Lippincott Manual of Nursing Practice, 8 th Ed Acute Biologic Crisis mikEL rlh mantong

ENVIRONMENTAL EMERGENCIES Heatstroke

Heat Exhaustion Heatstroke is a medical emergency that can result in significant
morbidity and mortality. It is defined as the combination of
Heat exhaustion is the inadequacy or the collapse of peripheral hyperpyrexia (105° F [40.6° C]) and neurologic symptoms. It is
circulation due to volume and electrolyte depletion. Heat caused by a shutdown or failure of the heat-regulating mechanisms
exhaustion is one condition in the spectrum of heat-related of the body.
illnesses, including heat rash, heat edema, heat cramps, and heat
Primary Assessment and Interventions
syncope. Untreated heat exhaustion may progress to heatstroke.
Primary Assessment and Interventions  Assess airway, breathing, and circulation.
 LOC may be altered.
 Expect the patient to be alert without significant
cardiorespiratory or neurologic compromise.  Expect to intervene immediately if cardiovascular collapse
occurs.
 If vital functions are significantly impaired, suspect
secondary condition, such as MI or stroke. Subsequent Assessment
Subsequent Assessment  Obtain a history from accompanying person about
environmental conditions, activity, underlying health, and
 Obtain history of headache, fatigue, dizziness, muscle
medications that may have contributed to heatstroke.
cramping, and nausea.
 Perform a neurologic assessment.
 Inspect skin usually pale, ashen, and moist.
o Initially, the patient may exhibit bizarre behavior
 The temperature may be normal, slightly elevated, or as
or irritability. This may progress to confusion,
high as 104° F (40° C).
combativeness, deliriousness, and coma.
 Measure vital signs for hypotension, orthostatic changes,
o Other central nervous system (CNS) disturbances
tachycardia, and tachypnea.
include tremors, seizures, fixed and dilated pupils,
 The patient will be awake but may give a history of syncope and decerebrate or decorticate posturing.
or confusion.
 Assess vital signs.
 Laboratory analysis will show hemoconcentration and
o Temperature greater than 105° F.
hyponatremia (if sodium depletion is the primary problem)
or hypernatremia (if water depletion is the primary o Hypotension.
problem). o Rapid pulse; may be bounding or weak.
 The ECG may show dysrhythmias without evidence of o Rapid respirations.
infarction.  The skin may appear flushed and hot; in early heatstroke,
General Interventions the skin may be moist, but, as the heatstroke progresses,
 Move the patient to a cool environment, and remove all the skin will become dry as the body loses its ability to
clothing. sweat.
 Position the patient supine with the feet slightly elevated.  ABGs show metabolic acidosis.
 If the patient complains of nausea or vomiting, do not give General Interventions
fluids by mouth.  Provide cooling measures.
 Start an I.V. line with Ringer's lactate or normal saline until o Reduce the core (internal) temperature to 102° F
electrolyte results are confirmed. (38.9° C) as rapidly as possible.
 Monitor the patient for changes in the cardiac rhythm and o Evaporative cooling is the most efficient. Spray
vital signs. Vital signs should be taken at least every 15 tepid water on the skin while electric fans are used
minutes until the patient is stable. to blow continuously over the patient to augment
 Provide fans and cool sponge baths as cooling methods. heat dissipation.
 Provide patient education. o Apply ice packs to neck, groin, axillae, and scalp
o Advise the patient to avoid immediate reexposure (areas of maximal heat transfer).
to high temperatures; the patient may remain o Soak sheets/towels in ice water and place on
hypersensitive to high temperatures for a patient, using fans to accelerate
considerable length of time. evaporation/cooling rate.
o Emphasize the importance of maintaining an o Immersion in cold water is contraindicated.
adequate fluid intake, wearing loose clothing, and o If the temperature fails to decrease, initiate core
reducing activity in hot weather. cooling: iced saline lavage of stomach, cool fluid
o Athletes should monitor fluid losses, replace fluids, peritoneal dialysis, cool fluid bladder irrigation, or
and use a gradual approach to physical cool fluid chest irrigations.
conditioning, allowing sufficient time for o Place the patient on a hypothermia blanket.
acclimatization. o Discontinue active cooling when the temperature
reaches 102° F. In most cases, this will reduce the
Lippincott Manual of Nursing Practice, 8 th Ed Acute Biologic Crisis mikEL rlh mantong
chance of overcooling because the body Frostbite
temperature will continue to fall after cessation of
cooling. Frostbite is trauma due to exposure to freezing temperatures that
cause actual freezing of the tissue fluids in the cell and intracellular
 Oxygenate patient to supply tissue needs that are
spaces, resulting in vascular damage. The areas of the body most
exaggerated by the hypermetabolic condition: 100%
likely to develop frostbite are the earlobes, cheeks, nose, hands, and
nonrebreather mask or intubate the patient if necessary to
feet. Frostbite may be classified as frostnip (initial response to cold,
support a failing cardiorespiratory system.
reversible), superficial frostbite, and deep frostbite.
 Monitor condition.
Primary Assessment and Interventions
o Monitor and record the core temperature
continually during cooling process to avoid  If not alert, assess airway, breathing, and circulation.
hypothermia; also, hyperthermia may recur  Deficits may indicate coexisting hypothermia or underlying
spontaneously within 3 to 4 hours. condition.
o Monitor the vital signs continuously, including  Protect frostbitten tissue while performing other
ECG, CVP, blood pressure, pulse, and respiratory interventions.
rate. Subsequent Assessment
o Perform frequent (every 30 minutes) neurologic
assessments. Frostnip
 Replace fluids.  History of gradual onset.
o Start I.V. infusion using Ringer's lactate to replace  Skin appears white.
fluid losses, maintain adequate circulation, and
 Numb, pain-free.
facilitate cooling.
o At least one I.V. line should be a central line. Superficial Frostbite
o Fluid replacement is based on the patient's  Damage is limited to the skin and subcutaneous tissue.
response and laboratory results.
 The skin will appear white and waxy.
 Other measures:
 On palpation, the skin will feel stiff but the underlying
o Dialysis for renal failure. tissue will be pliable, soft, and have its normal bounce.
o Diuretics, such as mannitol (Osmitrol), to promote  Sensation is absent.
diuresis.
o Anticonvulsant agents to control seizures. Deep Frostbite
o Potassium for hypokalemia and sodium  Skin will appear white, yellow-white, or mottled blue-white.
bicarbonate to correct metabolic acidosis,  On palpation, the surface will feel frozen and the
depending on laboratory results. underlying tissue will feel frozen and hard.
o Antipyretics are not useful in treating heatstroke.  The affected part is completely insensitive to touch.
They may contribute to the complications of
coagulopathy and hepatic damage. General Interventions
o Intense shivering may be controlled by diazepam  Frostnip may be treated by placing a warm hand over the
(Valium). Shivering will generate heat and increase chilled area.
the metabolic rate.  Leave the frostbitten area alone until definitive rewarming
o Patients with depleted clotting factors may be is undertaken. Pad the extremity to prevent damage from
treated with platelets or fresh frozen plasma. trauma.
 Insert an indwelling catheter with a urometer, and measure  Handle the part gently to avoid further mechanical injury.
urine output at least hourly acute tubular necrosis is a  Remove all constricting clothing that can impair circulation,
complication of heatstroke. including watchbands and rings.
 Perform continuous ECG monitoring and frequent  Rewarming:
cardiovascular assessments for possible ischemia, o Rewarm the extremity by controlled and rapid
infarction, and dysrhythmias. rewarming. Rewarm with a temperature of 98.6° F
 Perform serial laboratory testing (clotting parameters, to 104° F (37° C to 40° C) in a fairly large, tepid
electrolytes, glucose, and serum enzymes). water bath where the part can be fully immersed
 The patient should be admitted to an intensive care unit without touching the side or bottom. If clothing,
(ICU); complications can occur, including heart failure, socks, or gloves are frozen to the extremity, they
cardiovascular collapse, hepatic failure, renal failure, should be left on and removed after rewarming.
disseminated intravascular coagulation, and o More warm water may be added to the container
rhabdomyolysis. by removing some cooled water and adding warm
 Monitor the patient for the development of seizures, and water.
provide for a safe environment in case of seizures.
Lippincott Manual of Nursing Practice, 8 th Ed Acute Biologic Crisis mikEL rlh mantong
o Slow rewarming is less effective and may increase decrease heat loss; and (3) raising the basal metabolic rate.
tissue damage. Hypothermia may be classified as mild, moderate, or
o Dry heat is not recommended for rewarming. severe.
o The rewarming procedure may take 20 to 30 Primary Assessment and Interventions
minutes.  Assess airway and breathing.
o Rewarming is complete when the area is warm to o Spontaneous respirations may be extremely slow
the touch and pink or flushed. and imperceptible.
o Do not rub or massage a frostbitten extremity. The o Assist breathing and oxygenation with
ice crystals in the tissue will lacerate delicate supplemental O2 at 100% or a bag-valve mask
tissue. device.
 Pharmacologic interventions: o If intubation is necessary, extreme caution should
o Opioids for pain control. be used because ventricular fibrillation may be
o Antibiotics if there is an open wound. precipitated.
 Assess circulation.
o Tetanus prophylaxis.
o If the body temperature falls below 86° F (30° C),
 Protect the thawed part from infection. Large blisters may
the heart sounds may not be audible even if the
develop in 1 hour to a few days after rewarming; these
heart is still beating. Tissues conduct sound poorly
blisters should not be broken.
at low temperatures.
 Place sterile gauze or cotton between affected fingers/toes
o Blood pressure readings may be extremely difficult
to absorb moisture.
to hear because cold tissue conducts sound waves
 Use strict aseptic technique during dressing changes. poorly.
Frostbite injuries make the patient susceptible to infection.
o Pupil reflexes may be blocked by a decrease in
Make sure any dressings are loosely applied.
cerebral blood flow, so the pupils may appear
 Elevate the part to help control swelling. fixed and dilated.
 Use a foot cradle to prevent contact with bedding if the o A patient with a heartbeat may present like a
feet are involved prevents further tissue injury. patient in cardiac arrest with fixed dilated pupils,
 Perform a physical assessment to look for concomitant no pulse, and no blood pressure. Provide CPR until
injury (soft-tissue injury, dehydration, alcohol coma, fat further evaluation through ECG and hemodynamic
embolism due to fracture, immobility). monitoring.
 Restore electrolyte balance; dehydration and hypovolemia Subsequent Assessment
occur frequently in frostbite victims.
 There is progressive deterioration marked by apathy, poor
 Whirlpool bath for the affected extremity to aid circulation, judgment, ataxia, dysarthria, drowsiness and, eventually,
debride dead tissue, and help prevent infection. coma.
 Escharotomy (incision through the eschar) to prevent  Speech is slow and may be slurred.
further tissue damage, allow for normal circulation, and
 Shivering may be suppressed below a temperature of 90° F
permit joint motion.
(32.2° C).
 Fasciotomy (incision in fascia to release pressure on the
 Cardiac dysrhythmias cold disrupts the conduction system
muscles, nerves, blood vessels) to treat compartment
of the heart, and a variety of dysrhythmias may be seen. A
syndrome.
hypothermic heart is extremely susceptible to ventricular
 Encourage hourly active motion of the affected digits to fibrillation. Very cold hearts do not respond to drugs or
promote maximum restoration of function and to prevent defibrillation.
contractures.
 The heartbeat and the blood pressure may be so weak that
 Advise patient not to use tobacco because of the the peripheral pulsations become undetectable.
vasoconstrictive effects of nicotine, which further reduce
 Urine output may increase in response to peripheral
the already deficient blood supply to injured tissues.
vasoconstriction cold diuresis.
 Perform serial laboratory testing (urinalysis and serum
 Initial tachypnea followed by slow and shallow respirations,
enzymes) to monitor for the complications of
possibly two or three per minute in severe hypothermia.
rhabdomyolysis and subsequent renal failure.
 Fruity or acetone odor to the breath because the body may
Hypothermia be metabolizing fat as a result of decreased insulin levels.
 Hypothermia is a condition in which the core (internal) General Interventions
temperature of the body is less than 95° F (35° C) as a
Goal: rewarm without precipitating cardiac dysrhythmias.
result of exposure to cold. In response to a decreased core
temperature, the body will attempt to produce or conserve Supportive Measures
more heat by (1) shivering, which produces heat through
muscular activity; (2) peripheral vasoconstriction, to  Handle the patient carefully and gently to avoid triggering
ventricular fibrillation.
Lippincott Manual of Nursing Practice, 8 th Ed Acute Biologic Crisis mikEL rlh mantong
 Continuously monitor core temperatures with a low o Cardiopulmonary bypass.
reading rectal thermometer. o Disadvantage of active core rewarming is the
 Continuously monitor ECG. Because you may be unable to invasiveness of the procedures.
obtain a pulse due to the hypothermia, rely on the cardiac
monitor to determine the need for CPR.
TOXICOLOGIC EMERGENCIES
 Monitor the patient's condition through vital signs, CVP, Toxicology is the study of the harmful effect of various substances
urine output, ABG values, and blood chemistry on the body. Poisons are substances that are harmful to the body no
determinations. matter how much or in what manner they enter the body. Drugs
become toxic when they are taken in excess quantities or manners
 Maintain an arterial line for recording blood pressure and
that are not therapeutic. Alcohol is considered a drug. The
to facilitate blood sampling allows rapid detection of
treatment goals of toxicologic emergencies are first, supportive;
acid€“base disturbances and assessment of adequacy of
second, to prevent or minimize absorption; third, to provide an
ventilation and oxygenation.
antidote.
 Start I.V. therapy with normal saline. Ringer's lactate is not
recommended because the cold liver may not be able to Ingested Poisons
metabolize the lactate. Ingested poisons can produce immediate or delayed effects.
Immediate injury is caused when the poison is caustic to the body
Rewarming Techniques tissues (ie, a strong acid or a strong alkali). Other ingested poisons
The type of rewarming depends on the degree of hypothermia. must be absorbed into the bloodstream before they become
Rewarming should continue until the core temperature is 93.2° F harmful. Ingested poisoning may be accidental or intentional.
(34° C). If the patient is in cardiac arrest, rewarming should continue Primary Assessment and Interventions
until a temperature of 89.6° F (32° C) has been reached. Death in
hypothermia is defined as a failure to revive after rewarming.  Maintain an open airway some ingested substances may
cause soft tissue swelling of the airway.
 Passive external rewarming (temperature above 82.4° F
[28° C]).  Attain control of the airway, ventilation, and oxygenation;
in the absence of cerebral or renal damage, the patient's
o Remove all the wet or cold clothing, and replace
prognosis depends largely on successful management and
with warm clothing. support of vital functions.
o Provide insulation by wrapping the patient in
Subsequent Assessment
several blankets.
 Identify the poison.
o Provide warmed fluids to drink.
o Try to determine the product taken: where, when,
o Disadvantage: slow process.
why, how much, who witnessed the event, time
 Active external rewarming (temperature above 82.4° F). since ingestion.
o Provide external heat for the patient warm hot o Call the poison control center in the area if an
water bottles to the armpits, neck, or groin. (Do unknown toxic agent has been taken or if it is
not apply hot water bottles directly to the skin.) necessary to identify an antidote for a known toxic
o Warm water immersion. agent.
o Disadvantages:  Continue the focused assessment, observing any significant
 Causes peripheral vasodilation, returning deviations from normal. Different poisons will affect the
cool blood to the core, causing an initial body in different ways.
lowering of the core temperature.  Obtain blood and urine tests for toxicology screening.
 Acidosis due to the washing out of lactic Gastric contents may also be sent for toxicology screening
acid from the peripheral tissues. in serious ingestions.
 An increase in the metabolic demands  Monitor neurologic status, including mentation; monitor
before the heart is warmed to meet these the course of vital signs and neurologic status over time.
needs.  Monitor for fluid and electrolyte imbalance.
 Active core rewarming (temperature below 82.4° F). General Interventions
o Inhalation of warmed, humidified oxygen by mask
or ventilator. Supportive Care
o Warmed I.V. fluids.  Initiate large-bore I.V. access.
o Warmed gastric lavage.  Administer oxygen for respiratory depression.
o Peritoneal dialysis with warmed standard dialysis  Monitor and treat shock.
solution.  Prevent aspiration of gastric contents by positioning (on
o Mediastinal irrigation through open thoracotomy side with head down), use of oropharyngeal airway, and
has been used successfully but has serious suctioning.
complications.  Give supportive care to maintain vital organ systems.
Lippincott Manual of Nursing Practice, 8 th Ed Acute Biologic Crisis mikEL rlh mantong
 Insert an indwelling urinary catheter to monitor renal oxygen-carrying capacity of the blood. The affinity between carbon
function. monoxide and hemoglobin is 200 to 300 times that between oxygen
 Support the patient having seizures; many poisons excite and hemoglobin. (Carbon monoxide combines with hemoglobin to
the CNS, or the patient may convulse from oxygen form carboxyhemoglobin.) As a result, tissue anoxia occurs.
deprivation. Primary Assessment
 Monitor and treat for complications: hypotension, coma,  Assess airway and breathing.
cardiac dysrhythmias, and seizures. o Respiratory depression may be present.
 Psychiatric evaluations may be done after the patient is o If the carbon monoxide poisoning is due to smoke
stabilized.
inhalation, stridor (indicative of laryngeal edema
due to thermal injury) may be present.
Minimizing Absorption
Primary Interventions
 The primary method for preventing or minimizing
absorption is to administer activated charcoal with a  Provide 100% oxygen by tight-fitting mask. (The elimination
cathartic to hasten excretion. Newer superactivated half-life of carboxyhemoglobin, in serum, for a person
charcoals can reduce absorption of a toxic substance by as breathing room air is 5 hours 20 minutes. If the patient
much as 50%. Administering activated charcoal plus a breathes 100% oxygen, the half-life is reduced to 80
cathartic is just as effective or more effective than gastric minutes; 100% oxygen in a hyperbaric chamber will reduce
lavage. the half-life to 23 minutes [treatment of choice].)
o Administration of oral-activated charcoal absorbs  Intubate if necessary to protect the airway.
the poison on the surface of its particles and Subsequent Assessment
allows it to pass with the stool. Multiple doses
 A thorough history is important: determine the type and
may be administered.
length of exposure as well as possible other fumes inhaled.
o Activated charcoal is usually mixed tap water to An underlying anemia, cardiac disease, or pulmonary
make a slurry. disease may place a person at higher risk.
 Gastric lavage for the obtunded patient (see Procedure  Determine LOC the patient may appear intoxicated from
Guidelines 35-5, pages 1164 and 1165). Save gastric cerebral hypoxia; confusion may progress rapidly to coma.
aspirate for toxicology screens. This procedure is
 Assess complaints of headache, muscular weakness,
controversial.
palpitation, dizziness.
 Procedures to enhance the removal of the ingested
 Inspect skin: may be pink, cherry red, or cyanotic and pale
substance if the patient is deteriorating.
skin color is not a reliable sign.
o Forced diuresis with urine pH alteration to
 Monitor vital signs: increased respiratory and pulse rates
enhance renal clearance.
are generally present. Be alert for altered breathing
o Hemoperfusion (process of passing blood through patterns and respiratory failure.
an extracorporeal circuit and a cartridge
 Listen for rales or wheezes in the lungs (with smoke
containing an adsorbent, such as charcoal, after
inhalation, indicates acute respiratory distress syndrome).
which the detoxified blood is returned to patient).
 Obtain arterial blood samples for carboxyhemoglobin
o Hemodialysis used in selected patients to purify
levels.
blood and accelerate the elimination of circulating
toxins. o Normal is less than 12%.
o Repeated doses of charcoal for binding o Severe carbon monoxide poisoning is present
nonabsorbed drugs/toxins. when levels are greater than 30% to 40%.
o Gastric lavage may be used in conjunction with General Interventions
activated charcoal and a cathartic to maximize  History of exposure to carbon monoxide justifies
elimination of the substance. immediate treatment.
 Goals are to reverse cerebral and myocardial hypoxia and
Providing an Antidote
hasten carbon monoxide elimination.
 An antidote is a chemical or physiologic antagonist that will  Give 100% oxygen at atmospheric or hyperbaric pressures
neutralize the poison. to reverse hypoxia and accelerate elimination of carbon
 Administer the specific antidote as early as possible to monoxide. Patients should receive hyperbaric oxygen for
reverse or diminish effects of the toxin. CNS or cardiovascular system dysfunction.
Carbon Monoxide Poisoning  Use continuous ECG monitoring, treat dysrhythmias, and
correct acid€“base and electrolyte abnormalities.
Carbon monoxide poisoning is an example of an inhaled poison and
is the result of the inhalation of the products of incomplete  Observe the patient constantly psychoses, spastic paralysis,
hydrocarbon combustion. It may occur as an industrial or household visual disturbances, and deterioration of personality may
accident or as an attempted suicide. Carbon monoxide exerts its persist after resuscitation and may be symptoms of
toxic effect by binding to circulating hemoglobin to reduce the permanent CNS damage.
Lippincott Manual of Nursing Practice, 8 th Ed Acute Biologic Crisis mikEL rlh mantong
Insect Stings  Avoid perfumes, scented soaps, bright
colors attract bees.
Insect stings or bites are injected poisons that can produce either
 Keep car windows closed.
local or systemic reactions. Local reactions are characterized by
pain, erythema, and edema at the site of injury. Systemic reactions  Spray garbage cans with rapid-acting
usually begin within minutes and produce mild to severe and life- insecticide, and keep areas meticulously
threatening reactions. clean.
Primary Assessment and Interventions Snakebites
 Assess airway, breathing, and circulation. The majority of snakes in the United States are not poisonous. The
 Anaphylactic reactions may produce unconsciousness, poisonous varieties are pit vipers (rattlesnakes and copperheads)
laryngeal edema, and cardiovascular collapse. and coral snakes. Bites by these snakes may result in envenomation,
an injected poisoning.
 Epinephrine is the drug of choice the amount and route
depend on the severity of the reaction. Primary Assessment and Interventions
 Administer a bronchodilator to help relieve the  Assess airway, breathing, and circulation if patient is not
bronchospasm. alert.
 Initiate an I.V. with Ringer's lactate.  Severe envenomation may lead to neurotoxicity with
 Prepare for CPR. respiratory paralysis, shock, coma, and death.

Subsequent Assessment  Be prepared to resuscitate and provide advanced life

support.
 Obtain history of insect sting, previous exposure, and
Subsequent Assessment
allergies.
 Inspect skin for local reaction erythema, edema, pain at site  Get a description of the snake, the time of the snakebite,
of injury as well as generalized pruritus, urticaria, and and the location of the bite. Bites to the head and trunk
angioedema. may progress more rapidly and be more severe.

 Continue to monitor blood pressure and respiratory status o Pit vipers have triangular heads, vertical pupils,
for dyspnea, wheezing, and stridor. indentations between the eyes and nostrils, and
long fangs.
General Interventions
o Coral snakes are small, brightly colored, with short
 Apply ice packs to site to relieve pain. fangs and teeth behind them, and with a series of
 Elevate extremity with large edematous local reaction. bands of yellow, red, yellow, and black (in that
 Administer oral antihistamine for local reactions. order).
 Clean the wound thoroughly with soap and water or an  Assess for local reactions burning, pain, swelling, and
antiseptic solution. numbness at the site. Local reactions to coral snakebites
may be delayed several hours and may be very mild.
 Administer tetanus prophylaxis if not up to date.
 A few hours after the bite, hemorrhagic blisters may occur
 Provide patient education. at the site, and the entire extremity may become
o Always have epinephrine on hand (EpiPen). edematous.
o Wear medical emergency bracelets indicating  Watch for signs of systemic reactions, including nausea,
hypersensitivity. sweating, weakness, lightheadedness, initial euphoria
o Instructions when sting occurs: followed by drowsiness, difficulty in swallowing, paralysis of
various muscle groups, signs of shock, seizures, and coma.
 Take epinephrine immediately if stung.
 Monitor vital signs closely because tachycardia or
 Remove stinger with one quick scrape of
bradycardia may develop.
fingernail.
 Do not squeeze venom sac because this General Interventions
may cause additional venom to be  Keep the patient calm and at rest in a recumbent position
injected. with the affected extremity immobilized.
 Report to nearest health care facility for  Administer oxygen.
observation.  Start an I.V. line with normal saline or Ringer's lactate.
o Avoid exposure.  Administer antivenin and be alert to allergic reaction
 Avoid locales with stinging insects (camp (antivenin is horse serum-based).
and picnic sites).  Administer vasopressors in the treatment of shock.
 Stay away from insect feeding areas  Monitor for bleeding, and administer blood products for
flower beds, ripe fruit orchards, garbage, coagulopathy.
fields of clover.
 Avoid going barefoot outdoors yellow
jackets may nest on ground.