:Interdisciplinary Management•Who would be involved in this client’s

care?▫EVERYONE

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

Case Study: M. Jones •Question:

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

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?

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?

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.

Case Study: M. Jones •What would you anticipate EMS to do

when they arrive on the scene? (Prioritize)

Case Study: M. Jones •EMS interventions:

▫ Assess ABC’s 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

Case Study: M. Jones •What are some things you have to worry

about in a situation like this, with regard to airway?

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 @ 4 micrograms/min

Case Study: M. Jones •Yea!!!!! They saved him.

•Or did they?

•What other assessments do you want before you start celebrating?

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

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

67˚F•Loses control of car near a park- car

submerges into man made pond – 6 feet deep

•Witnesses were at the scene•Water temperature was 42˚F

Case Study: S. Smith•Witnesses call 911•Witness reports reveal

▫One witness attempted to enter the water but the water was too fridged 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 stuggleling to swim

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 women, she had been in the water for approx 25 minutes• The woman was face down, obtunded, but arousable

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

Case Study: S. Smith•Upon arrival to ER – approximately 10mins later

▫Assessment: Remained obtunded but arousable Complaints: thirst, being cold, and reported that she

may have swallowed a large amount of pond water Denies: chest pain, SOB Shivering vigorously with occasional coughing Initial vitals: Core body temp 86.5˚F ; pulse

irregulary irregular, HR 125-175 bpm; RR 29, BP 155/108; O2Sats 94% RA

Case Study: S. Smith•What level of hypothermia would this

patient be classified as:▫A. Mild▫B. Moderate▫C. Profound

Case Study: S. Smith•What other assessment information do you

want?

•LABS:▫Na 144 K 3.5 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 7.35 pCO2 50 HCO3 21What concerns do you have regarding these labs?What is this patient’s metabolic status?

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

Case Study: S. SmithOutcome•Admitted for observation•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?

Case Study: Johnny Williams •5 year old boy, 48 lbs, camping with

family at Inks Lake•Unaccounted for about 15 mins while on a

nature hike•Body found floating in lake, face down•Immediately pulled from water and CPR

started

Case Study: J. Williams You are a nurse in the ED where Johnny

will be arriving. What would you do to prepare for arrival?

Case Study: J. Williams•On arrival to ED

▫Assessment Cyanotic Pulseless Apneic Fixed and dilated pupils Core body temp 89˚F CPR continued

With this information, what will you anticipate?

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?

Case Study: J. Williams•20 mins after intubation/mechanical

ventilation,▫spontaneous HR returns▫adequate BP of 103/65▫core temp of 95˚F

▫What happens next?

Case Study: J. WilliamsOutcome•5 days in PICU – ventilated•Eventually weaned off of ventilator•5 more days on medical unit•Full recovery anticipated

Case Study: Extra InfoChildren’s 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 41°F or 5°C) 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.