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Nursing Care

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Adult Patients in the Emergency/Disaster Environment by Kelle Howard, ... S. Smith Therapeutic Hypothermia Arctic Sun Goal temp is 89.6-93.2 F Ms ... Crew noted: No ... – PowerPoint PPT presentation

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Title: Nursing Care


1
Nursing Care Interdisciplinary Roles with
Adult Patients in the Emergency/Disaster
Environment
  • by Kelle Howard, RN, MSN
  • Modified by Chris Puglia, MSN, RN, CEN

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 StrokePathophysiology
  • 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?
  • What are critical lab values for these lytes?

4
Heat Strokes/s of electrolyte depletion
  • Na gt155 critical
  • Change in mental status
  • Weakness
  • Irritability
  • Neuromuscular excitability
  • Na lt120 critical
  • Change in mental status
  • Combative, decreased LOC
  • Hallucinations
  • Loss of motor control
  • Cerebral edema hemorrhage
  • K lt2.8 critical
  • Hypo-reflexia, muscle weakness
  • Respiratory depression
  • EKG changes


5
Heat StrokeCauses
  • Development is directly related to
  • Amount of time the body temperature is elevated
  • What are some common causes?

Next
6
Heat Stroke Causes
  • Strenuous activity in hot/humid
  • environment
  • High fevers
  • Clothing that interferes with perspiration
  • Working in closed areas/prolonged exposure to
    heat
  • Infants left in cars
  • Drinking alcohol in hot environment

7
FYI
  • During 1999--2003, a total of 3,442 deaths
    resulting from exposure to extreme heat were
    reported (annual mean 688)
  • Childrens thermoregulatory systems are not as
    efficient as adults and warm at a rate of 3-5xs
    faster

STATISTICS Total number of U.S. hyperthermia
deaths of children left in cars   2012
29 2011 33 2010 49
Heat Stroke Deaths Children in Vehicles
8
FYI
  • 73 degrees outside
  • 100 degrees in 10 minutes inside a car
  • 120 degrees in 30 minutes inside a car
  • 90 degrees outside
  • 160 degrees in minutes inside a car

9
Heat StrokeManifestations Complications
  • What will your patient look like?

Next
10
Heat StrokeManifestations Complications
  • Core temp gt 104F
  • AMS - confusion, sluggishness,
  • No perspiration
  • Skin hot, ashen, dry
  • Seizure
  • Coma
  • BP
  • HR
  • S/S of what?

11
Heat StrokePrognosis
  • Related to
  • Age
  • Length of exposure
  • Baseline health status
  • Number of co-morbidities
  • Which co-morbidities would predispose your
    patient to heat related emergencies?

12
Heat StrokeTreatment Interventions
  • ABCs must stabilize
  • What assessments/interventions will you perform
    initially?
  • What do you think the goal of treatment is?
  • How would you achieve this goal?

Next
13
Heat StrokeTreatment Interventions
  • Assessments/Interventions
  • ABCs RR, O2 sats, BP, pulse
  • EKG
  • Large bore IV
  • Goal
  • Decrease the core temperature
  • To what temperature?
  • Prevent shivering
  • Why?
  • How? what med is used?
  • Attainment
  • Remove clothes, wet sheets, large fan
    (evaporative), ICE water bath (conductive), cool
    IV fluids
  • Would you use antipyretics?

14
Heat StrokeTreatment Interventions
  • Monitor for s/s of rhabdomyolysis
  • What is this?
  • How would you monitor for this?
  • Monitor for s/s disseminated intravascular
    coagulation (DIC)
  • What is this?
  • How would you monitor for this?

Next
15
Heat StrokeTreatment Interventions
  • Rhabdomyolysis
  • skeletal muscle breakdown
  • monitor
  • AKI what will you see (labs)?
  • DIC
  • Pathological activation of coagulation mechanisms
  • monitor
  • bleeding and bruising
  • coags platelets
  • AKI what will you see?

16
Heat StrokeInterdisciplinary Roles
  • Who would be involved in this Patients care?
  • RN
  • MD - which ones?
  • RT
  • SW why?
  • Anyone else?
  • Lets say your patient shows changes in LOC, who
    do you call?

17
HypothermiaPathophysiology
  • Definition
  • Core temperature less than 95F (35C)
  • Core temp lt86F - severe hypothermia
  • Core temp lt78F - 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
  • body temp ? peripheral vasoconstriction ?
    shivering movement ? coma results lt78F

18
HypothermiaCauses
  • What are some common causes?

Next
19
HypothermiaCauses
  • 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?

20
HypothermiaManifestations Complications
  • What will your patient look like?

21
HypothermiaManifestations Complications
  • Varies dependent upon core temp
  • Mild (93.2F - 96.8F)
  • Lethargy, confusion, behavior changes, minor HR
    changes, vasoconstriction
  • Intense shivering at higher temps difficulty
    speaking then shivering begins to decrease
  • Moderate (86F 93.2F)
  • Rigidity, dec HR, dec RR, dec BP, hypovolemia,
    metabolic resp acidosis, profound
    vasoconstriction, rhabdomyolysis
  • Shivering usually disappears around 92F
  • What about each system?
  • Profound/(Severe) (lt86F)
  • Person appears dead attempt to re-warm to 90F
  • Reflexes vitals very slow
  • Profound bradycardia, asystole 64.4F, or Vfib
    71.6F
  • usual cause of death? do cardiac
    drugs/defibrillation work?

22
Hypothermia ModerateManifestations
Complications
  • Hematologic
  • HCT inc. as volume dec. ?
  • cold blood thickens, thrombus occurs
  • Neuro
  • Stroke ?
  • lack of blood flow due to vasoconstriction/thrombu
    s
  • Cardiac
  • Irritable myocardium ?
  • atrial ventricular fibrillation, MI
  • Respiratory
  • PE
  • Acidosis ?
  • lactic acid builds up ? anaerobic metabolism ?
    metabolic acidosis
  • Renal
  • Dec blood flow, dehydration, rhabdomyolysis ?
  • Acute Kidney Injury

23
HypothermiaPrognosis
  • Dependant upon
  • Core body temperature
  • Co-morbidities

24
HypothermiaTreatment Interventions
  • ABCs must stabilize
  • What interventions will you perform initially?
  • What do you think the goal of treatment is?
  • How would you achieve this goal?

Next
25
HypothermiaTreatment Interventions
  • Goal
  • Rewarming to temp of _____F
  • Correction of dehydration acidosis
  • Treat cardiac dysrhythmias
  • What about CPR?
  • Attainment
  • Passive active external rewarming
  • What are some examples?
  • Passive move to warm place dry place
  • remove wet clothes, apply
    warm blankets
  • Active -- body to body contact, fluid or air
    filled blankets,
  • Active core rewarming
  • warm IV fluids, heated humidified O2,
  • peritoneal , gastric or colonic lavage
  • What should be warmed first core or
    extremities?
  • Why?

26
Bair Hugger
  • http//www.arizant.com/us/bairhuggertherapy

27
HypothermiaTreatment Interventions
  • Monitor
  • Core temp How?
  • for marked vasodilatation hypotension
  • After drop
  • What is this?
  • Teach
  • Warm clothes hats, layers, high calorie foods,
    planning

28
Submersion InjuryCauses Incidence
  • avg. 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

Next
29
Submersion Injury Pathophysiology
  • Definition
  • Drowning
  • Death from suffocation after submersion in water
    or other fluid medium
  • Near Drowning
  • Survival from potential drowning
  • Immersion syndrome
  • Immersion in cold water ? stimulation of vagus
    nerve potentially fatal dysrhythmias
    (bradycardia)

30
Submersion Injury Pathophysiology
  • Death is caused by hypoxia
  • Victims that aspirate
  • secondary to aspiration swallowing of fluid
  • fluid aspirated into pulmonary tree ? PULMONARY
    EDEMA - HYPOXIA
  • Victims that do not aspirate
  • bronchospasm airway obstruction ? dry
    drowning - HYPOXIA

31
Submersion Injury Manifestations Complications
  • What will your patient look like?
  • Pulmonary
  • Cardiac
  • Neuro

32
Submersion Injury 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

33
Submersion Injury Treatment Interventions
  • ABCs must stabilize
  • What interventions will you perform initially?
  • What should you assume with all victims?
  • What do you think the goal of treatment is?
  • How would you achieve this goal?

Next
34
Submersion Injury Treatment Interventions
  • Goal
  • Correct
  • hypoxia
  • acid/base balance
  • fluid imbalances
  • correct dysrhythmias
  • Attainment
  • Anticipate intubation
  • What about your dry drowning victims?
  • 100 O2 via non-rebreather
  • IV access

35
Real Life Drowning Victim
  • Near Drowning

36
Bites StingsPathophysiolgy
  • Direct tissue damage is a product of
  • Animal size
  • Characteristics of animals teeth
  • Strength of jaw
  • Toxins released
  • Death is due to
  • Blood loss
  • Allergic reactions
  • Lethal toxins

37
Bites Stings
  • Hymenopteran stings (hi-m?-näp-t?-r?n)
  • Bees, yellow jackets, hornets, wasps, fire ants
  • Mild to Anaphylactic
  • What are some manifestations of each?
  • What interventions would you implement to treat
    these manifestations?
  • Treatment
  • Remove stinger with scraping motion
  • Tweezers
  • Maintain ABCs
  • What meds might you give?

38
Bites Stings
  • Manifestations
  • Mild
  • Stinging, swelling, burning, redness
  • Anaphylactic
  • Airway constriction, wheezing, CV collapse
  • Interventions
  • Remove rings, watches, etc.
  • Elevate the limb
  • Cool compress
  • Meds
  • Topical, PO, IM, IV antihistamines --- Benadryl
  • Epi IM
  • Corticosteroids

39
Got any home remedies to share?
  • Meat tenderizer
  • Baking soda
  • Mud
  • Penny?
  • These are for site specific issues these should
    not be considered if the person is having a
    systemic reaction.

40
Black Widow
  • Black widow
  • Characteristic hourglass marking
  • Southern black widow
  • Venom is neurotoxic to humans
  • Symptoms progress over time 15mins 3hrs
  • Dx often missed bite usually not prominent
  • Symptoms dependent on where bitten
  • Upper part of body shoulder, chest and back
    rigidity
  • Lower part of body symptoms mimic appendicitis,
    pancreatitis, abdominal
  • emergencies
  • Can cause systemic issues
  • Treatment
  • Antivenin used in special at risk population

Where do you usually find them?
41
Brown Recluse
  • Brown recluse
  • Characteristic violin pattern on base head
  • Venom is cytotoxic to humans
  • Symptoms progress over hrs weeks
  • Often unnoticed painless bite
  • Can cause systemic issues
  • Like what?
  • Treatment
  • Clean area, treat pain, antibiotics (why?)
  • Surgical debridement with grafting may be
  • necessary

42
Bites Stings
  • Snakebites
  • Pit viper (rattlesnakes, copperheads , water
    moccasins) coral snakes
  • Pit viper hemolytic
  • Coral snake 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
  • Why?
  • Caffeine, alcohol smoking not recommended
  • Why?
  • Remember "red on yellow, kill a fellow"
  • red on black, friend of
    Jack

43
Bites Stings
  • Antivenin
  • Do you know how it is made?
  • Venom injected in animal ? antibodies made ?
  • antibodies harvested
  • Do we have enough?
  • No
  • Coral snake bites
  • treat with intubation mechanical ventilation
  • antivenin no longer made in US
  • what is left expired in 2009

44
Bites StingsTick bites
  • Lyme Disease
  • (mimics other diseases)
  • Caused by
  • spirochete borrelia burgdorferi (tick)
  • Inflammatory disorder
  • 3 stages
  • Initial rash (bulls 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
45
Poisoning
  • 1-800-POISON1 (1-800-222-1222)
  • Treatments
  • Activated charcoal, gastric lavage, eye/skin
    irrigation, hemodialysis, hemoperfusion, urine
    alkalinization, chelating agents and antidotes
    acetylcysteine (Mucomyst)
  • Contraindicated (charcoal gastric lavage)
  • AMS, ileus, diminished bowel sounds, ingestion of
    substance poorly absorbed by charcoal (alkali,
    lithium, cyanide)

46
Agents of TerrorismTypes
  • Bioterrorism
  • Anthrax, plague, tularemia, smallpox, botulism,
    hemorrhagic fever
  • Chemical terrorism
  • Sarin, phosgene, mustard gases
  • Radiological/Nuclear terrorism

47
Agents of TerrorismBioterrorism
  • Anthrax
  • Bacillus Anthracis - bacteria that forms spores
  • 3 types
  • cutaneous, inhalation, gastrointestinal
  • As a weapon
  • 2001 Postal Service
  • Treatment
  • 60 day course of antibiotics
  • (streptomycin or gentamicin)
  • Vaccination not available to general public at
    this time

48
Agents of TerrorismBioterrorism
  • Plague
  • Yersinia Pestis bacteria found in rodents
  • 2 types
  • Bubonic from rodent bites
  • Pneumonic person to person
  • As a weapon
  • Pneumonic plague can spread through the air
  • Infecting anyone who breaths it
  • Symptoms due not show for 1 to 6 days
  • Many easily infected
  • Treatment
  • Antibiotics (streptomycin or gentamicin)

49
Agents of TerrorismBioterrorism
  • Tularemia
  • Francisella Tularensis bacteria found in
    rodents rabbits
  • Can be spread by
  • Breathing in spores
  • Being bitten by carrier
  • Drinking contaminated water
  • (not spread person to person)
  • As a weapon
  • Would most likely be used as an aerosol
  • Could also contaminate water sources
  • Treatment
  • antibiotics

50
Agents of TerrorismBioterrorism
  • Smallpox
  • Variola virus
  • Treatment no specific treatment
  • disease has a very systematic progression
  • Prevention vaccine
  • Botulism
  • Clostridium Botulinum toxin made by bacteria
  • foodborne, infantile, wound
  • S/S muscle paralyzing disease
  • Treatment antitoxin
  • Hemorrhagic fever
  • Treatment no established treatment

51
Agents of Terrorism
  • 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

52
Agents of Terrorism
  • Radiologic/Nuclear Terrorism
  • Radiologic dispersal devices (RDDs)
  • 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

53
Radiologic/Nuclear Terrorism(FYI)
  • American Nuclear Society
  • Extremity (arm, leg, etc) Xray 1 mrem
  • Dental Xray 1 mrem
  • Chest Xray 6 mrem
  • Nuclear Medicine (thyroid scan) 14 mrem
  • Neck/Skull Xray 20 mrem
  • Pelvis/Huip Xray 65 mrem
  • CAT Scan 110 mrem
  • Upper GI Xray 245 mrem
  • Barium Enema 405 mrem
  • A single dose of around 300,000-500,000 mrem is
    usually considered produce death in 50 of the
    cases.
  • How much is okay?

54
Radiological/Nuclear Disasters
  • 2011 Fukishima
  • Japan
  • 1986 Chernobyl
  • Ukraine
  • 1969 Lucens reactor
  • Lucens, Vaud, Switzerland
  • 1961 K-19 nuclear accident
  • Russian nuclear submarine accident
  • 1957 Kyshtym disaster
  • Russia
  • 1957 Windscale fire
  • Great Britain

55
Zones of decontamination
  • Hot zone the area with the highest concentration
    of the toxic agent. In hospital shower area.
  • Warm zone the area next to hot
    zone/decontamination shower. This area is
    considered minimally contaminated.
  • Cold zone all hospital areas that are free of
    contamination.

56
Case Study Mike Jones
  • 29 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 sites
  • Generalized malaise lightheadedness, weakness
    nausea

http//www.firefighter-emt.com/archives/case-stud
y-anaphylactic-shock-from-bee-stings.php
57
Case Study M. Jones
  • Question
  • What are your concerns at this time?
  • What questions would you ask?
  • What would you suggest the man do?

58
Case Study M. Jones
  • Question
  • What are your concerns at this time?
  • Anaphylaxis
  • Circulation
  • What questions would you ask?
  • Where was he bitten?
  • Airway issues?
  • Allergies?
  • What would you suggest the man do?
  • ER
  • Take off jewelry, watches, bands etc.

59
Case Study M. Jones
  • Co-workers convince man to go to the hospital 5
    miles away they transport him.
  • During transport complaints of
  • Increased nausea
  • Some difficulty breathing
  • Audible wheezing
  • What would you suggest the coworkers do at this
    time?

60
Case Study M. Jones
  • Co-workers stop at local convenience store and
    call 9-1-1
  • While in the parking lot
  • M. Jones becomes unresponsive
  • Periods of apnea
  • No apparent pulse
  • What should the co-workers do at this time?

61
Case Study M. Jones
  • There was a severe thunder and lightening storm
    occurring, so the co-workers left the man inside
    the truck thinking the outside conditions would
    be hazardous
  • The man is found still in the vehicle when EMS
    arrived

62
Case Study M. Jones
  • What would you anticipate EMS to do when they
    arrive on the scene? (Prioritize)

Next
63
Case Study M. Jones
  • EMS interventions
  • Assess ABCs
  • man was pulseless apenic
  • Remove pt from vehicle
  • CPR initiated
  • Assess cardiac rhythm
  • asystole
  • Epinephrine given (Dose? Route?)
  • Intubation
  • Recheck rhythm
  • VFib
  • Defibrilliate
  • 200J
  • CPR continued transported to hospital

64
Case Study M. Jones
  • What are some things you have to worry about in a
    situation like this, with regard to airway?

65
Case Study M. Jones
  • In route to hospital Crew noted
  • No rash
  • Minimal facial or airway swelling
  • At facility
  • Multiple doses of Epi given
  • Palpable carotid pulse developed
  • Within 20mins
  • BP 100/60
  • HR 110
  • Epinephrine gtt _at_ 4 micrograms/min

66
Case Study M. Jones
  • Yea!!!!! They saved him.
  • Or did they?
  • What other assessments do you want before you
    start celebrating?

67
Case Study M. Jones Outcome
  • No neurological response after 3 days in ICU
  • Decision to discontinue life support
  • Family provides history
  • What will happen before life support d/cd?
  • What happened to this patient (diagnosis)?
  • How could it have been prevented?
  • What would you do differently?
  • Case study found at JEMS.com

68
Outcomes M. Jones
  • Before life support d/c
  • TOSA called
  • Diagnosis
  • Anaphylactic shock
  • Sudden cardiac arrest 2nd to anaphlaxis
  • Prevention
  • EPI pen would need to tell someone
  • What to do differently?
  • Call 911 right away
  • Start CPR right away

69
Case Study Sally Smithadapted from
http//www.casesjournal.com/content/2/1/9103
  • 24 year old, healthy female, driving SUV on sunny
    day in February in Austin TX.
  • Air was calm, ambient temperature of 67F
  • Loses control of car near a park- car submerges
    into man made pond 6 feet deep
  • Witnesses were at the scene
  • Water temperature was 42F

70
Case Study S. Smith
  • Witnesses call 911
  • Witness reports reveal
  • One witness attempted to enter the water but the
    water was too frigid and he had to turn back
  • After approx. 2 minutes in the water, woman was
    able to break the back window of the SUV and
    escape
  • Woman was yelling for help and struggling to swim

71
Case Study S. Smith
  • EMS and Fire Rescue arrive on the scene
    approximately 12 minutes after woman initially
    went in to the water
  • 2 firefighters attempted to enter the water but,
    again, were forced to turn back before they were
    able to reach the woman
  • By the time the rescue team made
  • it to the woman, she had been in
  • the water for approx 22 minutes
  • The woman was face down,
  • lifeless and pulseless

72
Case Study S. Smith
  • At this point, what interventions would you
    complete?
  • A. Perform CPR
  • B. Shake the patient, if necessary, t0
  • prevent/assess for loss of consciousness
  • C. Rub the patients extremities to keep promote
  • rewarming
  • D. Cover with blankets
  • E. Remove wet garments
  • F. Elevate the patients head
  • G. Avoid rough movements if possible
  • Why would this not apply to this person?

73
At the scene
  • Vitals
  • No pulse, unreadable blood pressure
  • Neuro
  • No eye movement, fixed dilated pupils
  • No response to pain, nonverbal
  • What is her GCS?
  • CPR
  • Initiated and performed for 15 minutes
  • 2mg Epi
  • Spontaneous circulation regained
  • Airway
  • Limited respiratory effort --- ET tube placed
  • Transfer
  • 10 minutes in route to ER

74
Case Study S. Smith
  • Upon arrival to ER approximately 25mins after
    being pulled from the water
  • Assessment
  • Initial vitals Core body temp 92.1F HR 64
    decreased drive to breath, BP 98/75 O2Sats 86
    RA
  • Assumptions she may have swallowed a large
    amount of pond water
  • What concerns you?

75
Case Study S. Smith
  • What level of hypothermia would this patient be
    classified as
  • A. Mild
  • B. Moderate
  • C. Profound

76
Case Study S. Smith
  • What other assessment information do you want?
  • LABS
  • Na 144 K 5.0 Cl 102
  • Glucose 238 BUN 17 Creat 1.9 Ca 10.2
  • CBC normal/ex. WBC 25
  • ABG pH 6.52 pCO2 75 HCO3 3.6
  • PaO2 50 on 100 FiO2 lactate 28mmol/L
  • What concerns do you have regarding these labs?
  • What is this patients metabolic status?

77
Case Study S. Smith
  • CXR
  • Mixed interstitial and alveolar infiltrates
    bilaterally
  • EKG
  • Afib
  • Which interventions are appropriate at this time?
  • A. Observation
  • B. Electrical cardioversion
  • C. Anticoagulation
  • D. Pharmacological cardioversion

78
Case Study S. Smith
  • Admitted to ICU
  • DX _____________ _____________
  • What orders/interventions would you expect?

79
Case Study S. Smith
  • Admitted to ICU
  • DX hypoxic brain injury aspiration pneumonia
  • What orders/interventions would you expect?
  • Sedation
  • Ventilation to control acidosis and hypoxia
  • IV fluids
  • Antibiotics
  • NGT tube
  • THERAPUETIC HYPOTHERMIA

80
Case Study S. SmithTherapeutic Hypothermia
  • Arctic Sun
  • Goal temp is 89.6-93.2 F
  • Ms. Smith
  • by the time the cooling device was placed on the
    patient, her temp dropped to 87.08 she was
    initially warmed to target temp of 93.2 F.
  • Why did her temperature drop so low?
  • 20 hours of active cooling then passively
    re-warmed

81
Arctic Sun
  • http//www.medivance.com/arcticsun5000

82
Case Study S. SmithOutcome
  • Average temp for 24hrs 93.4
  • Acidosis corrected in 1st 8hrs
  • Pupils responded to light in 8hrs
  • Seizure on day 2 dilantin started
  • GCS improved by day 3 with spontaneous eye
    movements and obeying commands
  • Day 4 transferred to dependant unit with GCS 15
  • Eventually transferred to rehab 3 months post
    injury independent with ADLs expected to
    discharge home

83
Why does it work?
  • Thought to allow for
  • Decreased metabolic demand of brain
  • Allow for healing time
  • Must be in a controlled enviorment
  • Time of hypothermia very important
  • Only 12-24 hours

84
Case Study Johnny Williams adapted from
http//www.vhct.org/case699/begin_the_case.htm
  • 5 year old boy, 21.8kg, camping with family at
    Inks Lake
  • Unaccounted for for about 15 mins while on a
    nature hike
  • Body found floating in lake, face down
  • Immediately pulled from water and CPR started by
    his father

85
Case Study J. Williams
  • You are a nurse in the ED where Johnny will be
    arriving. What would you do to prepare for
    arrival?

86
Case Study J. Williams
  • On arrival to ED
  • Assessment
  • Cyanotic
  • Pulseless
  • Apneic
  • Fixed and dilated pupils
  • Core body temp 89F
  • CPR continued
  • With this information, what will you anticipate?

87
Case Study J. Williams
  • After airway established and other assessments
    complete, rewarming begins.
  • How would you rewarm this patient?
  • What do we worry about with regard to CPR,
    hypothermia, and cardiac dysrhythmias?
  • What do you have to watch for during the
    rewarming process?

88
Case Study J. Williams
  • 20 mins after intubation/mechanical ventilation,
  • spontaneous HR returns
  • adequate BP of 103/65
  • core temp of 95F
  • What happens next?

89
Case Study J. WilliamsOutcome
  • 5 days in PICU ventilated
  • Eventually weaned off of ventilator
  • 5 more days on medical unit
  • Recovery anticipated with deficits

90
Case Study Extra InfoChildrens Health
Encyclopedia
  • 0-4 years old --- pools implicated in 60-90 of
    drowning
  • also bathtubs
  • Teen boys --- natural bodies of water
  • Roughly 4 out of 5 drowning victims are male
  • Death or permanent neurological damage is very
    likely when patients arrive at the emergency room
    comatose or without a heartbeat.
  • Of these patients, 35 to 60 percent die in the
    emergency department
  • Almost all of those who survive have permanent
    disabilities.
  • Early rescue of near-drowning victims (within
    five minutes of submersion) and prompt CPR
    (within less than ten minutes of submersion) seem
    to be the best guarantees of a complete recovery
  • Extremely cold water (less than 41F or 5C)
    seems to protect individuals from some of the
    neurological damage that occurs with near
    drowning. Some hypothermic near-drowning victims
    have been revived after they appeared dead and
    have experienced few permanent disabilities.
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