Lab: emergency nursing

TB transmission

airborne

• needs N95, negative pressure room

covid and flu transmission

• droplet and contact

anthrax transmission and precautions

• airborne, contact, ingestion

• standard precautions and decontamination (shower)

ebola transmission

• blood and body fluids

• contact precautions , full PPE

zika and west nile transmission and precaution

• mosquito bite

• west nile also transfusion

• standard precautions

ED triage

• sorts by ?

• most critically ill?

• Sorts patients by severity and urgency

• Most critically ill get the most resources, regardless of outcome

• An advanced skill learned in the ED

• Triage nurse also monitors the waiting room

disatser triage

• Used when casualties exceed resources

• Scarce resources go where they save the most people, heavily based out outcome (will they survive or not?)

• Uses color tags: Red, Yellow, Green, Black

ESI 1

• Needs immediate life-saving intervention

• ex: Cardiac or respiratory arrest, overdose with RR 6
  

ESI 2

• High risk, confused or in severe pain; will deteriorate

• Chest pain suspicious for ACS (heart attack), suicidal patient

ESI 3

• Stable, needs 2 or more resources

• Abdominal pain, dislocated shoulder
  ESI 3 Urgent Stable, needs 2 or more resources

ESI 4

• Stable, needs 1 resource

• Ankle injury, sore throat, simple laceration

ESI 5

• Stable, needs no resources

• Prescription refill, suture removal

Primary Survey

• after ABCDE

• Airway - ensure patency, intubate if needed, protect cervical spine

• Breathing - oxygen, look for flail chest or pneumothorax, ABGs

• Circulation - control bleeding, prevent shock, check pulses and color, keep warm

• Disability - Nuero - Glasgow Coma scale

• Exposure - undress fully look for hidden injuries, bleeding or deformity

• then full assessment, diagnostic test, and transfer to OR, ICU, or other unit

Glasgow coma scale

focused assessment - what do we ask

• S - signs and symptoms, when did they start, any LOC

• allergies

• medications - OTC and recreational included

• Past Hx - medical, surgical, smoking, LMP

• Last meal - time and what it was

• Event that led up to this & when was it

managing airway obstruction

• foreign body ?

• peds?

• when do we suction, or intubate

• give ?

• how does hypoxia lead to injury and how long does it take

• remove if foreign body

• peds - do not sweep unless you see the obstruction

• suction if vomit, blood, secretions are obstructing

• intubate for edema or swelling

• give oxygen or rescue breaths with a bag-valve mask

• Hypoxia → hypercapnia → arrest → brain injury or death in 3–5 min

managing hemorrhage and fluid replacement

• if we suspect internal bleeding

• other s/s

• replacement ? temp consideration?

• place?

• internal bleeding ? monitor for tachycardia, hypotension, thirst

• cool, clammy skin & anxiety

• slow cap refilll

• replace fluid → type and cross or O-, use a blood warmer for multiple units

• cold blood leads to clotting and uric acid buildup

• place a foley to track output

managing multiple traumas

• what order do we treat

• ABCs, then head and neck injury, then other injuries, then splint and reassess

• document very wound , mechanism and times

• preserve evidence , all trauma deaths go to medical examiner

intra abdominal injuries

• immobilize ?

• any protruding viscera?

• prophylaxis ?

• ABCs, immobilize cervical spine

• cover any protruding viscera with moist sterile dressing

• keep NPO - rapid transport to Surgery if needed

• NG tube to decompress

• teatanus and antibiotic prophylaxis

Heat stroke

• temp?

• skin?

• nuero?

• vitals?

• who’s at risk

• Failure of heat regulation; core temp above 39.2 °C (102.5 °F)

• Hot, dry skin (no sweating)

• Confusion, delirium, seizure or coma

• Tachycardia, tachypnea, hypotension

• At risk: elderly, very young, chronically ill, certain medications

managing heat stroke

• priority ?

• cool to what temp?

• methods ?

• monitor ? watch for ?

• Circulation priority , then airway and breathing

• Cool rapidly to 39 °C (102 °F)

• Cool sheets, ice to neck, groin, axillae; cooling blanket; cold- water immersion

• IV fluids; monitor temp, ECG, LOC, urine output

• Watch for rebound hyperthermia and overcooling

  
  

Hypothermia

• temp?

• priority ?

• active vs passive rewarming

• what can cold blood cause

• core temp 35 C or 95 F or less

• Circulation priority , then airway and breathing

• Active core rewarming: warm IV fluids, warm humidified O2, lavage, bypass

• Passive rewarming: warm blankets, overhead heaters

• Cold, acidotic blood from limbs can cause dysrhythmias

Frostbite - frozen tissue

• skin?

• during rewarming?

• water must be ?

• what can we give

• do not ?

• Hard, cold, white or mottled, numb skin

• Red and painful during rewarming

• Rapid rewarming in a 37–40 °C (98.6–104 °F) bath, 30–40 min

• water must be circulated and changed to keep warm

• Give analgesics

• do not massage and Do not walk on frozen feet - can cause cell death & necrosis

Poisoning

• use activated charcoal if the agent binds → causes vomiting

• gastric lavage only in select cases

• do not induce vomiting for caustics or petroleum products

• dialysis or diuresis for some agents

carbon monoxide poisoning

• Co binds to ?

• pulse ox? skin color?

• nuero?

• tx?

• unintentional vs intentional

• CO binds hemoglobin as carboxyhemoglobin, which carries no oxygen

• pulse ox looks normal - not reliable

• CNS signs dominate: headache, dizziness, confusion

• Skin color and pulse oximetry are NOT reliable

• Move to fresh air; loosen clothing; CPR as needed

• 100% oxygen or hyperbaric oxygen until carboxyhemoglobin below 5%

• Unintentional: report to health department. Intentional: psychiatric
  evaluation and law enforcement
  
  

chemical burns

• identify and protect?

• wet vs dry?

• recheck when ?

• Protect staff; identify the substance

• Wet chemical: flush immediately with running water, Prolonged, generous flushing

• Dry chemical (lye, white phosphorus): brush off first, then flush

• Recheck at 24 h, 72 h and 7 days

food poisoning

• what can paralyze breathing

• treat and control ?

• ABCs and supportive care

• Botulism or fish poisoning can paralyze breathing

• Treat fluid and electrolyte loss

• Control nausea and vomiting

• extra caution in pediatrics
  • Clear liquids, then advance diet

Acute alcohol or drug intoxication

• priority?

• rule out

• approach?

• 
  

• Protect the airway; watch for CNS depression and hypotension

• Rule out other causes before assuming intoxication

• Calm, nonjudgmental approach

• Restraint or sedation only with caution

• Check for withdrawal, injuries, other disorders

Sexual Assault

• ESI level?

• goals ?

• how do we preserve evidence

• expect?

• how do we handle evidence

• ESI 1 - See the patient immediately and follow written protocol

• Goals: support, reduce trauma, preserve evidence

• swab all surfaces , preserve clothes, pt cannot shower or be given meds before evidence is taken

• Expect rape trauma syndrome reactions

• evidence must follow chain of custody - held in locked refrigerator until given to PO (need badge #, name of PO, date, time)

Animal and Human Bites

• dog, cat, human ?

• all bites must be ?

• prophylaxis ?

• Dog bites are 80–90% of animal bites

• Cat bites: high infection risk (Pasteurella)

• Human bites: often linked to assault; high infection risk

• Report all animal bites to public health

• Animal can't be found or vaccination unverified start rabies→prophylaxis

• pt must come back at specific times for sequnce of vaccines

• documented and sent to DOH wether pt comes back or not

disaster

• types

• biggest obstacle

Sudden event that disrupts a community and exceeds its ability to
cope

• natural and made

• Loss of communication, clean water and power is often the biggest obstacle

Mass casualty incident (MCI)

Number of casualties exceeds available resources

Weapons of mass destruction

Weapons that cause widespread death and destruction

• • Explosive (blast) devices
  • Biological agents
  • Chemical agents
  • Radiological agents

Terrorism

Unlawful, systematic violence or threats used to coerce or intimidate

Decontamination

Removing or neutralizing contaminants on people, patients and
equipment

4 phases of emergency management

1. mitigation - prevent or reduce the cause and impact

2. preparedness - plan , train, educator for events that cant be prevented

3. response - immediate aftermath, normal operations stop

4. recovery - restore services with regular operations

requirements of Hospital Emergency Operations Plan

• required by and how often

• Required by The Joint Commission and CMS

• Drilled twice a year

• Linked with local, state, federal and private resources

black tags

• unlikely to survive even w treatment

• comfort care

red tags

• life threatening but survival with immediate tx

yellow tags

• serous but stable

• can wait a few hours

green tags

• minor injuries

• can wait hours to days

if pt is not breathing

• reposition airway

• still not breathing - black tag

• starts breathing - red tag, immediate tx

if pt RR is above or below 30

• cap refill?

• above - red tag, immediate tx

• under 30 - check cap refill

• if cap refill is less than 2 seconds assess mental status

• if cap refill ia longer than 2 seconds - control bleeding & red tag

when assessing mental status

• following simple commands - yellow

• cannot follow simple commands - red tag, immediate tx

outbreak

• If you notice a trend

• Unusual rise in people with fever, respiratory or GI symptoms

• Notice a trend? Take an exposure history and report it

epidemic

• death within ?

• Clusters with the same unusual illness from one place;

• deaths within 72 h of admission

pandemic

An epidemic across countries or continents (for example, COVID-19)

PPE levels

• level A Self-contained breathing apparatus (SCBA) and
  vapor-tight chemical suit — highest protection

• level B - SCBA with chemical-resistant suit (not vapor-tight)

• level C - Air-purifying respirator, splash-hood coverall,
  chemical-resistant gloves and boots

• Level D - Typical work uniform (scrubs)

blast injury phases

1. primary - blast pressure wave

2. secondary - flying debris

3. tertiary - victim thrown by blast

4. quaternary - everything else

common injuries in the primary phase

• Ruptured eardrum,

• blast lung,

• pneumothorax,

• bowel perforation,

• brain injury

common injuries in the secondary phase

• Penetrating wounds

• fractures

• traumatic amputation

common injuries in the tertiary phase

• Head injuries

• fractures including skull
  

common injuries in the quaternary phase

• Burns

• crush injuries

• worsened COPD, asthma, heart disease

anthrax (bacteria )

• infected through ?

• if inhaled ?

• not spread?

• meds ?

• after death ?

• infectd through Skin (most common), GI or inhaled

• Inhaled: flu-like; incubation up to 43 days

• Not spread person to person

• med to treat: Penicillin, ciprofloxacin, doxycycline

• Cremation after death, remains in soil, and can be spread to animals

Smallpox (virus)

• incubation period ?

• s/s?

• contagious when ?

• precautions

• vaccinated within ?

• Incubation about 12 days

• Fever, malaise, then rash from face outward

• Contagious once rash appears

• Isolation and transmission precautions

• anyone in contact should be vaccinated in 4 days to prevent infection

characteristics of chemical weapons

• Volatility: how easily it becomes vapor

• Persistence: how long until it dissipates

• Toxicity: how much harm it causes

• Latency: time from exposure to symptoms

nerve chemical agents

• common agents ?

• s/s?

• tx?

• sarin and soman

• Pinpoint pupils, heavy secretions, bronchospasm, twitching, seizures,
  apnea

• Soap and water ≥20 min, blot

• avoid plastic equipment.

• Atropine, pralidoxime, benzodiazepine

blood chemical agents

• common agents ?

• s/s?

• tx?

• cyanide

• Bitter almond smell rapid respiratory and cardiac arrest

• Cyanide antidote kit: amyl nitrite, sodium nitrite, sodium thiosulfate

• intubate

vesicant chemical agents

• common agents ?

• s/s?

• tx?

• mustard, lewisite

• Blisters, burns, conjunctivitis, airway injury, marrow suppression

• Soap and water, no scrubbing or bleach

• irrigate eyes

• Dimercaprol

pulmonary chemical agents

• common agents ?

• s/s?

• tx?

• phosgene and chlorine

• Pulmonary edema, dyspnea, hacking cough, frothy sputum

• Supportive care

• staff wear particulate filter masks

radiation exposure

• measuring devices ?

• types of exposure

• measured with geiger counter

• staff must wear dosimeter (measuring device)

• external exposure - no decontamination needed

• contamination exposure - needs urgent decontamination

• incorporation exposure - absorbed into cells and organs

radiation decontamination

• measure with geiger, then send to the decontamination area outside the ED

• Remove and bag clothing

• Wash skin and hair with soap and water, no scrubbing

• Remeasure collect nasal and throat swabs and blood

• Treat internal contamination

protecting facility and staff from radiation

• triage hwere

• cover ?

• radiation waste ?

• PPE

• Triage outside the hospital

• Cover floors; seal air ducts and vents

• Double-bag and label radiation waste

• PPE: Gown, double gloves, cap, goggles, mask, booties, dosimeter

Acute Radiation Syndrome (ARS)

• caused by ?

• early vs late signs

• early vomiting ?

• what kind of care? prevent ? monitor ?

• An acute illness caused by a high dose of penetrating radiation
  to body over a short time

• Caused mainly by external irradiation
  • Early: nausea, vomiting, diarrhea, fatigue
  • Later: marrow suppression, infection, bleeding

• Early vomiting means higher dose exposure

• Supportive care, infection prevention, monitor CBC

ARS

• probable survivor

• possible survivor

• improbable survivor

• depends on? check what lab at what time ?

• probable survivor - mild or no symptoms

• possible survivor - nausea and vomiting for 48 hrs

• improbable survivor - Severe vomiting, bloody diarrhea, shock; neurologic signs suggest a lethal dose

• Severity depends on dose; check absolute lymphocyte count at 48 hours