Environmental Emergencies

CHAPTER 14 Environmental Emergencies

Kathleen Flarity, ARNP, PhD, CEN, CFRN, FAEN

General Strategy

Analysis: Differential Nursing Diagnoses/Collaborative Problems

Planning and Implementation/Interventions

Evaluation and Ongoing Monitoring

Documentation of Interventions and Patient Response

Age-Related Considerations

Specific Environmental Emergencies

Heat-Related Emergencies

Heat Exhaustion

Cold-Related Emergencies

Water-Related Emergencies

Submersion Injuries

Bites and Stings

Domestic/Wild Animals

Aquatic Organism Injuries

High-Altitude Illness

Acute Mountain Sickness

High-Altitude Cerebral Edema

High-Altitude Pulmonary Edema

Diving Emergencies (Dysbarism)

Decompression Sickness

Arterial Gas Embolism

I. GENERAL STRATEGY

A. Assessment

1. Primary and secondary assessment/resuscitation (see Chapter 1)

2. Focused assessment

a. Subjective data collection

1) History of present illness/injury/chief complaint

a) Mechanism of environmental exposure

(1) Time of exposure or when injury occurred

(2) Length of time in the environment or since the incident occurred (e.g., time of submersion)

(3) Underlying factors predisposing patient to exposure/injury: mental status, use of alcohol or mind-altering substances, lack of available shelter or appropriate clothing, activity before exposure/injury

d) Pain (see Chapter 9)

(1) Location of injury and severity of pain

(2) Radiation with injury or toxicity, especially with envenomation

g) Efforts to relieve symptoms

(1) Home remedies

(2) Alternative therapies

(3) Medications

(a) Prescription

(b) Over-the-counter/herbal

2) Past medical history

b) Prior environmental injury (hypothermia, hyperthermia)

c) Substance and/or alcohol use/abuse

d) Smoking history

e) Last normal menstrual period: female patients of childbearing age

h) Immunization status

i) History of previous rabies immunization

j) History of previous antivenom therapy

3) Psychological/social/environmental factors

b) Physical factors

(2) Malnutrition

(3) Lack of psychological and physical preparation

c) Social risk factors

(1) Homelessness or lack of appropriate shelter

(2) Lack of appropriate clothing

(3) Possible/actual assault abuse, intimate partner violence situations (see Chapter 3)

e) Recreational risk factors

(1) Amateur athletics

(2) Long-distance running

(3) Vigorous exercise

(4) Heavy exertion

(5) Cold weather sports

(6) Hiking/walking in unfamiliar areas

b. Objective data collection

1) General appearance

a) Level of consciousness, behavior, affect

f) Level of distress/discomfort

3) Auscultation

a) Breath sounds

b) Heart sounds

c) Bowel sounds

a) Peripheral and central pulses

b) Skin temperature

c) Area tenderness

d) Motor/sensory

3. Diagnostic procedures

a. Laboratory studies

1) Complete blood count (CBC) with differential

2) Serum chemistries including glucose, blood urea nitrogen (BUN), and creatinine

3) Liver profiles

4) Coagulation profiles

5) Type and crossmatch

6) Arterial blood gas (ABG)

7) Creatine kinase (CK)

8) Urinalysis; pregnancy test in female patients of childbearing age

9) Serum and urine toxicology screen

b. Imaging studies: as indicated by injury

1) Plain radiograph

2) Computed tomography (CT) scan

3) Magnetic resonance imaging (MRI)

1) 12- to 15-lead electrocardiogram (ECG)

B. Analysis: Differential Nursing Diagnoses/Collaborative Problems

1. Ineffective airway clearance

2. Impaired gas exchange

3. Deficient fluid volume

4. Hyperthermia

5. Hypothermia

6. Impaired skin integrity

7. Acute pain

8. Risk for infection

9. Deficient knowledge

C. Planning and Implementation/Interventions

1. Determine priorities of care

a. Maintain airway, breathing, and circulation (see Chapters 1 and 31)

b. Provide supplemental oxygen as indicated

c. Establish intravenous (IV) access for administration of crystalloid fluid/blood products/medications as needed

d. Obtain and set up equipment and supplies

e. Prepare for/assist with medical interventions

f. Administer pharmacologic therapy as ordered

2. Relieve anxiety/apprehension

3. Allow significant others to remain with patient if supportive

4. Educate patient and significant others

D. Evaluation and Ongoing Monitoring (see Appendix B)

1. Continuously monitor and treat as indicated

2. Monitor patient response/outcomes, and modify nursing care plan as appropriate

3. If positive patient outcomes are not demonstrated, reevaluate assessment and/or plan of care

E. Documentation of Interventions and Patient Response

F. Age-Related Considerations

1. Pediatrics

a. Growth or development related

1) Death from drowning is among the leading causes of death in children

2) Infants and small children have small airways, which are more easily obstructed by edema

3) Children have a large ratio of body surface area to body weight and lose body heat more easily

4) Children have less adipose tissue to maintain body heat and to provide insulation

5) Infants less than 3 months of age are unable to produce heat through shivering and must burn brown fat for thermogenesis

6) Children are dependent on caregivers to educate and protect them about the environment in which they live

7) The potential for maltreatment should be considered (e.g., drowning may occur as a result of a lack of supervision)

8) Children’s healing responses are more rapid than those of adults

b. “Pearls”

1) Children are curious and want to explore their environment; they may be exposed to danger from the environment with little fear of the consequences of their actions (e.g., young children may not be afraid of a dog they do not know and may approach the animal without fear)

2) Adolescents may take more risks because of peer pressure (potential consequences of this behavior include drowning as a result of swimming while intoxicated)

3) Children are at a greater risk for injury from heat and cold emergencies because of their immature nervous system and dependency on caregivers to maintain the environment around them

4) Children are at greater risk for complications from envenomation because of their smaller size and lower body weight

2. Geriatric

a. Aging related

1) A decrease in elasticity of lung tissue and a decrease in amount of alveoli may contribute to a limited ability to respond to toxic inhalation exposures

2) Cardiovascular changes that occur with aging cause decreased distensibility of blood vessels, increased systemic resistance, decreased cardiac output, and decreased response to stress

3) Increased risk for hyperthermia or hypothermia because of an inability to vasodilate or vasoconstrict blood vessels; decreased cardiac output; and decreased subcutaneous tissue

4) Delayed and diminished sweat response

5) Thirst mechanism becomes less efficient with aging, as does the kidney’s ability to concentrate urine, thus increasing the risk of heat-related dehydration

6) Inactivity and immobility increase susceptibility to hypothermia by suppressing shivering and reducing heat-generating muscle activity

7) Medications such as beta-blockers can interfere with the body’s ability to increase heart rate in response to environmental emergencies

b. “Pearls”

1) Elderly patients have thinner skin and may sustain more serious injury from bites

2) Fluid overload during resuscitation can cause serious consequences

3) Elderly patients with altered mental status are dependent on caregivers to protect them from danger in the surrounding environment

II. SPECIFIC ENVIRONMENTAL EMERGENCIES

A. Heat-Related Emergencies

Heat-related emergencies occur when the body is no longer able to regulate its body temperature through normal physiologic mechanisms. Thermoregulation occurs through the preoptic anterior hypothalamus. Information about body temperature is sent to the brain by peripheral and central thermoreceptors located in the skin, limb muscles, and spinal cord. The hypothalamus then initiates methods that help the body maintain a normal or tolerable body temperature. The body attempts to maintain a temperature of 98.6°F (37.1°C). When the body is exposed to excessive heat, it will attempt to dissipate the heat by convection, radiation, or evaporation. Drugs, strenuous activity, and high ambient temperatures can increase internal heat production. Factors such as lack of acclimation, restrictive clothing, and high humidity affect the body’s ability to manage excessive heat. As the body’s temperature increases, there is stimulation of the sweat response to initiate evaporative heat loss. This is the body’s primary mechanism of cooling. Sweating not only assists in cooling the body but also may cause loss of body weight, sodium, and potassium. If fluids and electrolytes are not replaced, dehydration can occur. The body also attempts to dissipate heat by shunting blood to the skin. There is an increase in heart rate, stroke volume, and cardiac output. Additionally, the kidneys conserve fluid for evaporation by retaining salt and water. Under normal circumstances, with time to acclimate, these compensatory mechanisms assist the body in sustaining a normal temperature. However, if additional factors contribute to the heat stress, these mechanisms will fail, resulting in a heat-related emergency. People at risk for heat-related emergencies include the young, the elderly, and individuals not acclimated to hot weather. Heat exhaustion and heat stroke represent progressive degrees of heat illness (Table 14-1).

Table 14-1 HEAT-RELATED EMERGENCIES AND INTERVENTIONS

Emergency	Clinical Presentation	Interventions
Heat cramps	Brief, intermittent severe muscular cramps in muscles fatigued by heavy work, excessive fatigue, decreased coordination, nausea, vomiting, headache, dizziness	Place patient in cool environment and massage affected muscles; patient should rest until symptoms subside; administer intravenous salt solution: 0.9% normal saline 1000 mL, over 1 to 3 hr or 23.5% saline in 10- to 20-mL increments; or 0.1% saline solution orally; monitor electrolytes and magnesium levels, with replacement as needed
Heat exhaustion	Dehydration, malaise, weakness, flulike symptoms, thirst, tachycardia, frontal headache, and muscle cramps	Fluid and electrolyte replacement based on serum electrolytes and calculation of body water deficit; spontaneous cooling to 102° F (39 C); acetaminophen (Tylenol) or ibuprofen (Motrin, Advil) may be administered
Heat stroke	Hot, dry skin, altered level of consciousness, psychotic behavior, delirium, coma, seizures, and severe muscle cramps; temperature ranges from 106 F (41.4° C) to 116 F (47° C); this is a neurologic emergency	Aggressive cooling to 102° F (39° C) within 1 hr; mannitol (Osmitrol) may be administered to decrease intracranial pressure; initiate respiratory and cardiovascular support early

Heat Cramps (see Table 14-1)

Heat cramps result from depletion of fluids and electrolytes in exerted muscles. The patient is usually in good health but has not adequately replaced the fluids and electrolytes lost while sweating. The patient complains of pain in the exerted muscles and thirst. Treatment includes cessation of the exertional activity, resting in a cool place, massage of the painful areas, and replacement of fluids with a balanced solution such as a commercially prepared sports drink (e.g., Gatorade).

Heat Exhaustion (see Table 14-1)

Heat exhaustion is precipitated by major exertion in hot weather. Peripheral vasodilatation occurs to dissipate heat, and fluids and electrolytes are lost through profuse sweating. The patient’s core body temperature may be high normal or as high as 104°F (39°C). On physical examination, the patient is pale, ashen, and sweating profusely. The patient may complain of weakness or may present with altered mental status. Additional symptoms include hypotension, tachycardia, and severe thirst. Treatment includes the following: placing the patient in a cool environment; managing the airway, breathing, and circulation; and monitoring for cardiac dysrhythmias, including ventricular aberrance and peaked T waves secondary to electrolyte imbalances. Muscle damage may occur at high temperatures; therefore, the patient must be monitored for symptoms of rhabdomyolysis (e.g., dark urine, muscle cramps).

Heat Stroke (see Table 14-1)

Heat stroke is a medical emergency. The patient is no longer able to dissipate heat because of failure of the central thermoregulation mechanisms. Morbidity is directly related to the amount of time the patient’s body temperature remains elevated. Exertional heat stroke occurs primarily in young athletes. There is a history of extreme exertion in a hot environment with symptoms occurring over hours. Classic, or nonexertional heat stroke, more commonly occurs during periods of exposure to environmental temperatures exceeding 102.5°F (39.2°C) for a prolonged period of time. Risk factors include age extremes, concurrent use of phenothiazines, and debilitation. There is a lack of acclimation, and the core body temperature rises to greater than 106°F (41°C). The patient’s mental status ranges from confusion to coma, and the skin is hot and dry. Because of fluid loss, the patient is hypotensive and tachycardic. Patients with preexisting cardiovascular disease are prone to developing a hypodynamic state with a low cardiac index (output) and high systemic vascular resistance. Cardiovascular collapse may follow. Treatment includes stabilization of the patient’s airway, breathing, and circulation, along with rapid cooling. There continues to be controversy about which method is best. Cooling methods include the following: removal of clothing, covering the patient with wet sheets, and using a fan to enhance evaporative cooling; providing an ice water bath (conductive cooling); and administering cool fluids. Whatever cooling method is chosen, the patient’s temperature must be closely monitored, and shivering must be controlled. Fluid and electrolyte imbalances must be corrected, and the patient must be monitored for rhabdomyolysis. Clotting studies should be obtained to monitor the patient for the development of disseminated intravascular coagulation (DIC), a potential complication of heat stroke.

1. Assessment (heat exhaustion/heat stroke)

a. Subjective data collection

b. Objective data collection

2. Analysis: differential nursing diagnoses/collaborative problems

a. Risk for ineffective airway clearance

b. Impaired gas exchange

c. Deficient fluid volume

d. Ineffective tissue perfusion

e. Ineffective thermoregulation

f. Deficient knowledge

3. Planning and implementation/interventions

a. Maintain airway, breathing, and circulation (see Chapters 1 and 31)

b. Provide supplemental oxygen as indicated

1) Rapid-sequence intubation (RSI) and ventilatory support in a patient with a compromised airway

2) High-flow oxygen

c. Establish IV access for administration of crystalloid fluid/medications

d. Prepare for/assist with medical interventions

1) Advanced airway management

a) Nasal or oral intubation

b) Laryngeal mask airway

d) Surgical airway (e.g., cricothyrotomy)

3) Institute cardiac and pulse oximetry monitoring

4) Insert gastric tube and attach to suction

5) Insert indwelling urinary catheter

6) Assist with hospital admission

e. Administer pharmacologic therapy as ordered

1) RSI premedications: sedatives, analgesics, neuromuscular blocking agents

2) Mannitol (Osmitrol) may be considered to reduce intracerebral swelling

3) Chlorpromazine (Thorazine) or benzodiazepines to reduce shivering

4. Evaluation and ongoing monitoring (see Appendix B)

a. Airway patency

b. Level of consciousness

c. Hemodynamic status

d. Body core temperature

e. Breath sounds and pulse oximetry

f. Cardiac rate and rhythm

g. Intake and output

B. Cold-Related Emergencies

In a cool environment, the body will attempt to maintain normothermia by conserving heat through vasoconstriction and producing heat through shivering. Risk factors for developing a cold-related emergency include extremes of age, ambient temperature, inappropriate clothing, wet clothing, water/metal contact, wind, and length of exposure. Alcohol, drugs such as phenothiazines, trauma, and illnesses such as diabetes pose additional risks for the development of cold-related emergencies. Cold-related emergencies include frostbite and hypothermia.

Frostbite

Frostbite is true tissue freezing, which is the formation of ice crystals in the tissue. Ninety percent of frostbite cases involve the hands and feet; the cheeks, nose, ears, and penis are also commonly affected. Contributing factors include alcohol intoxication, homelessness, and not being appropriately dressed for the weather. The initial response to cold stress is peripheral vasoconstriction. Cooling increases blood viscosity and decreases capillary perfusion. It results in sludging and thrombosis of the vessels, decreased blood flow, and vascular stasis, which contribute to the development of tissue damage. Subsequently, alterations in vascular permeability lead to edema, progressive dermal ischemia, inflammatory mediator release, neutrophil adhesion, and endothelial damage.

Frostbite may be divided into four degrees, based on the appearance after rewarming: first-degree injury with a central, pale area and surrounding erythema; second-degree injury with blisters surrounded by erythema and edema; third-degree with hemorrhagic blisters and eschar formation; and fourth-degree frostbite with necrosis and tissue loss. Any patient with frostbite must always be evaluated for hypothermia. Treatment includes rewarming of the affected part, pain management, and wound care.

1. Assessment

a. Subjective data collection

b. Objective data collection

2. Analysis: differential nursing diagnoses/collaborative problems

a. Impaired tissue integrity

b. Ineffective tissue perfusion

c. Risk for infection

f. Anxiety/fear

3. Planning and implementation/interventions

a. Maintain airway, breathing, and circulation (see Chapters 1 and 31)

b. Provide supplemental oxygen

c. Establish IV access for administration of crystalloid fluids/medications

d. Prepare for/assist with medical interventions

1) Because most tissue damage occurs during the thaw-and-refreeze cycle, rewarming is begun when the body part can be warmed and not reexposed to cold

a) Remove wet clothing

b) Rewarm affected extremity in a warm (100.8°F to 106°F [38.2°C to 41.1°C]), agitated water bath

c) Rewarming activity continues until the body part appears pink or reddened

2) Leave hemorrhagic blisters intact

3) Assist with debridement of nonhemorrhagic blisters because they contain high levels of inflammatory mediators

4) Rinse with sterile water (90°F to 95°F [32.2°C to 35°C])

5) Pat dry, and apply a nonconstrictive, protective, bulky barrier dressing

6) Elevate the affected area to limit edema

7) Assist with hospital admission

e. Administer pharmacologic therapy as prescribed

1) Non-narcotic analgesics

3) Ibuprofen (Motrin, Advil)

5) Tetanus immunization

f. Educate patient and significant others

1) Hazards and effects of cold exposure

2) Need for protective clothing

3) Early signs and symptoms of frostbite

4) Avoidance of tobacco, caffeine, and alcohol

4. Evaluation and ongoing monitoring (see Appendix B)

a. Circulation, sensation, motor movement of involved digits

b. Pain relief

Hypothermia

Hypothermia has been defined as a core body temperature of less than 95°F (35°C). Hypothermia results when the body cannot maintain an adequate temperature. The body produces heat through cellular metabolism, muscle activity, and shivering. Heat is lost through conduction, convection, evaporation, and radiation. The ambient temperature does not have to be very low to cause hypothermia. Hypothermia needs to be rapidly recognized and treated in an effort to avoid life-threatening complications such as apnea, ventricular fibrillation, and acidosis. There are multiple risk factors for hypothermia, including the following: age (pediatric patients because of their inability to shiver and decreased body fat and elderly patients because of the high incidence of cardiovascular disease and decreased body fat); medications, such as phenothiazines and neuromuscular blocking agents, which interfere with the patient’s ability to shiver; alcohol; traumatic injury; shock; and diseases such as diabetes. The treatment of hypothermia focuses on returning the core body temperature to normal and providing supportive care. The method of rewarming is dependent on the severity of hypothermia.

1. Assessment

a. Subjective data collection

b. Objective data collection

1) Physical examination

a) General appearance

(1) Level of consciousness, behavior, affect: confusion to coma

(2) Subnormal temperature

(a) Mild hypothermia: 93°F to 95°F (35°C to 36°C)

(b) Moderate hypothermia: 86°F to 93°F (30°C to 34°C)

(c) Severe hypothermia: less than 86°F (30°C)

(3) Hypoventilation

(4) Hypotension: difficult to detect blood pressure

(5) Moderate to severe distress/discomfort, possibly critically ill

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Tags: Emergency Nursing Core Curriculum

Nov 8, 2016 | Posted by admin in NURSING | Comments Off

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