Interdisciplinary Roles with Adult Clients in the Emergency/Disaster Environment

1. Interdisciplinary Roles with Adult Clients in the Emergency/Disaster Environment Slides by Kelle Howard. Narrated by Leigh Anne Wilmot

2. 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

3. 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?

4. Heat Stroke:Causes • Development is directly related to • Amount of time the body temperature is elevated • What are some common causes?

5. 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

6. Heat Stroke:Manifestations & Complications • What will your patient look like?

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

8. 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?

9. 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?

10. 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

11. Heat Stroke:Treatment & Interventions • Monitor for s/s of rhabdomyolysis • Monitor for s/s disseminated intravascular coagulation (DIC)

12. Heat Stroke:Interdisciplinary Roles • Who would be involved in this client’s care? • RN • MD (physician's assistant, nurse practitioner) • RT • SW

13. 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

14. Hypothermia:Causes • What are some common causes?

15. 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?

16. Hypothermia:Manifestations & Complications • What will your patient look like?

17. 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?

18. Hypothermia:Prognosis • Dependant upon • Core body temperature • Co-morbidities

19. 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?

20. 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

21. Hypothermia:Treatment & Interventions • Monitor • Core temp • for marked vasodilatation & hypotension • After drop • Teach • Warm clothes & hats, layers, high calorie foods, planning

23. Hypothermia:Interdisciplinary Management • Who would be involved in this client’s care? • RN • MD • PT/OT • SW • CM • RT

25. 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

26. 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)

27. 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

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

29. 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

30. 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?

31. Drowning:Treatment & Interventions • Goal: • Correct • hypoxia • acid/base balance • fluid imbalances • Attainment: • Anticipate intubation • 100% O2 via non-rebreather • IV access

32. Drowning:Interdisciplinary Management • Who would be involved in this client’s care? • RN • MD • RT • SW • Chaplain

33. 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

34. 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

36. 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

37. Black Widow Brown Recluse

38. 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

40. 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

41. Bites & Stings:Interdisciplinary Management • Who would be involved in this client’s care? • RN • MD • RT

42. 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)

43. Bioterrorism

44. Agents of Terrorism:Types • Bioterrorism • Anthrax, plague, tularemia, smallpox, botulism, Hemorrhagic fever • Chemical terrorism • Sarin, phosgene, mustard gases • Radiological/Nuclear terrorism

45. 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!!!!!!!

46. 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

47. 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

48. Bioterrorism:Interdisciplinary Management • Who would be involved in this client’s care? • EVERYONE

49. 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

50. Case Study: M. Jones • Question: • What are your concerns at this time? • What questions would you ask? • What would you suggest the man do?