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Lina Navarro
Curative and Rehabilitative Nursing Care Management of Clients in Acute Biologic Crisis
Lina B. Navarro, RN
4 Days
Grading System
Q 50%
T 40%
P 10%
Course Content
Definition of Terms
o Emergency a situation which poses an immediate risk to life, heath, property or environment
o Emergency Care care given to clients with urgent or critical needs
o Emergency Nursing a nursing specialty in which nurses care for patients in the emergency or critical phase
of their illness of injury
o Paramedics health care professional specializing in emergency medicine
o Emergency Medical Service (EMS) a service providing out of hospital acute care and transport to definitive
care
o Skilled at dealing with clients in the phase when a diagnosis has not yet been made and the cause of the
problem is not known
o Specialize in rapid assessment and treatment when every second counts
o Tackle diverse tasks with professionalism efficiency, and above all caring
o Possess both general and specific knowledge about health care
o Ready to treat a wide variety of illnesses or injury situation, ranging from a sore throat to a heart attack
First Aid
o Immediate and temporary care given to a person who is injured or who suddenly becomes ill before
professional medical care is available
o Goals: 3 Ps
Preserve life
Prevent further injury
Promote recovery
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Bio-Crisis Ms. Lina Navarro
Characteristics of a Good First Aider
o Gentle
o Resourceful
o Observant
o Tactful
o Empathic
o Respectable
o Hemorrhagic Control
- Tourniquet
- Gauze
- Bandage
- Clamps
o Spinal Immobilization
- Backboard
- Cervical collar
o Extremity Immobilization
- Splint
- Bandage
- Slings
o Labor and Delivery
- Clamps
- Scissors
- Suction
- Linen
- Gauze
o Resuscitation
- Ambu bag
- Bag Valve Mask Device
- O2 tank (mask and cannula)
o Emergency Drugs
- Epi
- AtSo4
- Dopamine
o Wound Care
- Betadine
- Gauze
- Alcohol
- PNSS
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Bio-Crisis Ms. Lina Navarro
Ethical, Legal and Medical Issues in Nursing
Ethical Principles
Ethical Responsibility
Duty to Act
o Immunity from civil liability when providing assistance at the scene of an emergency; unless you did
something negligent
1. Do not leave the scene until the injured person leaves or another qualified person takes over
(Abandonment)
2. Limit actions to those considered first aid, if possible
3. Offer assistance, but dont insist
4. Have someone call or go for additional help
5. Do not accept any compensation
o Sharing of confidential information by the nurse about a patients condition is legal when:
- Information is shared with other members of the health care team
- With clients consent (signs a written release)
Negligence failure to provide care what another prudent person would allow do under the same circumstances
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Bio-Crisis Ms. Lina Navarro
Elements of Malpractice
1. Duty
2. Breach of Duty
3. Damages
4. Causation
Terms
o Abandonment
o Assault and Battery
- Assault verbal threat
- Battery threats into action; procedure without explaining
o Consent
- Informed (client is aware or told of procedure)
- Implied
- Minors (cant sign consent except those who are married, pregnant, parents, emancipated,
military)
- Mentally-ill (they can sign consent)
o Refusal of treatment
o Restraints needs doctors order
o Advance Directives written statement that specifies medical treatment desired, if px is unable to make
decisions
o Do Not Resuscitate (DNR) Orders
o Organ Donors (save particular organ)
o Medical Identification Devices
o Special reporting requirements
- Abuse of children, elderly, and spouse
- Drug-related injury
- Childbirth
- Infections disease exposure
- Crime scene
- Deceased
Eye opening
Spontaneous 4
To Voice 3
To Pain 2
None 1
Verbal response
Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible words 2
None 1
Motor Response
Obeys Commands 6
Localizes Pain 5
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Bio-Crisis Ms. Lina Navarro
Withdraw 4
Flexion 3
Extension 2
None 1
Level of Consciousness
A-Alert
V-Response to Verbal stimulus
P-Responsive to Pain
U-Unresponsive
Golden Rule
Altered level of consciousness is characteristic of nervous system dysfunction and warrants
thorough examination to rule out all possible causes
- Unequal pupil size (anisocoria) may indicate increased pressure on one side of the brain
General Overview
- Respirations
- Pulse
- Blood pressure
- Temperature
- Pain scale
- Capillary refill
Used as a basis whether clients conditions is improving or deteriorating
Head-to-Toes Assessment
- Inspections
- Palpation
- Percussion
- Auscultation
DCAPBTLS
- Deformities
- Contusions
- Abrasions/Penetrations
- Punctures
- Burns
- Tenderness
- Lacerations
- Swelling
History Information
- Onset
- Provoking factors
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Bio-Crisis Ms. Lina Navarro
- Quality of pain
- Radiation of pain
- Severity
- Time
SAMPLE
- Signs and Symptoms
- Allergies
- Medications
- Past medical history
- Last oral intake
- Events leading to the episode
Priority Setting/Triage
Level 1: Resuscitation
Level 2: Emergent
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Bio-Crisis Ms. Lina Navarro
Anaphylaxis
Vaginal bleeding/acute lower abdominal pain
Serious infections/fevers
Diabetes
Diarrhea and vomiting
Acute psychosis/drug withdrawal
Level 3: Urgent
- Conditions related to patient age, distress, or potential for deterioration or complications that would
benefit from intervention or reassurance within 1-2 hours
- Time to physician: 1 hour
Head injury
Minor trauma
Abdominal pain
Chest pain
Head act/earache
Suicidal/depressed
Chronic back pain
URI symptoms
Diarrhea and
Vomiting with no signs of dehydration
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Bio-Crisis Ms. Lina Navarro
Triage Coding
BLS
Goals
- Emergency oxygenation
- Maintain airway patency
- Support breathing
- Support circulation
- No equipment
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Bio-Crisis Ms. Lina Navarro
Cardio Pulmonary Resuscitation (CPR)
- Combination of rescue breathing (one person breathing into another person) and chest compression in
lifesaving procedure
- Performed when a person has stopped breathing or a persons heart has stopped breathing
- Books of Kings II (4:34), wherein the Hebrew prophet Elisha warms a dead boys body and places his
mouth over his
- Peter Safar father of CPR; wrote the book of ABC of Resuscitation in 1957
Phone First
- Cardiac
- Adults
- Children at high risk for cardiac arrhythmias
- Respiratory
- Children
- Submersion
- Drowning
- Arrest associated with trauma
- Drug overdose
Steps in CPR
1. Check safety
2. Determine responsiveness
o Are you okay? 2x
o If he responds, no need for CPR; keep safe and reassess
o If no response:
Adults: call EMS immediately
Child/Infant: perform 30:2 x 5 cycles, then call EMS
Lay him face up on a firm, flat surface, moving his head and body simultaneously
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Bio-Crisis Ms. Lina Navarro
Assess for Breathing:
2 Rescue Breaths
AR Method
o Adult/Child
- Mouth to mouth, nose pinched
- Mouth to barrier device
- Mouth to nose
- Mouth to stoma
o Infant
- Mouth to mouth and nose
Chest Compressions
o Infants
- Just below the nipple line within 2 fingers
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Bio-Crisis Ms. Lina Navarro
- 1/3 to of the depth of the chest
o Child
- Lower half of the sternum, falling at the nipple line using 1 or 2 hands; 1/3 to in depth
o Adults
- Center of the chest at the nipple line
- Both hands, 1 to 2 inches in depth
8. The moment his pulse returns, immediately stop compression and check for breathing
- If the victim is not breathing, perform rescue breathing at 12 times/minute (1 breath every 5
seconds) until victims natural breathing is restored
- If both pulse and breathing have returned, place victim in the recovery position and maintain an
open airway
- Continue to monitor for both breathing and pulse every few minutes until heap arrives
2 Rescuer CPR
o Gastric Distention
o Lacerations of internal organs
o Punctured lungs
o Fractured ribs or sternum
Mild/Partial Obstruction
Response
o Unable to speak
o May respond by nodding
o Unable to breath
o Breathing sounds wheezy
o Attempts at coughing are silent
o Victim may be unconscious
o Abdominal thrust
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Bio-Crisis Ms. Lina Navarro
o Heimlich Maneuver are a series of under-the-diaphragm abdominal thrusts
o Lifts the diaphragm and force enough air from the lungs to create an artificial cough to move and expel the
foreign body.
Step 3: Reassure the victim that you know the Heimlich maneuver and you are willing to help
Step 5: Make a fist with one hand and place your thumb toward the victim, just above the umbilicus and below the
Xiphoid process
Step 8: Repeat until the foreign body is expelled or until the victim becomes unconscious
Finger Sweep
Airway
- ET Intubation
- Give a source of air to be effective O2
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Bio-Crisis Ms. Lina Navarro
Confirm Placement of ET
- CXR
- Auscultate chest while ventilated by ambubag
- (+) Breaths sounds on both lung fields
- (+) chest wall rise
- Auscultate the stomach
Intubation Complication
Airway Adjuncts
Cricothyrotomy
Breathing
Respiration
- Spontaneous
- Rate, depth, and symmetry
- Breath sounds
- Bag, valve, mask device
- No breathing: Deliver 8-12 breaths/min
- Spontaneous breathing: together with chest rise
O2 Saturation
- Pulse oximetery
- 96-100% at room air
- No not suction when O2 Sat is below 95%
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Bio-Crisis Ms. Lina Navarro
Circulation
- Pulses
- Cardiac rhythm and rate
- Blood pressure
- Capillary refill and skin color
- CPR; 100compresssion/min
- IV lines
Types of Solution
Drugs
Cardiac Stimulants
Isoproterenol bradycardia
Cardiac Stimulant
- Shock drug
- Enhances force (inotropic) of heart contractions
- Increase rate (chronotropic) of heart contractions
- Renal dose, cardiac dose, vasopressor dose
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Bio-Crisis Ms. Lina Navarro
Dobutamine
Norepinephrine
- Potent vasoconstrictor
Lanoxin, Digoxin
Antianginal Drugs:
Morphine SO4
- Narcotic analgesic
- Relieves pain, vasodilation
- N and V, hypotension, respiratory depression
- Antidote: Narcan
Adenosine
Lidocaine HCl
Procainamide (Pronestyl)
Amiodarone (Cordarone)
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Bio-Crisis Ms. Lina Navarro
Antihypertensives
Central Acting
- Clonidine (Catapres)
- Methyldopa (Aldomet)
- Prazosin, Terazosin
Ca Channel Blockers: Nifedipine, Verapamil, Diltiazem (Slows down conduction, vasodulating effect)
Other Drugs
Antidotes
Steroids
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Bio-Crisis Ms. Lina Navarro
Antacids
- NaHCO3
- Watch for extravasation
Electrocardiography
Lead Placement
Limb Leads
Precordial Leads
Nursing Responsibilities
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Bio-Crisis Ms. Lina Navarro
The Normal ECG
HR absent
Rhythm absent
PR interval absent
Atrial Flutter
- The atria are contracting rapidly at about 300bpm, and the ventricles are responding every third or fourth
impulse
Ventricular Tachycardia
Ventricular Fibrillation
Ventricular Fibrillation
Defibrillation
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Bio-Crisis Ms. Lina Navarro
Rationale for Early Defibrillation
Non-Shockable Rhythms
- Asystole
- PEA (Premature Electrical Activity)
Fibrillation Treatment
Procedure
Defibrillators
Monophasic
- The CPR algorithm recommends single socks started at and repeated at 360J
Biphasic
- The CPR attachment algorithm recommends shocks initially of 150-200J and subsequent shocks of 150-360J
- Automated
- Semiautomated
W no Water
I no Internal pacemaker
P Patches; removed
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Bio-Crisis Ms. Lina Navarro
E Eight years and below, no defib
Cardioversion
- Organized rhythms
- Delivery of a therapeutic dose of electrical current to the heart at a specific moment in the cardiac cycle
- A synchronized countershock to convert an undesirable rhythm to a stable rhythm
- Lowe amount of energy is used
- Synchronized with the R-waves
- Informed consent is needed and client is sedated
Critical Care
Goal: Cerebral Resuscitation and post resuscitation intensive therapy (providing mechanical ventilation
Intensive Care
- Provision of life support or organ support systems in patients who re critically ill and who usually require
intensive monitoring
- Condition is potentially reversible and who have a god chance of surviving with intensive are support
- System by system approach to treatment
CV, CNS,ENDO, GIT (and nutritional condition), hematology, microbiology (including sepsis
status), peripheries (and skin), renal (and metabolic), respiratory system
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Bio-Crisis Ms. Lina Navarro
Goals
Diagnostic Devices
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Bio-Crisis Ms. Lina Navarro
C Circulation; no pulse, CPR; control hemorrhage, immobilize
F Foley Cath
Bleeding
- Hemorrhage
- Average adult has 5L of circulating blood
- Body cannot tolerate greater than 20% blood loss
- Blood loss of 1l can be dangerous in adults; in children, loss of 100-200mL is serious
Safety
PASG
- An inflatable garment that surround the legs and torso and can generate up to around 100mmHg of
pressure
- Controls significant internal bleeding by placing pressure on the abdomen
- Controls massive soft-tissue bleeding of the lower extremities
- Increases blood flow to vital organs
- May effectively increase the blood pressure
Tourniquet Precautions
Open Wounds
Controlling a Nosebleed
Internal Bleeding
- Ecchymosis
- Hematoma
- Hemoptysis
- Hematemesis
- Hematochezia
- Melena
- Hematuria
- Pain, tenderness, bruising, or swelling
- Broken ribs; bruises over the lower chest; shallow rapid respiration
- Rigid, distended abdomen, guarding
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Bio-Crisis Ms. Lina Navarro
First Aid
- Prioritize
Chest cavity
Abdominal cavity
Pelvic cavity (2-8 units)
Femoral area (2-8 units)
- EMS
- ABCDs
- Treat for shock
- Close injuries
Soft tissue damage beneath the skin
- Open injuries
Break in the surface of the skin
- Burn
Soft tissue receives more energy than it can absorb
- Amputations
Contusion
Hematoma
Abrasions
Laceration
Avulsion
Penetrating Wound
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Bio-Crisis Ms. Lina Navarro
Gunshot Wound
Amputation
Traumatic Emergencies
- Trauma assessment
DCAPBTLS
Mechanism of injury
Loss of consciousness
Vomiting
Current symptoms
Intake of drugs or alcohol
Tissue Perfusion
Shock
- A state of collapse and failure of the CVS due to the inadequate tissue perfusion and less oxygenation
Leads to inadequate circulation
Without adequate blood flow, cells cannot get rid of metabolic wastes
- Not a disease in itself, but a secondary cause
Phases of Shock
I. Compensated shock
- The preservation of vital organ function: body uses normal defense mechanism to maintain normal function
Classification of Shock
1. Hypovolemic Shock
- An absolute reduction in circulating volume
2. Cardiogenic
- Reduction in cardiac output secondary to pump failure
3. Distributive
- An increase in the volume of the circulatory system (vasodilation)
Septic/Anaphylactic/Neurogenic
4. Obstructive
- Resistance to the flow (respi insufficiency)
5. Psychogenic
- psychological
6. Metabolic
Management of Shock
- Maintain airway
- Oxygen
- Positioning shock position
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Bio-Crisis Ms. Lina Navarro
- Control bleeding
- Splint fractures
- Keep warm
- Keep safe
- NPO
- Monitor V/S
- Monitor Output
- Trendelenburg
Medical Mgt
Anaphylactic Shock
Psychogenic Shock
- Usually self-resolving
- Assess patient for injuries from fall
- Anxiety attack
Eye Injuries
- Considered as an emergency
- Foreign objects
Victim to blink several times
Irrigates with saline
- Lacerations
Never exert pressure on or manipulate eye
Cover with protective metal eye shield
- Burns
Flush for 20 minutes
Remove contact lenses
Neck Injuries
Chest Wounds
- A penetrating wound to the chest may cause air to enter the chest
- Air enters through a hole causing the lungs to collapse in a few seconds or minutes
- Sucking chest wound
Rib Fractures
- Rib fractures may lacerate surface of the lungs; common in the elderly
- Flail chest
Three or more fractured ribs
Sternum in fractures along with several ribs
Creates paradoxical movement
Immobilize flail segment with a pad of dressing or a small pillow; secure with a wide tape
Do not ever place anything completely around the chest!
Pneumothorax
- Spontaneous Pneumothorax
Weak areas in the surface of the lungs and rupture spontaneously
- Tension pneumothorax
Can occur from sealing all four sides of the dressing on a sucking chest wound
Can also occur from a fractured rib puncturing the lung or bronchus
Can also result from a spontaneous pneumothorax
Let air escape by inserting a needle
Cardiac Tamponade
Abdominal Wounds
Assessment
- Tenderness
- Rebound tenderness
- Guarding
- Rigidity
- Distention
- Pain
Management
- Prevent shock
- Control bleeding
- Positioning
- NPO
- Male
Painful by not life-threatening
Cut off zipper fastener and separate teeth
Ice or cold compress
- Female
Extreme pain, bleeding
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Bio-Crisis Ms. Lina Navarro
Straddle injuries, sexual assault, blows to the perineum or abortion attempt, childbirth, or
when foreign objects are inserted into the vagina
Direct pressure, moist compress (bleeding)
Ice packs or cold compress (pain, swelling)
Sexual assault, preserve chain of evidence
Skull Fracture
Head Injuries
- The most important sign in evaluating head injury is a changing state ofconsciousness
- A head-injured patient has a cervical spine injury until proven otherwise
- Shock means injury elsewhere
Cerebral Concussion
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Bio-Crisis Ms. Lina Navarro
- S/Sx transient confusion and disorientation (lasts several minutes), with or without loss of consciousness,
retrograde amnesia or anterograde amnesia
Cerebral Contusion
Coup-contrecoup
- Acceleration-deceleration injury
- Head comes to a sudden stop, but brain continues to move back and forth inside the skull, resulting in
massive injury
- Two sites of injury
Point of impact
Point on the opposite side when the head hits the skull
Brain Injury
- Cerebral Edema
- Convulsions and seizures
- Vomiting
- Leakage of CSF
***Check for increase ICP
- Increased BP (Systolic)
- Widening of pulse pressure
- Decreased Pulse (bradycardia)
- Abnormal respiration
- Increased temp
- Vomiting
- Decreased BP
- Narrowing of pulse pressure
- Increased Pulse (tachycardia)
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Bio-Crisis Ms. Lina Navarro
- Increased Respiratory Rate
First Aid
Interventions
Complications
- Inadequate breathing
Respiratory paralysis
Chest wall muscles are paralyzed
Diaphragm continues to function
- Paralysis
Weakness, loss of sensation or paralysis below level of injury
Paralysis of arms or legs most reliable sign
S/Sx
Management
Management of Fractures
Airway Problems
S/Sx
Treatment
- Oxygen
- IV line
- Bed rest; semi fowlers
- Cardiac monitor
- I and O
- Drugs vasodilators, hemolytics (<6 hours), analgesics, anti-arrhythmics, anticoagulants, stool softeners
Cardiac Arrest
Ventricular Fibrillation
- Defibrillate
- Intubation
- Oxygen
- IV line, fluids
- Drugs lidocaine
Asystole
- Start CPR
- Intubation
- Oxygen
- IV line, fluids
- Drugs Epi, AtSO4
- Defibrillate if in V Fib
- Sudden numbness or weakness of the face, arm or leg, especially on one side of the body. Sometimes
weakness in the muscles of the face can cause drooling
- Sudden confusion or trouble speaking or understanding
- Sudden trouble seeing in one or both eyes
- Sudden trouble waking, dizziness, loss of balance or coordination
- Sudden, severe headache with no known cause
- If the area of the brain affected contains of the three prominent CNS pathways the spinothalamic tract,
corticospinal tract, and dorsal column (medial lemniscus), symptoms may include:
Hemiplegia and muscle weakness of the face
Numbness
Reduction in sensory or vibratory sensation
Brain Stem
Cerebral Cortex
If the cerebral cortex is involved, the CNS pathways can again be affected, but also can produce the following
symptoms
Cerebellum
- Trouble walking
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Bio-Crisis Ms. Lina Navarro
- Altered movement coordination
- Vertigo and/or disequilibrium
- Loss of consciousness
- Headache
- Vomiting
- Patent airway, O2
- IV line
- Drugs
Treat within 3 hours for thrombolytic drugs
Antiplatelet, anticoagulants
Antihypertensives
Osmotic diuretics
- Protect paralyzed extremities
- CR Scan, MRI
- Surgery to remove blood
- Supportive care physiotherapy, occupational therapy
Seizures
Emergency Care
Diabetes Mellitus
- Excess insulin
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Bio-Crisis Ms. Lina Navarro
First Aid
Heat Stroke
- No cramping
- Headache, dizziness, impaired thinking; stupor, coma, seizure
- Hot flushed skin
- Hyperthermia
- Rapid, bounding pulse
- Hypertension, early stage, then drops
Hypothermia
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Bio-Crisis Ms. Lina Navarro
S/Sx
Mild
Severe
- Unconscious or stuporous
- Shivering stops
- Weak or absent V/S
- Muscular activity decreases
- Fine muscle activity ceases
- Eventually, all muscle activity tops
- Pupils unreactive
Frost Bite
Emergency Care
Frostbite Donts
- Drowning
Death as a result of suffocation after submersion in water
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Bio-Crisis Ms. Lina Navarro
- Near Drowning
Survival, at least temporarily, after suffocation in water
***Freshwater
***Saltwater
- Do not enter the water to save a drowning victim if you are not a qualified swimmer
- Begin rescue breathing as soon as possible, even before victim is removed from the water
- Continue AR and remove victim from water
- Maintain cervical spine stabilization
- If air does not enter the patients lungs, treat for obstructed airway
- Check pulse and start CPR if needed; intubate and administer O2
- IV line, drugs (bicarbonate)
Poisoning
Ingested Position
Food Poisoning
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Bio-Crisis Ms. Lina Navarro
Drugs and Alcohol
- Aspirin acid
N/V, hyperventilation, tinnitus, confusion, seizures, coma, fever, sweating
Induce vomiting; inactivated charcoal; NaHCO3
- Acetaminophen
Generally not very toxic
Liver failure might not be apparent after a full week
- CNS depressants alcohols, narcotics
Main concern is respiratory depression
Airway clearance and ventilatory support
- Stimulants cocaine, metamphetamines
Cardiac arrhythmias, seizures
Violent, burn out and crash
Inhaled Poisons
First Aid
Absorbed-Cholinergic Agents
First Aid
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Bio-Crisis Ms. Lina Navarro
Assess
- Respiratory system
Bronchospasm and wheezing, dyspnea
Chest tightness and coughing
- Circulatory system
Hypotension
- Mental status
Anxiety
- Skin
Swelling of the lips and tongue
Itching and burning
Widespread urticaria
- Muscle Spasms, cramps
Snake Bites
Snakebite Management
Do NOT
- Apply ice
- Apply arterial tourniquet
- Cut and suck
- Use electrical shock
- Actively attempt to locate a venomous snake
- Bring a live venomous snake to the hospital
Spiders
Bee Stings
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Bio-Crisis Ms. Lina Navarro
- Remove stinger by scraping it out
- Cold compress or ice
- Diphenhydramine, H2 Blockers, Epi
- Research has shown that the best course of action is to pull the stinger out as soon as possible with your
fingers
- The remaining venom in the sac of the stinger does not increase the reaction should you inadvertently push
more venom into your wound
Scorpion Stings
Coelenterate
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