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Flashcards in Emergency, Terrorism, and Disaster Nursing Deck (68):
1

Triage assessment questions

Is the patient dying?
Is this a patient who should not wait to be seen?
Put these patients ESI 1 or 2
Normal VS for ESI 3 or below;

2

Primary survey "A"

ABCDE
Airway: with Cspine stabilization or immobilization
-seizures, near-drowning, anaphylaxis, foreign body obstruction, or cardiopulmonary arrest; open airway using jaw-thrust maneuver->suction->insert airway-->intubate. Vent pt using 100% oxygen before intubation

3

rapid sequence intubation

is the preferred prpcedure for securing an unprotected airway in the ED. It involves the use of sedation (midazolam [Versed]) or anesthesia (etomidate [Amidate]) and paralysis (succinylcholine [Anectine]) apply cricoid pressure

4

Airway Emergency Assessment and Interventions

clear and open airway
assess for obstructed airway
assess for respiratory distress
check for loose teeth or foreign objects
assess for bleeding, vomitus, or edema

suction
jaw thrust maneuver
artificial airway
c spine immobilization

5

Primary Survey "B"

fractured ribs, pneumothorax, penetrating injury, allergic reactions, pulmonary emboli, and asthma attacks. Watch for dyspnea (PE), paradoxic or asymmetric chest wall mvmt (flail chest), decreased or absent breath sounds on the affected side (pneumothorax), visible wound to chest wall (penetrating injury), cyanosis (asthma), tachycardia and hypotension

6

Breathing Assessment and Interventions

Assess ventilation
look for paradoxic mvmt of chest wall
note use of accessory muscles
listen for air bein expired through nose and mouth
feel for air being expelled
observe and count RR
note color of nail beds, MM, skin
auscultate lungs
assess JVD and position of trachea

Give O2 (often 100% via non-rebreather)
vent with bag-valve-mask with 100% o2 if respirations are inadequate or absent.
prepare to intubate if respiratory arrest
have suction available
if absent breath sounds, prepare for needle thoracostomy and chest tube insertion

7

What do you do as an ED nurse if breath sounds are absent?

think about mechanically venting, or preparing for needle thoracostomy and chest tube insertion

8

Primary Survey "C"

Circulation: Heart, intact blood vessels and adequate blood volume. ** Altered Mental Status and delayed cap refill (>3sec) are the most significant signs of circulatory shock.

9

Circulation Assessment and Interventions

check carotid and femoral pulse
palpate pulse for quality and rate
assess color, temp, and moisture of skin
check cap refill
assess for external bleeding
measure BP

if no pulse, initiate CPR
If shock symptoms or if pt is hypotensive, start two large-bore (14-16 gauge) IVs and initiate infusions of NS or LR
Control bleedings with direct pressure and sterile dressing
administer PRBC's (warmed if rapid infusion, and don't forget to replenish clotting factors too!)
consider use of a pneumatic antishock garment or pelvic splint in the presence of pelvic fracture with hypotension.
Obtain blood samples for type and crossmatch

10

Primary Survey "D"

DIsability: conduct a brief neuro exam--> pt's LOC determines the degree of disability. GCS
assess pupils for size, shape, equality, and reactivity.
Inspect extremities for any obvious deformities and splint them if found.
Assess pain (PQRST)

11

Primary Survey "E"

Exposure/Environmental Control
Remove all trauma patient's clothing to preform a thorough physical assessment. Once the patient is exposed, it is important to limit heat loss, prevent hypothermia, and maintain privacy by using warming blankets, overhead warmers, and warmed IV fluids

12

Life Threatening Conditions Identified During Primary Survey related to AIRWAY

inhalation injury
obstruction (partial or complete) from foreign bodies, vomitus, or tongue
penetrating wounds and/or trauma to upper airway structures

13

Life Threatening Conditions Identified During Primary Survey related to BREATHING

anaphylaxis
flail chest with pulmonary contusion
hemothorax
pneumothorax

14

Life Threatening Conditions Identified During Primary Survey related to CIRCULATION

MI
pericardial tamponade
shock (massive burns, hypovolemia)
uncontrolled external hemorrhage
hypothermia

15

Life Threatening Conditions Identified During Primary Survey related to DISABILITY

head injury
stroke

16

Secondary survey

the secondary survey begins after addressing each step of the primary survey and initiating any lifesaving interventions. The secondary survey is a brief, systematic process that aims to id ALL injuries.

17

Secondary Survey Steps: "FFFGHI"

Full set of VS
Focused Adjuncts
Facilitate family presence
Give comfort measures
History and Head to toe Assessment
Inspect posterior surfaces

18

What are the actions to take during the Focused Adjuncts aspect of the secondary survey?

determine HR and rhythm.
Initiate ECG, O2 sat, and end-tidal CO2 monitoring
foley
gastric tube
obtain blood for labs
arrange for diagnostic studies
provide tetanus prophylaxis

19

What is the mnemonic to use during the History and Head to Toe assessment aspect of the secondary survey?

AMPLE
Allergies, Med Hx, Past Health HX, Last Meal, and Events/Environment preceding illness or injury

20

Post-cardiac arrest hypothermia

Therapeutic hypothermia for 24 hours following resuscitation improves mortality and neurologic outcomes in many patients. It should be considered for all patients who are comatose or who do not follow commands after resuscitation.

21

Therapeutic hypothermia

three phases: induction, maintenance, and rewarming

22

Induction phase of therapeutic hypothermia

goal core temp is 89.6-93.2. Achieve this through infusion of cold NS and cooling devices (Arctic Sun, Blanketrol). Patients require invasive monitoring (arterial and central pressures) and continuous assessment while receiving this therapy.

23

non-heart-beating donation

corneas, heart valves, skin, bone, and kidneys can be harvested from patients after death.

24

So you are cooling a person with heat stroke and they start to shiver. What do you do?

Administer Chlorapromazine (Thorazine) IV. Shivering increases core temp due to associated heated generated by muscle activity, so you should stop the shivering with meds. Antipyretics are not appropriate in this situation because the elevated temp is not due to infection.

Monitor for rhabdomyolysis (the muscle breakdown leads to myoglobinuria which places the kidneys at risk of acute failiure). Watch for tea-colored urine.

25

What happens physiologically if a person is hypothermic?

As core temp drops, BMR decreases two or three times. The cold myocardium is irritable and vulnerable to dysrhythmias. Decreased renal blood flow decreases GFR, which reduces water reabsorption, leading to dehydration. Hct increases as vascular volume decreases-cold, thick blood forms thrombuses-->risk for stroke, MI, PE, renal emboli

Shivering stops at core temps below 86. BMR, HR, and RR may be so slow that they are difficult to detect. reflexes are absent and pupils are fixed and dilated. The cause of death is typically refractory vfib.

26

Interventions for hypothermia

remove pt from cold environment
manage and maintain ABC's
Provide high flow O2 via non-rebreather mask or BVM
rewarm patient (warming blanket, warm iv fluids, heated, humidified O2, warmed lavage)
**Warm central trunk first to limit rewarming shock

27

Immersion syndrome

occurs with immersion in cold water. This leads to stimulation of the vagus nerve and potentially fatal dysrhythmias (bradycardia and cardiac arrest)

28

What happens if a patient aspirates freshwater?

freshwater is typically hypotonic, and is rapidly absorbed into the circulatory system through the alveoli. Freshwater is often contaminated with chlorine, mud, and/or algae. This causes breakdown of lung surfactant, fluid seepage, and pulmonary edema. Body tries to compensate by shunting blood to the lungs. This only increases pressure in the lungs and further deteriorates respiratory status as the blood cannot be properly oxygenated and hypoxemia worsens-->ARDS

29

What happens if a patient aspirates saltwater?

Salt water is hypertonic. The hypertonic salt water draws fluid from the vascular space into the alveoli, impairing alveolar ventilation and resulting in hypoxia. This causes pulmonary edema. Body tries to compensate by shunting blood to the lungs. This only increases pressure in the lungs and further deteriorates respiratory status as the blood cannot be properly oxygenated and hypoxemia worsens-->ARDS

30

Secondary drowning

refers to delayed death from drowning due to pulmonary complications. Consequently, all near-drowning victims are observed in a hospital setting for a minimum of 23 hours.

31

Stings

remove the stinger using a scraping motion with a fingernail, knife, or needle--DONT use tweezers as they may squeeze the stinger and release more venom

32

flu like symptoms and a bulls eye rash

think Lyme disease and anticipate doxycycline as tx; later stages of Lyme disease are treated with Rocephin

33

a pink, macular rash on the palms, wrists, soles, feet, and ankles within 10 days of exposure; fever, chills, malaise, myalgies, and HA.

Rocky Mountain Spotted Fever
Tx doxycycline

34

flaccid ascending paralysis which develops over 1-2 days

tick paralysis; without tick removal, pt will die when respiratory muscles become paralyzed. Once the tick is removed, return of muscle movement occurs with 48-72 hours

35

What is gastric lavage

Gastric lavage involves oral insertion of a large-diameter (36-42F) gastric tube for irrigation of copious amounts of saline. Elevate the HOB or place pt on the side to prevent aspiration. Patients with an altered LOC or diminished gag reflex are intubated prior to gastric lavage. Patients who ingest caustic agents, co-ingest sharp objects, and ingest nontoxic substances should not receive gastric lavage. Perform gastric lavage within one hour of ingestion of most poisons to be effective. Problems associated with lavage include esophageal perforation and aspiration.

36

How does activated charcoal function to help a poisoned patient?

Administration of activated charcoal orally or via a gastric tube within one hour of poison ingestion is helpful bc toxins will bind to charcoal and pass through the GI tract rather than be absorbed into the circulation. Activated charcoal does NOT absorb ethanol, hydrocarbons, alkali, iron, boric acid, lithium, methanol, or cyanide. Adults receive 50-100g of charcoal. Contraindications to charcoal: diminished bowel sounds, ileus, and ingestion of substance poorly absorbed by charcoal. Charcoal may absorb and neutralize antidotes-space out administration.

37

malaise, diaphoreses, N/V, RUQ pain, hypoglycemia, increased LFTs

tylenol poisoning: activated charcoal or N-acetylcysteine [Mucomyst]

38

excess salivation, dysphagia, epigastric pain, burns of mouth, esophagus, and stomach

acids and alkalis: immediate dilution with water or milk; corticosteriods for alkali burns

39

tachypnea, tachycardia, hyperthermia, seizures, pulmonary edema, occult bleeding/hemorrhage, metabolic acidosis

aspirin poisoning: activated charcoal, gastric lavage, urine alkalinization, hemodialysis for severe acute ingestion, intubation and mechanical vent, supportive care

40

irritation of lips, mouth, and eyes, superficial injury to esophagus, chemical pneumonia and pulmonary edema

bleach poisoning: wash exposed skin and eyes; dilute with water or milk, gastric lavage, prevention of vomiting and aspiration

41

dyspnea, HA, tachypnea, confusion, impaired judgement, cyanosis, respiratory depression

carbon monoxide poisoning: remove from source, administer 100% O2 via non-rebreather, BVM, or intubation and mechanical vent. consider hyperbaric oxygen therapy

42

almond odor to breath, HA, dizzy, nausea, confusion, hypertension, bradycardia followed by hypotension and tachycardia, tachypnea followed by bradypnea and respiratory arrest

cyanide poisoning: amyl nitrate (nasally), IV sodium nitrate, IV sodium thiosulfate, supportive care

43

sweet aromatic odor to breath, n/v, slurred speech, ataxia, lethargy, respiratory depression

ethylene glycol: activated charcoal, gastric lavage, supportive care

44

bloody vomit, bloody diarrhea, fever, hyperglycemia, lethargy, hypotension, seizures, coma

iron poisoning: gastric lavage, chelation therapy [Desferal]

45

sorbitol

cathartic often given with activated charcoal in the event of a poisoning and acts to stimulate intestinal motility and increase elimination

46

What is added to IV fluids to enhance excretion of amphetamines and quinidine?

Vit C

47

What poisoning event is sodium bicarb benefical?

sodim bicarb raises pH which is helpful for phenobarbital and salicylate poisonings

48

Which bioligical agents of terrorism can be treated with antibiotics?

anthrax, plague, and tularemia

49

The placement of a nasogastric tube is contraindicated during emergency care when the patient has a possible
a. inhalation injury
b. head or facial trauma
c. intraabdominal bleed
d. ceervical spine fracture

B. head or facial trauma as the NG tube may enter the brain!

50

no established treatment for most forms

hemorrhagic fever

51

the septicemic form is most lethcal

plague

52

toxins cause hemorrhage and destruction of lung tissue (inhaled form)

Anthrax

53

neurotoxins that cause paralysis and respiratory failure

botulism

54

spread by flea bites

plague

55

hemorrhage of tissues with organ failure

hemorrhagic fever

56

lesions are pustular vesicles

smallpox

57

skin lesions are most common form

anthrax

58

primarily an infection of rabbits

tularemia

59

disease was eradicated in 1980

smallpox

60

death may occur within 24 hours of exposure

botulism

61

A victim of a sublethal dose (

b. nausea and vomiting
Ionizing radiation exposure in a sublethal dose will cause nausea and vomiting within 2-4 hours of exposure, hair loss in 2 days to 2 weeks, and coagulopathies in 2 days to 2 weeks.

62

What treatment should a nurse anticipate if a worker is exposed to anthrax?

cipro: antibiotics are effective to prevent systemic manifestations if treatment is begun early. Cipro is the treatment of choice for anthrax. Typically a 2 month antibiotic regimen

63

How to do treat Botulism?

induce vomiting and administer antitoxin

64

how do you treat hemorrhagic fever

isolation to prevent spread of virus

65

how do you treat smallpox?

vaccinia immune globulin (VIG) is used for smallpox

66

how do you treat frostbite?

immersion of extremities in water bath (102-108 degrees)

67

what is active core rewarming?

administration of warmed IV fluids for moderate to severe hypothermia.

68

when do you use passive of active external rewarming techniques?

mild hypothermia (warming blanket or radiant heat lamps)