Download Environmental Emergencies

Project: Ghana Emergency Medicine Collaborative
Document Title: Environmental Emergencies
Author(s): Genny Carley, RN-BSN, Kathleen McIlmurray, RN-BSN, Kelly
Schmiedeknecht, RN-BSN, Christa Gallagher, MSN, MPH
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2
Environmental
Emergencies
Genny Carley, RN-BSN
Kathleen McIlmurray, RN-BSN
Kelly Schmiedeknecht, RN-BSN
Christa Gallagher, MSN, MPH
3
Assessment
When a patient reports to the emergency room with an environmental emergency
many factors need to be considered:
•
•
•
Primary Assessment: ABCD (Airway, breathing, Circulation and Disability).
If the patient is stable after a primary assessment more information needs
to be obtained.
Secondary Assessment: Any other injuries (Injuries that are non-life
threatening). Observe for broken bones, swelling, and bleeding. Find out
some history about the patient, review allergies and current medications.
Plan of Care: Determine if this patient is appropriate to wait for care or
needs immediate treatment. With environmental emergency some pt's
can wait for treatment but some need close observation to make sure
that their condition does not worsen.
4
Analysis
What is the patient's plan of care once their level of priority has been
determined?
•
•
The plan of care for a patient that presents to the emergency room
will depend on their specific environmental emergency.
In order to determine the state of the emergency diagnostic and
laboratory tests will be performed. Some of the baseline labs are:
o Labs: Comprehensive Metabolic Panel, PTT/INR, CBC, Liver
Function Tests, Lactic Acid, Type and Screen.
o Xray
o EKG
o Vital Signs
To complete the analysis of a patient, tests need to be performed to
determine the the patient’s status.
5
Heat Related Emergencies
•
Normal compensatory response to extreme heat.
o
o
Under normal circumstances the central nervous system will work to maintain a core body
temperature between 36.5 and 37.5 degrees celsius.
Hypothalamus (often called the thermostat) is primarily responsible for regulating heat.

Increased body temperatures cause the hypothalamus to trigger the autonomic nervous
system (ANS)-increased HR, sweating, increased RR, shunting of blood to skin to reduce
temperature via:
••
••
Radiation: Transfer of heat through the air.
Conduction: Transfer of heat from one object to another.
Convection: Transfer of heat through circulating air currents.
Evaporation: Transfer of heat from water vapor on the skin (sweating).
6
Extreme Heat
•
•
When the body cannot maintain a
normothermic temperature due to either
exposure to extreme temperatures or an
increase in internal heat production such as
exercise, heat related emergencies occur.
o Heat cramps
o Heat Exhaustion
 Dehydration!
Children and the elderly are the most at risk
for complications related to overheating.
7
Heat Cramps
•
Involuntary muscle spasms often due to
exercise and extreme heat.
o
•
Thought to be related to dehydration and a loss of sodium and
potassium.
Interventions
o
o
o
Rest
Rehydration/replacement: May include oral rehydration or IV
hydration with 0.9NS. Possible potassium replacement if needed.
Monitoring
 Monitor blood pressure, heart rate and level of consciousness for
signs of dehydration.
 Heat cramps are usually not life-threatening but can be an early
warning to heat exhaustion and heat stroke.
8
Heat Exhaustion/Heat Stroke
Heat Exhaustion
•
•
•
Heat Stroke
Children (under age 4), the elderly (over age 65) and the chronically ill are most at risk for
both heat exhaustion and heat stroke.
Signs/symptoms of heat exhaustion include
headaches, feeling tired, weak or dizzy,
nausea and increased perspiration (cool,
moist skin).
Core temperature can be more than 37.7C
(but this is not necessary for a diagnosis)
with an elevated heart rate.
•
•
•
•
Signs/symptoms of heat stroke include
feeling tired, weak and dizzy. Skin becomes
warm, dry, red and flushed. May progress
to delirium. decreased level of
consciousness, cardiac arrhythmias and
renal failure.
Core temperature can be more than 40.5C
(but this is not necessary for a diagnosis)
with tachycardia and tachypnea.
Blood pressure can initially be elevated and
then drop as dehydration increases.
Address ABC's, remove heat source, cool patient, treat dehydration, assess.
9
•
•
Dehydrationfrom heat exhaustion/stroke
S/S: Tachycardia, weak peripheral pulses, hypotension, tachypnea, dry mucous membranes,
altered mental status, fever, poor skin turgor and decreased urine output
Assessment:
o
o
Assess ABCD's and treat appropriately, monitor vital signs, ECG, mental status, pupil
response, skin changes, intake and output.
Laboratory studies: Electrolyte panel (K+. Cl-, Na+, CO2), blood sugar, BUN urinalysis.


o


In dehydration from heat stroke you can expect sodium and glucose to be decreased
and BUN to be increased. Potassium may be increased or decreased.
Clotting times may be prolonged, liver studies may be elevated and ABG may show
respiratory alkalosis or metabolic acidosis.
Urinalysis may show myoglobinuria indicating a breakdown of muscle tissue.
Treat alterations in electrolytes with appropriate replacement.
CT studies: head

Mannitol may be used to reduce cerebral edema
10
Rehydration and cooling
• Begin with oral rehydration solution containing sodium if the patient
can tolerate fluids. Avoid liquids with high glucose levels.
• If the patient cannot tolerate fluids or needs fluids more rapidly
administer normal saline by IV.
Cooling
o
o
o
o
If possible cool down the room and remove restrictive clothing.
Allow for evaporation by placing cool cloths or misting cool water on the
patient; fanning will increase evaporation
Cool with ice packs to axilla, groin and trunk but not to the point of
shivering which will increase the temperature.
 Monitor for tissue injury from ice.
Aggressive cooling may be done internally with cool water lavage via NG
tube, rectal tube or foley catheter.
 Avoid cooling lower than 39C which may cause complications
11
Education
•
Importance of educating patients on
preventing heat stroke and related
dehydration prior to discharge.
o
o
o
Avoid prolonged sun exposure or activity during the
hottest part of the day.
If early signs of heat exhaustion occur such as
dizziness, nausea, fatigue or headaches the person
should be encouraged to rest, move to a shady area
and increase fluid intake.
Always drink a lot of fluids on hot days.
12
Cold Weather Emergencies
• Frostbite-damage is caused to skin and other
•
tissues due to freezing. Frostbite is most likely
to happen in body parts farthest from the heart
and those with large exposed areas.
Below freezing, blood vessels in the skin begin
to shunt blood to the core, this is a protective
mechanism. If prolonged, tissues may die from
lack of circulation and freezing.
13
Frostbite Treatment
• Passive warming: wrap in blankets, place in
•
warm room. Avoid rubbing or massaging as
this will further damage tissues.
Active warming: placing frostbitten tissues
in warm water-not hot water.
14
Frostbite
http://www.emedicinehealth.com/frostbite/article_em.htm
15
Frostbite
http://www.washingtonfootdoc.com/blog/date/2011-12-01.html
16
Cold Weather Emergencies:
Hypothermia
• Hypothermia-when the body’s core
•
temperature is unusually low. A result of a
cold and/or wet environment. Symptoms
quite severe under 95(35C)degrees.
Symptoms:shivering, exhaustion,
confusion,drowsiness, lack of coordination,
slurred speech. The patient may not realize
she has hypothermia until it is too late.
17
Hypothermia Treatment
• Raise the body: temperature
o
o
o
o
o
Remove any wet clothing
Place in warm room
Give warm liquids
Wrap in blankets
Skin to skin re-heating
If symptoms are severe, patient may go into shock,
will need fluids, cardiac monitoring, electrolyte
imbalance correction, patent airway.
18
Near Drowning
•
•
•
•
Respiratory impairment from submersion
into liquid resulting in anoxia and brain
injury.
Most often affects young people.
Rapid resuscitation is key for survival.
o Reducing hypoxia and brain injury.
Always assume patient could also have a
spinal or head injury from falling/diving
into shallow water.
19
•
•
•
Assessment- subjective
Was there an event contributing to the submersion injury such as a head injury,
spinal cord injury, drug or alcohol use?
How long was the victim submerged?
What was the type of water?
o
o
Cold versus warm?

Near drowning in cold water (<20C) increases survival due to decreased metabolic
rates and O2 requirements in hypothermia. Diving reflex causes decrease in HR and a
shunting of blood to brain and heart.
Freshwater versus saltwater



Aspiration of saltwater causes fluid to be pulled from vascular space into alveoli
leading to pulmonary edema
Aspiration of freshwater can cause hemodilution, hypovolemia, alveolar collapse,
atelectasis, hypoxia and V/Q mismatching. Can have seizures due to hyponatremia.
Particulates in the water can lead to lung infections
20
Assessment-objective
•
•
ABC's!
Signs of respiratory distress or respiratory failure
o Apnea-> cardiopulmonary arrest
o Dyspnea, cyanosis, coughing frothy sputum, tachypnea.
•
•
•
•
•
o Breath sounds may be crackles, rhonchi or wheezes with aspiration.
Altered level of consciousness
o Anxiety, restless and confusion are signs of hypoxia.
Vital signs: Tachycardia, hypotension, hypothermic if in cold water
Monitor for hyporeflexia or seizures if hyponatremia occurs related to
freshwater drowning.
Assess for trauma.
Laboratory and imaging
o Electrolytes, CBC
o ABG
o
o ECG
o Chest x-ray, CT's for trauma.
21
Management- Airway and Breathing
•
•
•
•
•
•
Start patient on 100% oxygen and decrease as patient tolerates.
Use BVM for to assist ventilation for patients with respiratory arrest.
Intubation may be necessary
Bronchodilators such as isoproternol or terbutaline may used if
wheezing occurs to help open the airways.
Bronchoscopy may be used for removal of aspirated material.
Consider that approx 40% of near drowning victims develop Acute
Respiratory Distress Syndrome (ARDS) in the first 48 hours.
o Acute inflammation of the lungs
22
Normal X-ray
http://biochem2.umin.jp/contents/TS_slides/sld/sld025.htm
ARDS X-ray
23
Management
•
•
•
•
•
Circulation
o Initiate BLS/ACLS for patients in cardiopulmonary arrest.
o IV Access: normal saline most likely unless sodium levels are
out of range.
o Monitor for arrhythmias associated with electrolyte changes
and hypothermia.
Monitor temperature
o If patient is hypothermic use warming techniques such as
warm fluids, blankets and heat lamps.
***Monitor blood pressure carefully during rewarming as
hypotension may occur due to vasodilation.
Monitor for infection
Monitor for seizures
Neuro checks for cerebral ischemia.
o Mannitol may be indicated for cerebral edema
24
Education- Prevention is Key!
How much water does it take for a child to
drown?
A child can drown
in any body of
water that can
cover their nose
and mouth.
http://upload.wikimedia.org/wikipedia/commons/0/0
4/Drowning_child_warning.jpg
25
Animal Bites
•
All animal bites can be serious because of
the potential for infection.
o
o
o
o
o
o
o
Rabies
Staphylococcus
Streptococcus
Enterobacter
Streptococcus
Enterobacter
Clostridium
o Pasturella multicida
o +++
26
•
Dog Bites
o
o
•
•
•
Can cause both puncture wounds and crush injuries due to the strong jaws of dogs
Dog bites are usually on hands and lower extremities

Evaluate for injury to skin, vessels, bones, nerves and tendons
Cat Bites
o
Deep puncture wounds can lead to osteomyelitis.
Rodent Bites
o
Most often seen in children, small puncture wounds.
Management : stop bleeding, assess wound, irrigate and
clean wound, prepare for possible xray, prepare for
wound closure or wound dressing, administer tetanus if
indicated, rabies prophylaxis (immunoglobulin and rabies
vaccine series), prophylactic antibiotic is clavulanic
acid/amoxicillin. Hand wounds must be frequently re
evaluated.
27
Snake Bites
•
•
Since there is no simple way to determine if a
snake is venomous, assume all snake bites are
serious.
Poisonous snakes in Africa include:
o
o
o
o
o
Mambas (cardio and neuro toxic)
Puff Adder (cytotoxic)
Boomslang (hemotoxic)
Gaboon Vipers (hemotoxic)
Cobra (neurotoxic)
28
http://upload.wikimedia.org/wikipedia/commons/e/e4/Natri
x_natrix_%28Marek_Szczepanek%29.jpg
Factors Affecting Symptoms
•
•
•
•
•
•
Amount of venom injected.
Makeup of the venom (varies by time of the
year, type, size and age of snake).
Characteristics of the patient including age,
size and overall health.
Location of the bite.
Amount of activity after bite.
Time to medical attention.
29
Types of Toxins in Snake Venom
•
•
•
•
Cytotoxins which cause local tissue damage.
o Localized pain and swelling
o Blistering around the site.
Hemotoxins that cause internal bleeding.
o Ecchymosis or hematomas
o hematuria
Neurotoxins cause damage to the nervous system.
o Pins and needles or numbness around the site that spreads
through body.
o Paralysis of muscles
 Aphasia or difficulty swallowing
Cardiotoxins that act on the cardiovascular systems.
o Shortness of breath (pulmonary edema)
o Tachycardia or bradycardia
30
Interventions
•
•
•
•
•
•
Airway and breathing
o Snake bites can cause pulmonary edema, chest tightness,
respiratory arrest or laryngeal edema.
o Place the patient on oxygen, prepare for possibility of assisted
ventilations.
Circulation
o Monitor heart rate and blood pressure closely.
o Obtain IV access, medications or fluids for blood pressure support
if needed.
Prepare for administration of antivenom
Laboratory Studies
o CBC, Electrolytes, BUN/Creatinine, coags, UA, Livers
Clean the area of the bite.
Immobilize the area.
31
Insect Bites
Insect bites can
cause localized
infections, allergic
reactions or
transmit diseases
http://upload.wikimedia.org/wikipedia/commons/2/2f/SWS_
Bite.JPG
•
•
•
•
•
•
Spiders (shown in
picture)
Ticks
Mosquitoes
Flea
Bees
Flies
32
•
•
•
Allergic reaction
Bee stings are most likely to cause an allergic reaction.
Assessment
o Airway and breathing
 Swelling to face, tongue or throat, shortness of breath and
wheezes.
o Circulation
 Hypotension and tachycardia
o Level of consciousness
Management
o Monitor airway
 Oxygen, prepare for assisted ventilation if needed.
o Obtain IV access for medication administration
 Antihistamines (Diphenhydramine, Cimetidine), epinephrine,
steroids (solumedrol), IV fluids.
33
Localized infection
•
•
Insect bites, particularly spider bites, can
cause localized skin infection or irritation.
Assessment
o
o
•
Redness, pain and swelling to the area of the bite.
Area may be dry or have opened up itself and be
draining.
Management
o
o
The area may need to be opened to let the infection
drain. Teach the patient about keeping site clean
and dry using dressings.
Antibiotics will likely be needed.
34
Insect transmitted diseases
•
•
•
Malaria (mosquitoes): Symptoms typically appear after 7 days and include fever,
chills, fatigue, abdominal pain, nausea and vomiting, headaches, body aches and
splenomegaly.
o Diagnosis is made by blood test. Treatment is by antimalarial drugs
(chloroquine, atovaquone-proguanil, artemether-lumefantrine, mefloquine,
quinine)
Dengue Fever (mosquitoes): Symptoms include headache, fever, body aches,
lymphadenopathy, rash (redness to palms and soles), eye pain.
o Diagnosis is made by blood test. Treatment is by NSAIDs, fluids and rest.
Yellow Fever (mosquitoes): Symptoms usually appear after 3-6 days and include
fever, muscle pain, headaches, nausea and vomiting. Symptoms may disappear
after a few days, but in some cases they return causing high fevers, jaundice,
abdominal pain, systemic bleeding, kidney failure.
o Diagnosis can be difficult based on symptoms. Blood tests can be done to
detect the virus. Treatment is supportive. Prevention via vaccination or
mosquito control is key.
o Treatment includes fluid and rest in early stages and airway, breathing and
blood pressure support in severe cases.
35
Insect transmitted diseases
•
•
•
Filariasis (mosquitoes): filarial worms are spread from person to person via
mosquitoes. The person infected may not experience any symptoms. Damage
occurs to the lymphatic system and may cause lymphedema years after
infection.
o Diagnosis is made by a blood smear. Treatment with medication
Diethylcarbamazine.
Onchocerciasis (black flies): Black flies transmit Onchocerca worms which cause
nodules under the skin. Other symptoms include rash swollen lymph nodes and
blindness.
o Diagnosis is most commonly done by a skin snip or examining the nodule.
Treatment is by the medication ivermectin.
Typhus (ticks or lice): Symptoms include a pink rash that blanches that later
turns into a red rash that does not blanch beginning on the trunk and spreading
out, abdominal pain, body aches, nausea, vomiting, diarrhea, fevers, chills,
delirium, hypotension.
o Diagnosis by blood test. Treatment by antibiotics doxycycline or
tetracycline.
36
Insect transmitted diseases
•
Crimean-Congo Hemorrhagic Fever (ticks/blood and tissue from
infected livestock):
o Symptoms: Sudden onset of fever, myalgia, dizziness, neck pain and
stiffness, backaches, headaches, sore eyes and photophobia with
nausea, vomiting, diarrhea, sore throat and generalized abdominal
pain then developing. The next 2 days patients will exhibit sharp
mood swings, confusion, aggression, and general agitation. Days 2-4
will switch from agitation to sleepiness, depression, lassitude, and
right upper quadrant pain with hepatomegaly. Other clinical signs
include tachycardia, lymphadenopathy, and petechial rash on both
internal mucosa and on skin. Rash can give way to ecchymoses and
other hemorrhagic problems such as melena, hematuria, epistaxis,
and bleeding from the gums. The severely ill may develop
hepatorenal and pulmonary failure after day 5.
o Mortality is 30% with death occurring in week 2 after symptom onset.
In those who recover improvement is seen after days 9-10,
37
Insect transmitted diseases
•
Crimean-Congo Hemorrhagic Fever
o Diagnosis : Lab studies - IgG, or IgM antibodies or virus detection in
the blood samples.
o Treatment: Support ABCDs with volume and blood replacement if
necessary. Antiviral drug ribavirin is available with apparent benefit.
o Prevention: Personal protection measures against ticks. Gloves when
handling blood and tissue of livestock. It is possible for nosocomial
spread of infection. Known patients should be isolated and universal
precautions used.
38
Spider Bites
•
•
Tarantula/Baboon Spiders : Bites will look like other insect bites with
redness at site, localized pain, swelling and a probable weal. Treat area
with soap and water. Possible use of topical cortisone cream to reduce
irritation and watch for signs of infection. Inhalation of tarantula hair
presents like allergic rhinitis with runny nose, sneezing, congestion and
sinus pressure. Watch for signs of generalized allergic reaction.
Black Widow/Button Spiders : Bites will look red with minor swelling at
site. Approximately 15 minutes to 1 hour after bite pain will develop in
chest if bitten in upper body and develop in abdomen if bitten in lower
body. Symptoms may include: anxiety, difficulty breathing, extremely
painful muscle cramps, headache, high blood pressure, increased
salivation, diaphoresis, light sensitivity, muscle weakness,
nausea/vomiting, numbness, restlessness, and seizures in children.
Venom is neurotoxic. Treatments should include support of ABCDs,
treatment of symptoms, and in severe cases an antivenin can be
administered. Symptoms mostly resolve within 2-3 days but some can
linger for a few weeks. The extremely ill, children, and elderly may not
survive a bite.
39
Spider Bites
•
•
•
Violin/Brown Recluse Spiders : Possible pain when bitten, venom is
cytotoxic causing swelling, pain, and blistering sore. Children will have a
more severe reaction than adults and anyone that survives 48hrs is
thought to survive. Treatment of bite site may take weeks to heal, and
could need surgical intervention. Systemic symptoms may include chills,
itching, generalized ill feeling, fever, nausea, discoloration around bite
with possible ulcer, and diaphoresis. Rare symptoms are coma,
hematuria, jaundice, kidney failure, and seizures. Treatments should
include support of ABCDs, and treatment of symptoms.
Sac Spiders : Venom is mildly cytotoxic and neurotoxic causing swelling,
redness, pain, and possible blister or sore at site. Redness, and swelling
dissipate in 72 hours, but can take 1-2 weeks for site to heal. Treatment
includes watching site for signs of infection.
Rain Spiders : Bites heal in a matter of days as the venom is very weak,
although the spider is VERY large. Redness, pain and possible swelling at
site of bite with treatment to include watching for s/s of infection.
40
Spider Bites
•
Six-Eyed Sand Spider : Considered the most lethal spider in the world as
the venom is hemolytic and necrotoxic. The venom leads to blood vessel
leakage, tissue destruction, and multi-organ breakdown/failure.
Treatment includes support of ABCDs, prevention of secondary
infections, and combating DIC if developed. There is not an antivenom,
but luckily only 1 human death is attributed to this spider.
41
Six eyed sand spider
•_
http://theadventourist.com/swim-at-the-edge-of-the-worlds-largest-waterfalldevils-pool-victoria-falls
42
Diving Emergencies
Barotrauma: Injury caused by pressure effects on air spaces. Most common
during diving, and can occur during ascent or descent. Ears are most
commonly affected with extreme cases being ruptured eardrums, bleeding
sinuses, exploding tooth cavities, and lung injuries.
Prevention: Never hold your breath. Breathing continuously to avoid any
pressure differences between lungs and ambient pressure.
•
Decompression Sickness: Also known as "the bends." Occurs from
ascending too fast without decompression stops. Bubbles form large
enough to cause physical injury. Bubbles disrupt tissue in joints, brain,
spinal cord, lungs and other organs.
o Signs and symptoms of decompression sickness include: rash,skin
itching, fatigue, muscle weakness, pain in muscles or joints,
43
Diving Emergencies
•
Decompression Sickness:
o Signs/Symptoms: difficulty urinating, dizziness, vertigo, ringing in
the ears, confusion, personality changes, loss of memory, tremors,
staggering, numbness, tingling, shortness or breath, collapse,
paralysis, unconsciousness and death. S/S vary greatly and can be
subtle, or dramatic.
o Treatment: 100% oxygen immediately then hyperbaric oxygen
therapy in a recompression chamber.
o Support ABCDs.
44
Diving Emergencies
•
Air Gas Embolism: Occurs in arteries and presents like an arterial
blockage.
o Signs and symptoms include: blurred vision, dizziness, disorientation,
weakness, blood from nose/mouth, areas of decreased sensation,
chest pain, myocardial infarction, shortness of breath, pulmonary
embolism, seizure, paralysis, stroke, coma, apnea, and death.
o Treatment: 100% oxygen immediately in Trendelenburg or left
lateral decubitus position then hyperbaric oxygen therapy in a
recompression chamber.
o Support ABCDs
45
High Altitude Emergencies:AMS
• Acute Mountain Sickness-a condition caused
•
•
•
•
by low oxygen levels in high altitudes,
usually occurs over 6000 feet.
Symptoms:headache, fatigue, N/V, SOB,
dizziness, and sleep disturbance, peripheral
edema.
Can usually be prevented with slow ascent.
Treatment: descend!
Prevention: slow ascent, allow
acclimitization.
46
HACE
• High Altitude Cerebral Edema-advanced acute
•
•
•
mountain sickness that affects the brain.
Symptoms: severe headache, confusion, N/V,
coma,vision changes, and if untreated: death.
Treatment: descend! Oxygen, Fluids, steroids ,
medications. This is a lifethreatening condition.
Prevention: slow ascent, acclimatize, some
medications may help.
47
Acetazolamide (Diamox)
• Medication used for prevention and
•
•
treatment of AMS. The medication increases
the amount of oxygen in the blood.
Can be used prior to mountain climbing to
prevent AMS.
Can be used during treatment of AMS
including HAPE and HACE.
48
HAPE CXR
• Fluid in lungs
http://hape.wikispaces.com/
49
HAPE
• High Altitude Pulmonary Edema-a condition
•
•
•
that occurs at high altitudes causing edema
in the lungs.
Symptoms: dry cough, fever, SOB, chest
pain, unable to catch breath even at rest,
frothy bloody sputum.
HAPE can progress to death.
Treatment: descend! Oxygen,
fluids,steroids,medication, monitoring.
50
Hyperbaric chamber or bag
• A bag which can be used to artificially
create pressures of a lower atmosphere, this
is a temporary treatment until patient can
be transported to lower altitude.
51
Hyperbaric Chamber/bag
http://www.high-altitude-medicine.com/hyperbaric.html
http://alfa-img.com/show/hyperbaric-sleeping-bag.html
52