Chapter 11

Care of Patients with Common Environmental Emergencies

Marion Kreisel MSN, RNAdult Health NU 230Fall 2011

Heat-Related Illnesses: Heat Exhaustion

• Heat exhaustion is a syndrome caused primarily by dehydration, stemming from heavy perspiration and inadequate fluid and electrolyte consumption during heat exposure over a period of hours to days.

• Patients feel ill, and their clinical manifestations resemble the flu.

• Treatment involves immediate termination of physical activity and transfer to a cool place.

Heat-Related Illnesses: Heat Stroke

• Heat stroke is a true medical emergency in which body temperature may exceed 104° F (40° C).

• High mortality rate if not treated in a timely manner.• Exertional heat stroke — sudden onset, typically

caused by strenuous physical activity in hot, humid conditions.

• Classic heat stroke — occurs over a period of time as a result of chronic exposure to a hot, humid environment.

Heat Stroke Assessment

• Profoundly elevated body temperature (>104° F or 40° C)• Mental status changes as a result of thermal injury to

the brain. Vertigo, syncopy, etc.• Hypotension, tachycardia, tachypnea• Hot and dry skin; however, persons may continue to

perspire

Heat Stroke Complications

• Multiple organ dysfunction syndrome• Renal impairment• Electrolyte and acid-base disturbances• Coagulopathy• Pulmonary edema• Cerebral edema

Heat Stroke Treatment

• In the prehospital setting, rapid cooling is the first priority of care after ensuring that the patient has a patent airway, effective breathing, and circulation

• Hospital care—oxygen therapy, IV 0.9% saline solution, Foley, aggressive cooling methods, continuous core temperature monitoring

• Thorazine 25 to 50 mg IM or IV for shivering• Valium for seizure activity

Snakebites

Envenomation

Pathophysiologic Effects of Pit Viper Envenomation

• Local tissue necrosis• Massive tissue swelling• Intravascular fluid shifts and hypovolemic shock• Pulmonary edema• Renal failure• Hemorrhagic complications from DIC

First Aid—Snakebite• First priority is to move the person to a safe area away from

the snake and encourage rest to decrease venom circulation.

• Remove jewelry and constricting clothing.• Immobilize affected extremity in a position of function.• Maintain the extremity below the level of the heart.• Keep individual warm and calm.• Do not offer any stimulants such as caffeine.• If transportation is delayed, apply a 2 to 4 cm constricting

band that is not used as a tourniquet.• Assess distal circulation frequently.• Do not incise and suck or apply ice to the wound.

Hospital Care—Snakebite

• Supplemental oxygen• Two large-bore IV lines for NSS or RL• Continuous cardiac and BP monitoring• Opioids• Tetanus prophylaxis• Wound care• Broad-spectrum antibiotics• Baseline labs and coagulation profile

Arthropod Bites and Stings• Bites from brown recluse spiders result in

ulcerative lesions:• Necrotic wound (necrotic arachnidism)• Systemic effects (loxoscelism)

First Aid—Brown Recluse Spider Bite• Use ice intermittently during the first 4 days after the bite.• Do not use heat.• Elevate the affected extremity.• Provide local wound care.• Rest the extremity.

Hospital Care— Brown Recluse Spider Bite• Topical antiseptic and sterile dressing • Possible antibiotics• Dapsone (Avlosulfon)• Possible reconstructive surgery• Supportive care for loxoscelism including management of

renal failure, leukopenia, seizures, hemolytic anemia, and coma

Black Widow Spider• Envenomation produces latrodectism, severe abdominal

pain, muscle rigidity and spasm, hypertension, and nausea and vomiting.

• Other symptoms include facial edema, ptosis, diaphoresis, weakness, increased salivation, priapism, respiratory difficulty, increased respiratory secretions, fasciculations, and paresthesias.

First Aid—Black Widow Spider Bite

• Apply an ice pack. Slows the neurotoxins• Monitor the individual for systemic toxicity.• Support the patient’s airway, breathing, and circulation.• Transport the patient to a medical facility.

Hospital Care—Black Widow Spider Bite• Monitor vital signs• Opioid pain medication• Muscle relaxants such as Valium, calcium gluconate• Tetanus prophylaxis• Antihypertensive agents as needed• Treatment of pulmonary edema, uncontrollable

hypertension, and shock

Tarantula• Largest spiders of the arachnid class.• Most bites to humans result in only local effects.• Treatment—supportive management, analgesics, immobilize

and elevate involved extremity, tetanus prophylaxis.• Remove tarantula hairs as soon as possible through

repeated use of sticky tape or duct tape, and then thoroughly irrigate the skin.

Scorpion Sting• Effects of a sting that injects venom from a scorpion are

typically self-limiting and best treated by analgesics, supportive management, and basic wound care.

• One species of scorpion can inflict a sting associated with a severe, potentially fatal systemic response.

Interventions for Scorpion Sting

• Vital sign assessment• Continuous monitoring for symptom

progression• Ice pack to sting site to control pain• Analgesic and sedative agents• Treat fever• Tetanus prophylaxis• Basic wound care

Bees and Wasps• Potential for anaphylactic reaction• Emergency care to remove stinger and apply an ice pack• Advanced emergency care in a hospital to ensure that the

airway, breathing, and circulation are maintained• “EpiPen” administration of epinephrine with the click

of a button, which is especially valuable for allergic patients

• Call 911

Lightning Injuries

• Both the cardiopulmonary and the central nervous systems are profoundly affected by lightning injuries.

• Most lethal initial effect on the cardiopulmonary system is asystole.

• Treatment includes immediate CPR.• Rescuer is in no danger of electrical charge from contact

with the victim.• MOVE VICTIMS TO A SAFE AREA!

Hypothermia

• Hypothermia occurs at core body temperature of <95° F (35° C)

• Mild hypothermia (32° C to 35° C)• Moderate hypothermia (28° C to 32° C)• Severe hypothermia (<28° C)

Hospital Treatment—Hypothermia• Mild Hypothermia: Shivering, slurred speech, poor

muscle control and impaired cognitive abilities.• TX MH: dry clothes, warm blankets, slow warm• Moderate and severe hypothermia: heart slows eventually

can lead to V-FIB• Prevent ventricular fibrillation• Horizontal position• Maintenance of ABCs• Extracorporeal rewarming methods: Huggy Bear, Warm IV’s

Frostbite

• Frostbite is accompanied by initial pain, numbness, and pallor of the affected area.

• Deep frostbite requires aggressive management in a medical facility.

Altitude-Related Illness

• Elevations >5000 ft can produce physiologic responses in the body that can be fatal

• Acclimatization: Slowly. Get higher gets colder watch for S&S of hypothermia (white skin)

• Acute mountain sickness (AMS)• High altitude cerebral edema (HACE): If you can’t think

straight get to lower altitude• High altitude pulmonary edema (HAPE). normal to be

short of breath moving but at rest not. • Medical treatment may include the drug acetazolamide

(Diamox, Apo-Acetazolamide) to prevent and treat acute mountain illness

Near-Drowning Event• Prevention is key• Mostly children• Safe rescue of the victim• After removal from the water, airway and cardiopulmonary

support interventions• CPR if necessary• REMEMBER ABC not CBA: Get air into the child asap• Gastric decompression• Support of body systems

Chapter 11

Care of Patients with Common Environmental Emergencies

NCLEX TIME

Question 1

True or False: Young adult males account for the majority of lightning-related deaths.

A. TrueB. False

Question 2

A patient is brought into the emergency department after becoming ill while working on a construction site. During the assessment, he complains of weakness, nausea, and vomiting. His blood pressure is abnormally low, and he is complaining of severe foot pain. He ismost likely suffering from a:

A. Brown recluse spider bite B. Myocardial infarction C. Cerebrovascular accident D. Snakebite

Question 3While trying to finish mowing his lawn before a thunderstorm, your neighbor is struck by lightning. You go to him to assess the situation, and you note that he is unconscious but breathing. He is severely burned on both of his hands. What is the priority of care?

A. Covering the skin burns with a dressingB. Performing cardiopulmonary resuscitation C. Taking care not to touch him for several minutes because of the

electrical charge D. Spinal immobilization with attention to stabilization of airway, breathing,

and circulation

Question 4

Hypothermia is defined as a core body temperature less than:

A. 90 FB. 92 F C. 95 F D. 97 F

Question 5

A woman is brought to the emergency department by her boyfriend. They had been hiking and were caught in a snowstorm, and she has severe frostbite on her feet. The boyfriend had applied dry chemical warmers and was rubbing her feet before she was admitted. The nurse expects these actions to result in:

A. Possible further tissue injury B. Less pain during the rewarming session C. Reduction of the area of injury D. Reduction of swelling of the injured area