Nosocomial Nightmare & Emergency Response

3.1. Nosocomial Nightmare

3.1.1 Outbreak

  • Epidemiologist: Health care experts who study trends in health issues in populations and deploy public announcements, education initiatives, and protocols to protect the health of the nation.
  • Epidemic: A disease that affects a large number of people within a community, population, or region.
  • Endemic: A disease perpetually present in a community or population within a specific geographic area. Example: malaria in parts of Africa, South America, and Asia.
  • Outbreak: A sudden increase in the occurrence of a disease in a localized area.
  • Pandemic: An epidemic that has spread across several countries or continents and affects a large number of people.
  • Nosocomial: An infection acquired in a hospital; also known as a hospital-acquired infection or HAI.

3.1.2 Agents of Disease

Prions
  • What they are: Non-living, submicroscopic, proteins (proteinaceous infectious particles).
  • How they infect: Exposure through consumption of tainted meat, contaminated medical equipment, or receiving organs/corneas from infected individuals. These prions cause normal brain proteins to fold abnormally.
  • Diagnosis: MRI, cerebrospinal fluid analysis, electroencephalogram (EEG), and blood tests.
  • Treatment: No cure, but medications can slow the progression.
  • Prevention: Properly cleaning and sterilizing medical equipment. Educating infected individuals about not donating organs/tissue.
  • Example: Creutzfeldt-Jakob disease (CJD) results in dementia, walking difficulties, hallucinations, confusion, and death.
Bacteria
  • What they are: Living, microscopic, unicellular, prokaryotic organisms.
  • How they infect: Depends on the type of bacteria. Infection may occur through an orifice (nose, eyes, mouth), through a wound, by ingesting contaminated food or water, through inhalation, through sexual contact, or due to an imbalance in normal flora. Bacteria can invade cells, cause tissue damage, and produce harmful toxins.
  • Diagnosis: Physical examination and clinical laboratory testing.
  • Treatment: Antibiotics.
  • Prevention: Vaccines, maintenance of sanitary conditions, and proper personal hygiene.
  • Example: Mycobacterium tuberculosis causes tuberculosis (TB). Symptoms include a bad cough (lasting three weeks or longer), chest pain, coughing up blood/phlegm, weakness, fatigue, weight loss, no appetite, chills, and fever.
Helminth
  • What they are: Living, multicellular, eukaryotic worms. Both microscopic and macroscopic varieties exist.
  • How they infect: Depends on the type of worm. Infection may occur through consumption of contaminated foods/water or by insect bites. Helminths deprive the host of nutrients and can cause tissue/organ damage.
  • Diagnosis: Microscopic examination of fecal material or blood.
  • Treatment: Deworming medications.
  • Prevention: Avoiding exposure to contaminated food/water, ingestion of meat from infected animals, and insect bites.
  • Example: Taenia (tapeworm) results in nausea, loss of weight, abdominal pain, loss of appetite, diarrhea, weight loss, and malnutrition. Invasive infections result in fever, cystic masses, allergic reactions to larvae, bacterial infections, and neurological symptoms including seizures.
Viruses
  • What they are: Non-living microscopic agents made up of an outer protein shell (capsid) and either DNA or RNA.
  • How they infect: Depends on the type of virus. Infection may occur through touch, saliva, blood, or sexual contact. Viruses cannot replicate on their own; they infect cells and take over the host cells' protein synthesis processes, destroying host cells and tissues.
  • Diagnosis: Physical examination and clinical laboratory testing.
  • Treatment: Antivirals may be used. Over-the-counter treatments can relieve symptoms (pain relievers, decongestants, cough syrups).
  • Prevention: Vaccines and proper personal hygiene.
  • Example: The influenza virus (the flu) affects the respiratory system. Symptoms include runny/stuffy nose, itchy/sore throat, cough, congestion, slight body aches/headache, sneezing, watery eyes, a low-grade fever, and fatigue.
Protists
  • What they are: Living, microscopic, single-celled, eukaryotic, animal-like organisms.
  • How they infect: Infection typically results through ingestion of food or water contaminated with feces from an infected organism. Protists infect the digestive tract, blood, or organs, depriving the host of nutrients and causing tissue/organ damage.
  • Diagnosis: Microscopic examination of fecal material.
  • Treatment: Some infections can be treated with antiprotozoal medication.
  • Prevention: Maintenance of sanitary conditions and proper personal hygiene.
  • Example: Giardia lamblia causes giardiasis. Giardia parasites live in the intestines of people and animals. Before being passed in stool, they become cysts, which allows them to survive outside the intestines. Once inside a host, the cysts dissolve and the parasites are released.
Fungi
  • What they are: Living, multicellular, eukaryotic organisms. Fungi include yeasts, mildews, molds, and mushrooms. Both microscopic and macroscopic varieties exist.
  • How they infect: Some forms infect when spores are inhaled or land on a host. Infection can result in tissue damage.
  • Diagnosis: Microscopic examination of tissue or blood.
  • Treatment: Antifungals.
  • Prevention: Avoiding contact with an infected host.
  • Example: Tinea pedis causes athlete's foot. Symptoms include dryness, itching, stinging, burning, cracking/peeling skin, and blisters between the toes or on the soles of the feet. Toenails may be thick, crumbly, ragged, discolored, or pulling away from the nail bed. Athlete's foot thrives in thick, tight shoes that create warm, moist areas.
How pathogens cause disease
  • An infection results when a disease-causing organism invades and begins growing within another organism, a host.
  • Disease occurs when the invasion and growth of a pathogen impair bodily functions.
  • To cause disease, pathogens must enter the host body, evade the immune system, adhere to specific host cells, invade and colonize host tissues, and inflict damage on those tissues.
How infectious agents can be beneficial
  • Viruses can be used in genetic engineering to insert genes into an organism.
  • Bacteria can be used to make yogurt.
  • Blue-green algae (protist) makes oxygen.
  • Yeasts can be used to make bread or beer.

3.1.3 Modes of Transmission

Chain of Infection

The chain includes:

  • Agent of disease (Prions, Viruses, Bacteria, Protists, Fungi, Helminths)
  • Reservoir (People, Animals, The Environment)
  • Portal of Exit (Skin, Respiratory tract, Gastrointestinal tract, Urogenital, Conjunctiva)
  • Mode of Transmission (Direct, Indirect)
  • Portal of Entry (Skin, Respiratory tract, Gastrointestinal tract, Urogenital, Conjunctiva)
  • Susceptible Hosts (Anyone, especially: Children, Elderly. People with weakened immune systems, Unimmunized people)
Innate vs. Acquired Immunity
  • Innate immunity: Defends against any pathogen; it is non-specific. This is a general response to anything other than recognized self-cells. Defenses you are born with: skin, chemicals (lysozyme in tears or stomach acid), immune cells (phagocytes).
  • Acquired Immunity: Promotes specific attacks against foreign invaders. This form of immunity is acquired over a lifetime and involves immune cells designed to attack specific pathogens.
  • Active immunity: Acquired following infection and recovery, or from a vaccine. Your body makes its own antibodies.
  • Passive immunity: Acquired from the mother. Antibodies are given to a child through the placenta or through breastfeeding.
Innate Immunity
  • 1st (barrier) and 2nd (inflammation) line of defense
  • Includes:
    • Lysozyme in tears
    • Removal of particle by cilia in nasopharynx
    • Mucus lining trachea
    • Skin surface (physical barrier), fatty acids, normal flora
    • Rapid pH change
    • Stomach (pH 2)
    • Normal flora
    • Flushing of urinary tract
Normal Flora
  • Bacteria that normally live on or in your body.
  • Benefits:
    • Protect from pathogens
    • Synthesize vitamins
    • Assist in food digestion
Acquired Immunity
  • Immunity that develops during your time
  • Two basic types:
    • Active Immunity
      • Natural: Antibodies developed from an infection
      • Artificial: Antibodies developed from a vaccination
    • Passive Immunity
      • Natural: Antibodies transferred from mother through breast milk
      • Artificial: Antibodies administered from a medicine, from a gamma globulin injection or infusion
Acquired Immunity (T-cells and B-cells)
  • HUMORAL (ANTIBODY-MEDIATED) IMMUNE SYSTEM
    • Control of freely circulating pathogens
    • Extracellular antigens
    • A B cell binds to the antigen for which it is specific.
    • A T-dependent B cell requires cooperation with a Tμ cell. B cell proliferates and some progeny become plasma cells or memory cells.
    • Cytokines transform B cells into antibody-providing plasma cells (see Figure 17.4).
  • CELLULAR (CELL-MEDIATED) IMMUNE SYSTEM
    • Control of intracellular pathogens
    • Activates helper T cell
    • Exposure to antigen.
    • Intracellular antigens expressed on the surface of a cell infected by a virus, bacterium, or parasite. (Also may be expressed on surface of an APC.)
    • A T cell binds to MHC-antigen complexes on the surface of the infected cell, activating the T cell (with its cytokine receptors).
    • Activation of macrophage (enhanced phagocytic activity).
    • The B cell, often with stimulation from a helper T cell, differentiates into a plasma cell.
    • Plasma cells proliferate and produce antibodies against the antigen.
    • Some T and B cells differentiate into memory cells that respond rapidly to any secondary encounter with an antigen (see Figure 17.15).
    • CD8 T cell becomes cytotoxic T lymphocyte (CTL) able to induce apoptosis of target cell (see Figure 17.10).

3.1.4 Evidence Evaluation

Etiology of Disease
  • The cause of a disease or condition.
  • Can include things like diet or other lifestyle factors, genetics, or pathogens.
  • Examples:
    • Flu: virus
    • Athlete’s foot: fungus
    • Familial hypercholesterolemia: genetics
    • Lifestyle factors: Type 2 diabetes, heart disease, lung cancer, skin cancer

3.1.5 Isolation

Causes of Antibiotic Resistance
  • Random mutations
  • Receiving antibiotic resistance genes from another bacteria
  • Misusing antibiotics
Aseptic Technique
  • Procedure performed under sterile, or totally clean, conditions
  • To protect you from your sample
  • To prevent contamination of your sample
Isolation Streak
  • Streak Plate Method
  • To get individual colonies
  • Helps in the identification process.
Colony Morphology
  • 1st step in identification process
  • Size, color, texture, elevation, form, margin
  • Size:
    • Punctiform
    • Small
    • Moderate
    • Large
  • Color
  • Texture:
    • Dry
    • Smooth
    • Viscid
    • Mucoid
  • Elevation:
    • Flat
    • Raised
    • Convex
    • Umbonate
    • Crateriform
    • Draughtsman Colony
  • Form:
    • Round
    • Irregular
    • Filamentous
    • Rhizoid
    • (Punctiform)
  • Margin:
    • Entire
    • Lobate
    • Scalloped Filiform
    • Undulate
    • Curled
    • Serrate

3.1.6 Gram Stain

Shapes of Bacteria
  • Shapes and Arrangement
  • Shapes of Bacteria:
    • Cocci
    • Bacilli
    • Spirilla
  • Note: The term used to reference cell morphology changes based on whether one cell, or many, is being referenced:
    • Singular
      • Coccus
      • Bacillus
      • Spirillum
    • Plural
      • Cocci
      • Bacilli
      • Spirilla
  • BACTERIAL CELL ARRANGEMENT
  • BACILLI
    • Individual bacilli
    • Chain of bacilli
  • COCCI
    • Individual cocci
    • Diplococci
    • Chain of cocci
    • Tetrad
    • Staphylococci
  • SPIRILLA
    • Individual spirilla
Gram Stain
  • Gram Positive
  • Gram Negative
  • Gram negative bacteria have a thin peptidoglycan layer, and Gram positive bacteria have a thick layer of peptidoglycan. Figure 5 illustrates the differences between the Gram negative and Gram positive cell walls.
  • GRAM NEGATIVE
    • Lipopolysaccharide
    • Outer Membrane
    • Peptidoglycan
    • Cell Membrane
  • GRAM POSITIVE
Gram Stain
  • Gram Negative Bacteria
    • The cell wall contains multiple layers, including a thin layer of peptidoglycan.
    • The outside layer is called the outer membrane, which is made of a lipid bilayer whose outside is composed of lipopolysaccharides called endotoxins.
    • The outer membrane serves as a barrier to the passage of most molecules and contains specialized proteins, called porins, which allow certain molecules to pass through the membrane.
    • The region between the plasma membrane and the outer membrane is called the periplasm and is filled with a gel-like fluid and proteins involved in a variety of cellular activities.
    • The Gram-stained cell is reddish-pink (Figure 2).
  • Gram Positive Bacteria
    • The cell wall contains a thick layer of peptidoglycan and teichoic acids. The cell wall contains approximately 20 times more peptidoglycan than the Gram negative bacteria.
    • There is no outer membrane present.
    • There are no porins present.
    • The Gram-stained cell is purple (Figure 2).
Reducing Nosocomial Infections
  • Provide regular employee training on personal hygiene and the expected hygiene practices that should occur between patients.
  • Provide regular training on using and disposing of personal protective equipment.
  • Highlight the importance of sterilization of surfaces.
  • Highlight the importance of aseptic technique.
  • Make it a priority for medical staff to look for signs and symptoms of hospital-acquired infections.
  • Conduct routine testing of hospital staff, patients, and surfaces to culture for organisms typically associated with hospital-acquired infections.
  • Instruct staff to not come to work sick.
Testing for Bacteria Identification
  1. Colony morphology
  2. Gram Stain
  3. Chemical (Metabolic) testing
How to write the name of bacteria
  • Bacteria are named by their genus and species.
  • The first letter of the genus is always capitalized, and both names are always italicized OR underlined.
  • Many times the genus is abbreviated by its first letter and the species is written out. For example:
    • Escherichia coli can also be written as E. coli or E. coli.

3.2 Emergency Response

3.2.1 Survey and Assess
Assessing the Scene Steps of a Scene Size-up
  • Control the situation
    • Stay calm and act quickly to ensure everyone’s safety.
  • Look for potential hazards
    • Assess whether there is anything that could harm your team, the patient, or a bystander (a person who is present but uninjured).
  • Assess the situation
    • Quickly gather any available information about the situation using your own senses and also asking questions of the patient or any bystanders.
  • Protect and prioritize
    • Use personal protective equipment to protect yourself, keep bystanders out of harm’s way, and prioritize individuals who appear to be in the most need of help.
Primary Assessment
  • Steps of Primary Assessment
    • Form a general impression of the patient
      • What appears to have happened? How serious is the patient’s condition?
    • Determine the Mechanism of Injury (MOI)
      • What caused the trauma, or physical damage, to the patient’s body?
    • Determine the patient’s responsiveness
      • Is the patient alert, able to speak, in too much pain to respond, or unconscious?
    • Consider stabilizing the patient’s spine
      • Is a spinal injury suspected based on their position and MOI? If so, the patient’s back and neck must be held in place to prevent further injury.
    • Check the patient’s ABCs (Airway, Breathing, and Circulation)
ABC
  • Airway
    • Is the patient’s airway partially or completely blocked? Can you feel air moving from their mouth or nose? Is their breathing noisy or high-pitched?
  • Breathing
    • Is the patient breathing properly? What is their respiration rate? Are their breaths sporadic?
  • Circulation
    • Does the patient have an adequate pulse? Is there any bleeding?
Secondary Assessment Steps of Secondary Assessment
  • Perform a rapid physical assessment
    • Check the patient head to toe for injuries or signs of illness, including the head, neck, chest, abdomen, and extremities.
  • Take the patient’s vitals
    • Using medical devices to obtain more accurate readings, record the patient’s pulse, blood pressure, and respiration rate.
  • Get a patient history
    • If the patient is not responsive, get a history from any family members or bystanders if possible.
  • Provide appropriate emergency care
    • Ensure adequate airflow, provide oxygen if necessary, stop bleeding, and provide any medicines deemed appropriate.
3.2.2 Drug Delivery
Anaphylaxis
  • Severe allergic reaction
  • Lightheaded, breathing difficulties, wheezing, fast/weak heartbeat, low blood pressure clammy skin, confusion, skin reactions
  • Swelling of airways can cause airways to close
  • Blood pressure drop can cause heart to stop
Routes of Drug Delivery
  • ENTERAL
    • Oral
      • Swallowed or dissolved and absorbed in the mouth
      • Ex: Pills and liquids
    • Rectal
      • Absorbed through the rectum
      • Ex: Suppositories or enemas
  • PARENTERAL
    • Inhaled
      • Breathed in through the nose or inhaled into the lungs
      • Ex: nasal sprays, inhalers
    • Topical
      • Applied directly to a specific site
      • Ex: Skin creams and ointments, ear drops, eye drops
    • Injection or Infusion
      • Injections (shots): a dose of medication delivered for quick absorption by the bloodstream
      • Infusion: fluid and/or medication delivered through the veins over a period of time
Injection Drug Delivery (IV)
  • IV (intravenous): Delivers medicine directly into a vein. Used when a medication is needed quickly, if the liquid cannot be taken by mouth, or if it is too irritating for intramuscular or subcutaneous injections.
  • Intramuscular: Delivers medicine into muscle tissue where it can be quickly absorbed by the bloodstream. Used to administer medication more quickly than a subcutaneous injection and is easier to administer than an IV.
  • Subcutaneous: Delivers medicine into the tissue layer under the skin and above the muscle. Used to deliver medicine quickly, but it takes longer to go into effect than IV as it needs time to diffuse into the body.
Factors used to determine medication, route of administration, and dose for a patient
  • Sex
  • Age
  • Weight
  • Symptoms
  • Concentration of medication
Solutions
  • Solution: A liquid that is a homogeneous mixture of two or more substances.
  • Solute: The substance that is dissolved in another substance.
  • Solvent: The dissolving agent of a solution. Water is the most versatile solvent.
Types of Solutions
  • Isotonic: The concentration of solutes in the solution outside the cell is the same as that in the cell. There is no net movement of water.
  • Hypotonic: The concentration of solutes outside the cell is less than that inside the cell. Water moves into the cell and it swells.
  • Hypertonic: The concentration of solutes outside the cell is greater than that inside the cell. Water moves out of the cell and it shrinks.
Why Saline in IV?
  • Distilled water is hypotonic to the patient’s cells
  • Water from blood would go into the cell
  • Could cause cells to swell (affecting function) and possibly burst
3.2.3 Control Bleeding
Negative feedback
  • Brings levels back to normal (homeostasis
  • Reduces change
  • Examples
    • Body temperature
    • Blood glucose
Positive Feedback
  • Amplifies change
  • Increase of something causes the increase of something which causes the increase of the original, etc.
  • Example
    • Blood clotting
    • Child birth
ABCs of Controlling Bleeding
  • A: alert
  • B: find source of bleeding
  • C: compression
Control Bleeding Flowchart
  1. Is the scene is safe?
    • No. Get help and wait until the scene is safe.
    • Yes
  2. Look for life-threatening bleeding
    • Is a Trauma First Aid Kit available?
  3. Where is the wound?
    • Neck, shoulder, or groin Pack the wound with gauze or clean cloth and apply direct, steady pressure on the wound.
    • Arm or leg
      • Do you have a tourniquet?
        • Apply tourniquet above the bleed and tighten until bleeding stops.
        • No. Use any clean cloth and apply direct, steady pressure on the wound.
Control of Bleeding
  • Arterial bleed harder to control because
    • More pressure
    • Greater velocity
  • Types Of External Bleeding
    • Capillary
      • Slow And Oozing
      • Easily Controlled
      • Stops Spontaneously
    • Venous
      • Steady Flow
      • Easier To Control
      • Low Pressure System
    • Arterial
      • Rapid And Profuse
      • Spurting With Heart Beat
      • Most Difficult To Control
3.2.4 Crisis Communication
Triaging
  • Emergent: highest priority; may not survive without treatment
    • Breathing difficulties, obstructed airways, unconscious, severe injuries/bleeding, extremely high or low hr, bp, or temp, chest pain, heart attack or stroke symptoms
  • Urgent: Care needed quickly but can be delayed temporarily
    • Severe symptoms/injuries/illness, head injury, major bleeding, dehydration, high or low hr, bp, resp rate or temp,
  • Semi-urgent: care needed, but can wait if other higher priority patients exist
    • Less severe symptoms/illness/injury, mild bleeding, may have vital sings which are slightly abnormal or normal
  • Non-urgent: low priority; not time sensitive;
    • Minor symptoms/injury/illness, normal bleeding, stable/normal vital signs
Factors used when triaging
  • Is it life threatening?
  • Signs/symptoms
  • Vital signs
  • Breathing and circulation
  • Type/severity of injuries
3.2.5 Medical Surge
Medical Surge
  • Medical Surge: Occurs when the number of new patients challenges or exceeds a hospital’s ability to serve all of them.
  • Surge capacity: Refers to the ability to care for an increased volume of patients that challenges or exceeds normal operations. This is a measure of how many patients a medical facility can triage, treat, and manage in addition to its normal average number of patients.
  • During a medical surge, it is vital to redistribute resources among a region’s medical facilities to treat as many patients as possible.