NSG MGNT of PT. in EMERGENCY & DISASTER SITUATION.pptx

NURSING MANAGEMENT OF PATIENT IN EMERGENCY & DISASTER SITUATTION By : Snehal Johnson Associate Professor Community Health Nursing RIN

GLOSSARY Advanced life support: A medical procedure performed by paramedics that include the advanced diagnosis and protocol-driven treatment of a patient in the field Alarm procedure: A means of alerting concerned parties to a disaster; various optical and acoustical means of alarm are possible including flags, lights, sirens, radio, and telephone Assets: A term used for all resources required, including human, to adequately respond to a disaster. Basic life support: Noninvasive measures used to treat unstable patients, such as extraction of airway obstructions, cardiopulmonary resuscitation, care of wounds and hemorrhages, and immobilization of fractures. Bio-terrorism: The unlawful release of biological agents or toxins with the intent to intimidate or coerce a government or civilian population to further political or social objectives; humans, animals, and plants are often targets.

Case management: The collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individual's health needs. Casualty: Any person suffering physical and/or psychological damage that leads to death, injury, or material loss. Contamination: An accidental release of hazardous chemicals or nuclear materials that pollute the environment and place humans at risk. Contingency plan: An emergency plan developed in expectation of a disaster; often based on risk assessments, the availability of human and material resources, community preparedness, and local and international response capabilities. Coordination: A systematic exchange of information among principal participants to carry out a unified response in the event of an emergency.

Disaster epidemiology: The study of disaster-related deaths, illnesses, and injuries in humans; also includes the study of the factors and determinants that affect death, illness, and injury following a disaster. Disaster informatics: The theoretical and practical operation of processing information and communicating in a disaster situation. Disaster severity scale: A scale that classifies disasters by the following parameters: the radius of the disaster site, the number of dead, the number of wounded, the average severity of the injuries sustained, the impact time, and the rescue time. Disaster vulnerability: A measure of the ability of a community to absorb the effects of a severe disaster and to recover; vulnerability varies with each disaster, depending on the disaster's impact on the affected population or group. Emergency: Any natural or man-made situation that results in severe injury, harm, or loss of humans or property. Evacuation: An organized removal of civilians from a dangerous or potentially dangerous area.

First responder: Local police, fire, and emergency medical personnel who arrive first on the scene of an incident and take action to save lives, protect property, and meet basic human needs. Golden hour: A principle that states that unstable victims must be stabilized within 1 hour following injury to reduce the risk of death. Hazard: The probability that a disaster will occur (hazards can be caused by a natural phenomenon [e.g., earthquake, tropical cyclone], by failure of man-made energy sources [e.g., nuclear reactor, industrial explosion], or by an uncontrolled human activity [e.g., conflict, overgrazing]). Mitigation: Measures taken to reduce the harmful effects of a disaster by attempting to limit the disaster's impact on human health and economic infrastructure. National preparedness goal: Describes the core capabilities required for each of the five mission areas: prevention, protection, mitigation, response, and recovery. Natural disasters: Natural phenomena with acute onset and profound effects (e.g., earthquakes, floods, cyclones, tornadoes).

Planning: To work cooperatively with others in advance of a disaster to initiate prevention and preparedness activities. Post impact phase: The period of time after a disaster event; often associated with the activities of response and recovery. Readiness: Links preparedness to relief; an assessment of readiness reflects the current capacity and capabilities of the organizations involved in relief activities. Recovery: Actions of responders, government, and the victims that help return an affected community to normal by stimulating community cohesiveness and governmental involvement. Recovery plan: A plan to restore areas affected by disaster; developed on a state-by-state basis with assistance from responding federal agencies. Relief: Action focused on saving lives. (Relief activities often include search and rescue missions, first aid, and restoration of emergency communications and transportation systems.

Crisis management: Administrative measures that identify, acquire, and plan the use of resources needed to anticipate, prevent and resolve a threat to public health and safety (e.g., terrorism). Triage is a process of prioritizing patients or resources based on the severity of their condition, prognosis, and likelihood of survival. Richter scale: A scale that indicates the magnitude of an earthquake by providing a measure of the total energy released from the source of the quake; the source of an earthquake is the segment of the fault that has slipped. Risk indicator: Descriptor that denotes risks that may cause a disaster. Vulnerability: T he state of being exposed, weak, or susceptible to harm, attack, or damage, whether physically, emotionally, financially, or in a system.

DISASTER Disaster as any incidence that causes damage loss of human life, ecological disruption, worsening of health and health services. Disaster can occur anytime and anywhere. It is not restricted only to a particular part of the world. According to WHO (1995) “Disaster is any occurrence that causes damage ecological disruption, loss of human life or deterioration of health and health services on a scale sufficient to warrant an extraordinary response from outside the affected community or area.” Disaster nursing can be defined as an adaptation of professional nursing skills in diagnosing the physical and emotional needs and problems of people who are affected by the disaster.

Disasters may affect as follows: Source of illness, premature deaths, and injuries. Abolish the local health care system and infrastructure of the disaster place. Disturb the health, emotional, psychological, and social wellbeing of the population. Source for shortages of food and origin of severe nutritional deficiencies. Create huge population movements. Produce ecological inequalities. Criteria for a Disaster Report states that 100 or more people affected by disaster Announcement of a state of emergency Call for international support

Causes of Disaster Urban areas Rural areas Ecological imbalance Inappropriate construction Inadequate planning Rapid growth Unmanaged urbanization Poor management in land usage Destruction Deforestation Unemployment and lack of development Intense rain falls within short period of time Poverty and population Changeover in cultural practices Lack of awareness and information about disaster Misuse and abuse of modern technology

Types of Disaster Natural Human-made Earth: Earthquakes, toxic mineral deposits, erosions, landslides, volcano eruption Air: Cyclones, dust storms, typhoons, hurricanes, tornadoes, avalanches Fire: Lightning and bushfires Water: Floods, tsunamis, and storms People: Endemic disease, over population, and epidemics Typhoon-a tropical storm with very high winds, occurring in the region of the Indian ocean Tornadoes-a aggressively rotating wind storm having the appearance of a funnel-shaped cloud Avalanches-a mass of ice falling and snow falling rapidly down the side of a mountain Earth: Road and train accidents, ecological irresponsibility, ecological neglect, pollution, radioactive, toxic waste disposal, and war Air: Aircraft accident, hijackings, space craft accidents, acid rain, radioactive cloud Fire: Fire-setting Water: Accidents People: Terrorism, criminal activities by chemical and biological contaminants, sports-crowd violence, siege (military operation in which enemy forces try to capture a town or building by surrounding it and cutting off its supplies

Concept of Disaster A disaster is a sudden, calamitous occurrence that extremely disturbs the functioning of a society or community causes material losses, human losses, economic losses and environmental losses that exceed the society's or community's ability to manage by using its own resources. Diagnosing a Disaster Case study approach: Study each disaster incidence individually in case based because each disaster is independent and unique in nature, place, and time of occurrence. Comparative studies approach: Compare each disaster with previous disasters incidence and study the differences among them. Descriptive and analytical approach: It includes studies the characteristics of the disaster, describe the disaster, analyze the consequences of disaster. Environmental approach: Study the disaster and its environmental factors involved in the occurrence of the disaster.

Historical approach: It includes study the disaster causative factors in previous years information on historic viewpoint. Describe the incidence happened in past years and its impacts. Systems approach: Disaster consists of various systems and each system role and responsibilities at the time of incidence occurrence. Integrated studies approach: Integrates all the approaches to study the disasters. Strategies for Preventing Disasters Emerging communication system to announce the disaster early warning, information and communication systems. Establish community-based strategies to study the disaster risk management to rise the populations' resilience, particularly for vulnerable groups. Constitute internal and external management plans based according to priorities in the disaster. Collect and store the necessary food, medical supplies, rescue tools, water, etc.

Priorly prepare plans for accommodation centers, mobilization of emergency forces, logistic and communication, engineering equipment, volunteers, and disasters management teams. Allocate the role and responsibilities of each and every department involved in disaster management. Manage the fearful disaster situations through awareness, increase morale, and appropriate management of the occurrence and avoiding social conflict.

Goals of the Disaster Nursing To meet the instant basic needs for survival of populations who were affected by disaster. To recognize the secondary disaster possibility. To evaluate risks and resources to provide health care and requirement to restore the health. To allow survivors to contribute and promoter for their own health and wellbeing. To respect cultural, religious diversity, and lingual of individuals and families. To apply cultural belief and practice in all health promotion activities. To help the highest possible quality of life for survivors.

Principles of Disaster Nursing Assess the disaster condition and find the affected people needs and problems. Provide the appropriate care based on the affected people needs. Triage the injured people and initiate life-saving treatment according to triage categories. Implement the essential nursing interventions depend on priorities. Evaluate the disaster damage in affected environment. Removal of health hazards from disaster area to prevent the infection. Prevent further damage in the disaster area. Organize the disaster team, triage system, provide essential medical care to save life, and transport the affected people from affected place to away during the crisis period. Educate, supervision, and utilization of auxiliary medical personnel and volunteers. Provide sympathetic care, show kindness, and emotional support to all sufferers and their families.

Guidelines of Disaster Code designated for disaster. Disaster plan activate and declare by competent authorities of the institute. Disaster should be informed to all integrated department like police department, health department, railway department, navy department, public service department, forest department, transport department, communication department, broad cast department, security department and fire departments. If required announce to whole Institute immediate. After authority declare disaster, the operator requires to announces code three times and repeats the announcement every 30 seconds for a period of 2 minutes. The off-duty health care professionals recall depends on the severity of the disaster. Allot the duty and responsibility for each health care professional to avoid duplication of the works. Each zone of the care area function under the supervision of the senior health experts.

Traffic and security department responsibility to control the traffic in and around the disaster area. Triage is started next to the ambulance entrance. Avoid to accumulate casualties in one place. Triage people rapidly to start treatment immediately without delay. Triaged people tag them appropriately. Provide appropriate immediate treatment without delay like respiratory problem and hemorrhaging. Severely injured patient sent to surgery area Ambulatory care patients not required admission and sent out after first aid care. Provide the emotional support by spiritual masters. Maintain the all data in confidential way with proper document. Termination of disaster status also by the competent authority.

After termination of disaster, health care professionals return to their respective place of work. Competent authority may release data through the press Public relations department: releases information and messages to media, as necessary. Nurse acts as liaison officer between patients and relatives. Avoid unnecessary photographs. Maintain all records and registry in confidential cardboard. It should not access by others. Lists bodies with their identification, date and time of arrival, time of release, with signature of respective person.

Equipment and Resources Emergency medical equipment Emergency medicine Office equipment Computer equipment and supplies Resources for freezer space or freezer trucks Local volunteers or temporary help The disaster recovery plan must specify by name, position, address, and phone number the various resources the disaster team will use stationeries also. Collect fund from Government, private donation, international organization, national organization, and NGOs.

Department Involved in Disaster Local fire department Police department Civil defense Ambulance services Medical department Telephone department Mass media Transport Railway department Postal department Army Public work department Financial dept

Disaster Cycle

Prevention phase: Its primary aim is to prevent possible natural and man-made disasters from physical damage and biological damages as much as possible. But all disaster is not possible to prevent, at the same time can be reduce the damages. Damage-mitigation phase: Its main aim to prepare preventive measures to reduce the disaster threats before the occurance of disaster. It includes take steps before the incidence of disaster. Preparedness phase: It consists of the steps taken to reduce the anticipated disaster damage such as decrease the mortality, reduce morbidity, transplantation of people from vulnerable disaster area to non-vulnerable other area. Announce the warning the signs of possible risk of disaster with the help of satellite network. The role of nurse is supported to prepare the emergency first aid and medical aid stations, and start to collaborate with other disaster team.

Response phase: Its main responsibilities take action after incidence of the disaster actually happen to save the people, provide the basic needs of the affected people, and looking for survivors. Establish the emergency operation center, and communication center, make available the shelter for the affected people to provide medical care, psychological support to the affected people, communicate to Government health care providers and other agencies. Make available nurse in each disaster action team. Recovery phase: It includes reconstruction and rehabilitation phases. Recovery starts during the emergency phase ends with the return of normal community order and functioning. Remove the disaster's debris ( मलबा ) , provide care and shelter, assess the damage, and get funding assistance for further recovery plan. Rehabilitation phase: After the disaster, take necessary action for return the people to the pre-disaster condition. Provide emotional support to the victims.

Reconstruction phase: It include implement the planned action to reconstruct the community from disaster to complete return to pre-disaster condition along with collaborate with the affected peoples after rehabilitation phase.

Elements of Disaster Plan Chain of authority Care of dead bodies Disaster worker rehabilitation Equation Lines of communication Modes of transport Mobilization Warning Rescue and recovery Support of victims and families Triage Treatment

Role of Nurse in Disaster-Personal Preparedness Capacity building Control room Certified first aider and CPR Communication skill Knowledge about community Knowledge about policies and protocols License and health resources Personal equipment, such as a stethoscope, a flashlight, extra batteries, warm clothing and a heavy jacket and weather appropriate clothing, recording keeping materials Pocket-sized reference books Readiness to work in the multidisciplinary team Prepared disaster written plan Rapid response team Types of disaster and its management

Organizing an Effective Disaster System Generally, the disaster system organizes into three zones: 1. Disaster zone: This is the actual site disaster happened. The affected victims removed from the disaster location as soon as possible. Triage is carried out, most of the skillful disaster personnel working in this zone. 2. Treatment zone: In this zone, treatment is carried out for the affected victims. It should be 50 feet away from the disaster zone. Nurses holding vital role in this zone to carryout treatment, triage the victims, assess the health status, treat the injuries, and arrange the transportation facilities to move the victims. 3. Transportation zone: The patients are transferred from this zone after the primary treatment to the hospital for further appropriate advance management. This zone should be arrange with sufficient place for ambulance and other vehicles enter and exit services.

Disaster Preparedness Disaster preparedness plan should be activated immediately when disaster happened . Establish emergency communication plan, public awareness education plan, warning system, training plan, evaluation of plan, and resource inventories. Prepare plan to prevent outbreak of infectious disease Create the public awareness through education Activate hospitals, healthcare system immediately before, during and after a disaster or emergency occurs. Activate the rescue, search, triage activation, field care, first aid, feeding, referral services clearing debris, and sheltering for affected people. Reinforce the technological advancement in disaster management, managerial capacity of Government organizations and communications. Safeguard and reserve medicine, food, equipment, water, and other essential elements.

Role of Nurse in Disaster Preparedness Nurses in disaster preparedness help for preparation within the community and place of employment. Initiate the updated disaster plan, provide materials regarding disasters specific to the area educational programs, and organize disaster drills. Provide an updated data of vulnerable populations within the community. Involve in educating special population about its impact. Identify the resources available in the community after a disaster strikes Help to maintain a safe environment. Knowledge about the community-wide disaster plans. Understand the available community resources. Nurses are also involved in the shelter functions of assessment and referral Assurance of medical needs First aid management Meal serving Keep patient records Ensure emergency communications Transportation

Impact of Disasters Death Severe injuries needing extensive treatment Increase risk of communicable diseases and epidemics outbreak Surplus mortality Mental health-disaster syndrome Destruction of the health care infrastructure Damage basic sanitation and water supply Food shortage and malnutrition Population movement and migration

Principles of Disaster Management Prevent the incidence of the disaster as much as possible. Save the wounded sufferers Offer the specific first aid Helping for reconstruction and recovery of community If the disaster is unable to prevent, at least reduce the casualty's rate. Avoid further casualties from disaster after the initial impact of the disaster Evacuate the wounded to medical services Provide specific medical care Encourage reconstruction of lives.

Principles of Diasater Mangement

Actions in Disasters Humanity: Remove the affected people suffering and saving human lives anywhere it is found, is essential to humanity. Impartiality: All actions implement exclusively based on requirement, without discrimination between affected peoples. Neutrality: All humanitarian action should distribute equal without any dispute among the affected people where such action carried out. In-dependency: The autonomy of humanitarian objectives from the economic, political, military and other objectives where humanitarian action is being implemented, any action may hold with regard to areas

Preparedness: Pre-plan the disaster management activities before the occurrence of disaster. For example, preparedness plans, warning systems, emergency exercise, and training program. Response: Implement the activities during a disaster. For example, public warning systems, search activities, rescue response, and emergency operations. Recovery: Activities to be implement after the disaster. For example, long-term medical care, temporary housing, claims processing, fund grants, and counselling. Mitigation: Activities to taken to reduce the effects of disasters. For example, vulnerability analyses, building codes, zoning, and public education.

Disaster Management Committee Chairman, director, medical superintendent Additional medical superintendent Chief nursing officer, nursing superintendent Chief medical officer Head of department such medicine, surgery, Orthopedics, radiology, anesthesiology, neurosurgery, urology, cardiology, Pulmonology, ENT, ophthalmology, pediatric, etc. Blood bank in charge Security officer Transport officer Sanitary personnel Multidisciplinary Disaster Management Team

Multidisciplinary disaster management team Physician, surgeon, orthopedics, emergency medicine, etc . M ulti-disciplinary team Nurses and other health care workers Fire service department, police department, public service department, military, politicians, railway department Psychiatrist and psychologist Social workers. occupation therapist non-government organization Religious people

Role of Nurse in Disaster Response Create safety to affected people Provide the medical treatment and nursing care as per requirement of the patients Properly use all the available resources Provide psychological support Provide life-saving measures and first aid management Provide necessary health care, shelter, supply water, food, medicine, and communication. Continuing public moral Voluntary reception, and relative waiting areas Management of infection control Relieve post disaster stress Encourage ventilation Establishing outreach program to provide community support Referral service

Role of Nurse in Mitigation Assessment Assess the risk factors and analysis the prior disaster Assess the degree disaster impact Coping strategies of local disaster plan Assess the health personnel and health facilities resources available Review the existing community disaster plan Local climate conductive to disaster formation. Evaluate local agencies and organizations. Risk Reduction Avoid the risk of disaster Reduce the likelihood of the incidence Reduce the significances Accept or retain the risk of disaster

Various Agencies in Disaster Management National Disaster Management Authority All India Disaster Mitigation Institute National system for DM National Centre for DM Ministry of Agriculture Disaster Risk Management Programme National Disaster Management Framework Calamity Relief Fund National Calamity Contingency Fund (NCCF) Non-Government Organization International Red Cross Indian Red Cross Youth Red Cross Lion Club

Major Roles of Nurse in Disaster Define health needs of the affected groups Establish priorities and objectives Identify actual and potential public health problems Determine resources needed to respond to the needs identified Collaborate with other professional disciplines, government and non-government agencies Maintain a unified chain of command Disaster Nursing It can be defined as the “adaptation of professional nursing skills in recognizing and meeting the physical, health and emotional needs of the affected community resulting from a disaster.” Disaster nursing goal: To attain highest level of health level among the affected people and community the disaster.

Professional Preparedness Disaster management committee Disaster beds Information and communication Logistic support system Standard operating protocol Training and drills Use of personal protective devices Unity of command with mobile van

Activation of Disaster Management Plans Crowd management-control crowd Develop a standard operating procedure Documentation at control room-maintain the data about the disaster Public relation-announcement to the people Reception area-disaster control room Triage system-prioritized the patient

Qualities of nurse working in disasters. Leadership Coordination Trust Responsibilities Control Value of human life Sensitivity Team spirit Toughness Confidence Gentleness Accept self-criticism Cooperation Interdependence Accountability Commitment Strength

Nurses' Duty in Disaster's Impact and Response Assess the severity of disaster State the victims' health needs and problems Priorities the intervention based on the triage Recognize actual and possible public health issues Coordinate with other health care members government and non-governmental agencies Maintain an integrated chain of command Maintain proper communication

Response to Alert Inform to authority, supervisor, and arrange mobile van to care victims. Care the patients with multidisciplinary team Initiate search, rescue and provide first aid Allot the duty and responsibilities every team member without duplication Involved field care Triaging and tagging the victim Provide care for injured persons Perform referral services for severely injured patients Arranging for physical facilities for the victim Effective communication

Triage Triage means to category the affected person based on priorities when the resources are limited. Objectives of Triage To provide prompt medical intervention in life threatening condition to save the patient. To provide the advance care of life-threatening patients. To reduce morbidity and morbidity by initiate the treatment at right time without delay. To communicate the patient's condition to the family members and relatives. To avoid the accumulation of patient in the emergency department. To improve patient flow within emergency departments and other referral or disaster management institutions. To provide supervised learning for suitable personnel.

Triage (Categorizing) Red-high priority Yellow-medium priority Green-ambulatory (refers to patients with minor injuries who are able to walk, meaning they are stable and require less urgent, non-life-threatening care) Black-dead Need for triage: Triage involves the classification of injured person rapidly based on the severity of injuries and possibility of their survival with speedy medical interventions.

Principles of Triage Skillful health care professionals should be triaged every patient appropriately. Triage must integrate with other department and include collective planning for treatment discission making. The triage procedure helps to initiate the effective treatment without delay. Components of a Triage System Personnel: The individuals working should be responsible, clinically knowledgeable, have critical thinking, have ability to rapidly elicit relevant history, display expertise in physical assessment skills and possess exemplary interpersonal skills.

Space requirements: The area should be large enough to hold a sufficient amount of frequently used supplies and equipment. Equipment and supplies: Specific sufficient amount of frequently used supplies and equipment for existing triage and treatment protocols. Communication and information: Comprehensive communication system. (Alarm, closed circuit TV, pager, telephone.......)

Equipment required in triage area. Wheelchairs Stretches Backboards IV poles Disaster tags Emesis basins Scissors Emergency trolley with equipment Stethoscope Stationaries Splints, bandages, scissors Blanks Emergency trolley with equipment Stethoscope Stationaries Adhesive tape Oral airway Splints, bandages, scissors Blanks Adhesive tape Oral airway

Tagging Tag all the patients with name, age, triage category, hospital number, diagnosis, initial treatment, and place of origin. Identification of Dead Care of dead include: Removal of dead body from the disaster scene Dead body after removal shift to the mortuary Identification of dead by family members or relatives Hand over the dead body to the family members after complete all the hospital formalities.

Mental Wellness Allow the family members or friends talk to the affected person, make the patient to understand the reality of the situation, encourage the spiritual people or local healers to talk with the patient to support them. Majority of the people return to normal within 2 weeks.

Role of Nurse in First Aid Establish rapport with the patient Provide care to needs of the patient Communicate with affected patient Administer appropriate medicine as order Supervision responsibilities Ventilation support Conduct meeting with peer group Managing social behavior Encouraged to express about disaster

Role of Nurse in Phases of Disaster Role of Nurse in Restoration of the Predisaster Condition Modify the behavior of person Provide care for survivors Control of vectors Provide counseling Supply food Investigate and prevention of epidemic outbreak Follow all safety measure to prevent infection and further complications Administrate vaccination Supply water

Reconstruction Arrange the temporary shelter Create awareness about preventive measures Deliver the basic resources like food, water, etc. Nurse act as a shelter manager Provide health care, supply food and necessary amenities in the camps Pay attention to the victims Provide compassion and dignity to the victim Reassure victims to overcome the crisis Train of people, students, and volunteers

Rehabilitation Alert for environmental health hazards Community rehabilitation Counseling Financial support and assistance Follow-up care Home visits Health and safety information Long-term medical care Restore essential services Physical restoration or reconstruction Temporary housing Teach proper hygiene

POLY-TRAUMA Poly-trauma is the syndrome of multiple injuries with systemic distressing reactions which may lead to vital organ dysfunction or failure. Poly trauma affects more than one system result in cognitive, physical, psychological or other psychosocial impairment (e.g., amputation, post-traumatic stress disorder, auditory and visual impairment), related to chest injury, head injury, spinal injury, pelvic injury, and abdominal injury. Poly-trauma management required by a team of physicians and surgeons in multi-specialty like orthopedic, cardio, neurosurgery, urologist, gastroenterologist, etc. Definition Poly-trauma is a substantial injury at least two of the following six body regions:

1. Abdomen and lumber spine 2. Chest and thoracic spine 3. External organ skin, significant injury in AIS (abbreviated injury score) 4. Face 5. Head, neck and cervical spine 6. Limbs and bony pelvis

Severity of Injury Abbreviated injury score (AIS) and injury severity Abbreviated injury score (AIS) AIS injury Types of injury Uninjured No injury 1 Minor Superficial injury 2 Moderate Reversible injuries, required medical attention 3 Serious Reversible injuries, not life-threatening, patient required hospitalization 4 Severe Life-threatening, survival uncertain, not fully recoverable without care 5 Critical, survival uncertain Non-reversible injury, not fully recoverable even with medical care 6 Unsurvivable Fatal

Criteria of Poly-trauma Contain any one of the following combination injuries: Two major system injury + one major limb injury One major system + two major limb injury One major system injury + one open grade three skeletal injury Unstable pelvis fracture with related visceral injury (damage to one of the body's internal organs, also known as viscera) Etiology Assault Airplane crashes, train derailment Blast Fall from height cause blunt or penetrating injury Road traffic accident Thermal, chemical injury

Pathophysiology It is complex phenomenon and its aims to restoration of homeostasis and preservation of life. There are two theories in host defense response during poly-trauma. First theory: The Two-Hit Model First hit (Hyper-inflammation): The initial trauma, like a car crash, causes immediate damage to organs and tissues. In response, the immune system goes into overdrive, releasing a "storm" of inflammatory chemicals to repair the damage. This widespread inflammation is called Systemic Inflammatory Response Syndrome (SIRS). Instead of staying local, the inflammation spreads throughout the body and can damage healthy organs, leading to organ failure. Second hit (Immunosuppression): The initial, intense inflammatory response is often followed by a period where the immune system becomes suppressed, or weakened. This is called Compensatory Anti-inflammatory Response Syndrome (CARS). During this phase, the patient is highly vulnerable to infection and sepsis, which can also lead to organ failure.

Second theory: Mixed Antagonistic Response Syndrome (MARS) This is a more recent understanding that suggests the body isn't simply shifting from a hyper-inflammatory state to an immunosuppressed state. Instead, both pro-inflammatory (SIRS) and anti-inflammatory (CARS) responses happen at the same time. The patient's outcome depends on whether the body can find the right balance between these two competing responses.

Pathophysiology of poly-trauma Injury Tissue swelling Perfusion pressure Local hypoxia Compartment pressure Cell membrane damage

Theory of host defense response during poly-trauma Primary insult Trauma organ injury, tissue injury, fracture Hyper-inflammation Systemic inflammatory response syndrome, multi-organ failure, molecular adsorbent recirculating system Compensatory anti-inflammatory response syndrome (CARS) Secondary insult Ischemic/reperfusion injury, interventional load, surgery Hypo-inflammation

Criteria of systemic inflammatory response syndrome (SIRS) are two or more of the following: Heart rate >90 beats/minute Respiratory rate >20 beaths/minute or (Partial pressure of arterial carbon dioxide) PaCO2 <32 mm Hg Temperature >38 ° C WBC >12,000 cell/mm³, <4,000 cells/mm³, or >10% immature forms Type of Shock in Poly-traumatized Patient Hemorrhagic shock due to severe blood loss, it causes hypotension, tachycardia, and cold skin. Hypoxic shock due to severe blood loss cause reduce the vital organ perfusion and decrease tissue perfusion lead hypoxic shock. Neurogenic shock due to spinal cord injury. Its causes disturbance in circulation of sympathetic outflow to heart and blood vessels characterized by bradycardia, hypotension, and warm skin. Septic shock due to severe infection.

Shock in poly-trauma. Decreased CO Increased blood volume ADH Aldosterone Angiotension Renin secreted by kidney Vasoconstriction SNS stiumulation Blood pressure maintained Epinephrine and norepinephrine released Increased SVR Fluid pulled into capillary Hydrostatic pressure

Diagnostic Evaluation Nature of incidence history collection Primary and secondary physical examination to find out the significant signs and symptoms to initiate treatment ECG monitoring to find the heart involvement and assess the severity of bleeding X-ray-C-spine lateral, chest, pelvic, abdomen and extremities. Neuro examination-GCS

Poly-trauma Management Team Physicians: Emergency dept, ICU anesthesiologist Social workers, psychologist, family members, community health nurse, Police for MLC Physiotherapist, occupation therapist Nurses-critical care, emergency, rehabilitiative nurse, ortho nurse, CTVs nurse, etc. Radiologist to confirm the diagnosis Surgeons: Trauma, vascular,neuro, ortho, plastic, thoracic, etc. Patient

Management Management main aim to restore the patient life, based on priorities like limb salvage, life salvage, and salvage of total function if possible. Phases of Poly-trauma Care Pre-hospital care Emergency department Rehabilitation

Pre-hospital Care Phase ABC assessment-Air way, breathing and circulation assessment Air way patency should to maintain by endotracheal intubation if required Start the CPR (Cardiopulmonary resuscitation) if indicated Replacement of fluid with isotonic solution. Reduce and splint age of fractures Complete primary survey assessment of patient and document the findings. Perform triage in mass-casualty incident and critically ill patient transport to the hospital immediately. Golden hour: Transfer the severely injured patient immediately within one hour without delay to a trauma center. Because after one hour possibility of survival reduces. Golden hour 10 minutes may be used for on-scene activities.

Protocol to Start Triage All walking wounded patient-Green If respirations absent means positions airway, if no respirations mean deceased; if respiration started means immediately start emergency treatment. If respiration present and more than 30/minutes mean immediately start emergency treatment. If respiration less than 30/minutes → perfusion → radial pulse absents or over 2 seconds → capillary refill → under 2 seconds → control bleeding-start immediate emergency management. Radial pulse present → mental status → cannot follow simple commands → start immediate emergency management. Mental status → can follow simple commands → may delayed treatment

Primary Survey A-airway maintenance and control of cervical spine: If conscious-ask the patient's name, if unconscious-look for additional abnormal sound such as stridor, cyanosis, etc., if patient does not respond to any question start resuscitate immediately. Always assure a cervical spine injury is present. Maintain airway patency and oxygen administration through mask, endotracheal intubation, ambu-bag, and protection of the spine is very important while giving airway maintenance. Airway maintenance sequence of events are: (i) Chin lift, → (ii) Jaw thrust, → (iii) → Finger sweep, (iv) Suction, → (v) Oropharyngeal/orotracheal tube, → (vi) Cricothyroidotomy, → (vii) Tracheostomy

Needle Cricothyroidotomy Surgical Cricothyroidotomy

B-breathing and ventilation: Exposure, inspection, auscultation, palpation, and pulse oximetry. The aim is to treat the life-threatening thoracic conditions are open pneumothorax, tension pneumothorax, flail segment, and cardiac tamponade. Open pneumothorax-manage by closing of the wound, and tube thoracotomy. Tension pneumothorax develops decrease breathing, reduce breathing sound, respiratory distress, tracheal deviation, and distended neck veins. Immediate needle thoracentesis through 2nd intercostal space in mild clavicular line essential. Flail segment-manage by endotracheal intubation and mechanical ventilation. Cardiac tamponade-it is almost seen with a penetrating wound. Beck's triad-'3Ds'-Distant (Muffled) heart sounds, distended neck veins, decreased pulse pressure. It treated by needle pericardiocentesis thoracotomy.

Open pneumothorax: An open pneumothorax is a traumatic wound to the chest wall that allows air to enter the pleural cavity, the space between the lungs and the chest wall. This entry of outside air increases pressure on the lung, causing it to collapse Tension pneumothorax: A tension pneumothorax is a life-threatening complication of a simple pneumothorax. Air enters the pleural space but cannot escape, causing immense pressure to build up. This pressure compresses the lung, shifts the heart and major blood vessels to the opposite side of the chest, and drastically reduces blood flow to the heart. Flail segment: A flail segment, or flail chest, occurs when two or more adjacent ribs are fractured in at least two places, detaching a section of the chest wall. Cardiac tamponade : Cardiac tamponade occurs when blood or other fluid accumulates in the pericardial sac, This fluid buildup compresses the heart, preventing its chambers from filling properly.

Open pneumothorax-manage by closing of the wound, and tube thoracotomy. Tension pneumothorax develops decrease breathing, reduce breathing sound, respiratory distress, tracheal deviation, and distended neck veins. Immediate needle thoracentesis through 2nd intercostal space in mild clavicular line essential. Flail segment-manage by endotracheal intubation and mechanical ventilation. Cardiac tamponade-it is almost seen with a penetrating wound. Beck's triad-'3Ds'-Distant (Muffled) heart sounds, distended neck veins, decreased pulse pressure. It treated by needle pericardiocentesis thoracotomy.

Signs of airway obstruction: Look-agitation, deformity in chest, rib retraction, and foreign material in airway pathway. Listen-speech, noisy breathing, hoarseness, gurgle, and stridor. Feel-tracheal deviation and hematoma. When to ventilate: Apnea, diaphragmatic injury, flail chest, hypoventilation, high spinal cord injury, head injury GCS-8, hypercapnia, and hypothermia.

C-circulation and hemorrhage control Causes of major bleeding External Visual inspection Local pressure Thoracic Primary survey and CXR Intercostals tube insertion Pelvic Pelvis X-ray Usually self limiting/pelvic ring closure Long bones Clinical examination Spontaneously traction splintage Abdomen Clinical findings/exclusion of other/USG/CT/DPL Laparotomy

Classification of hemorrhage Classes Descriptions Class-1 hemorrhage If blood loss happens up to 15% of the blood volume, it does not cause a any change in blood volume or blood pressure. Treated with 1.5 liters of ringer lactate or 1 liter of polygelatin (Haemaccel) Class-II hemorrhage (mild) If blood loss occurs from 15 to 30% of the blood volume. It causes increased pulse but there is no change in blood pressure. It managed by fluid resuscitated with a crystalloid, 1.5 liters of ringer's lactate and 1 liter Haemaccel, but some patient requires blood transfusion Class-III hemorrhage (moderate) If blood loss happens from 30 to 40% of circulating blood approximately 2 liters. It causes tachycardia, reduce systolic blood pressure and reduced mental status. It's managed by administrated 2 liters of saline over 20 minutes. Blood pressure should be maintained by crystalloid until blood is ready. Recurrent hypotension, managed by administrate 2 liters of crystalloid and type-specific or non-cross-matched universal donor (e.g., blood group O -ve') blood is given Class-IV- hemorrhage (severe) If the blood loss occurs >40% of the blood volume. It results noticeable changes in vital signs, tachycardia, reduced systolic blood pressure, cold and pale skin, severely reduced mental status, tiny urine output. Its managed by two to three units of Fresh frozen plasma (FFP) and a six pack of platelets for every 5 liters of volume replacement

Assessment of internal and external blood loss in chest, abdomen, pelvis, and limbs. In thoracic bleeding, it is required to take chest X-ray and intercostal drainage tube insertion to relieve fluid accumulation in the thoracic region. Pelvic bleeding is required to takes pelvis X-ray and apply pelvic binder and external fixator. Intra-abdominal bleeding is confirmed by USG, Doppler study, and CT scan. It required an emergency laparotomy. Long bones fractures management by splint. External bleeding managing by arrest bleeding by apply local pressure, obtain vascular access and start IV fluid line one above and one below the diaphragm and administrate crystalloids and colloids. Administrate 2 liters of ringer lactate solution as initial fluid challenge for adult, for children 20 mg/kg of body weight. After initiate the IV fluid, the patient's vital signs continued return immediately. It will occur if the blood loss <20%. Transient responders, the patient bleeding occur within the body cavities. For them required surgical intervention. If there is no improvement in vital after fluid resuscitation, and bleeding >40% required immediate surgery and continued IV fluid harmful.

Rapid responders (blood loss <20%): A patient with minor blood loss will respond quickly to an initial IV fluid bolus, and their vital signs will return to normal. This positive response indicates minimal blood loss, and the patient will likely remain stable. Transient responders (blood loss 20–40%): These patients initially improve with fluid administration but then deteriorate as their blood pressure drops again. This indicates ongoing blood loss, often from internal injuries. Transient responders typically need a blood transfusion and require surgical intervention to control the source of bleeding. Non-responders (blood loss >40%): If a patient does not respond to initial fluid resuscitation and their vital signs remain unstable, it suggests a major, uncontrolled hemorrhage. For these patients, continued fluid administration is harmful because it dilutes the remaining blood's clotting factors, potentially worsening the bleeding. The priority is to get them to the operating room for immediate surgical control of the bleeding.

D-disability limitation: Head injuries is the main cause for 50% of the trauma deaths. Rapid CNS motor and sensory functions assessment is very important. Check the patient alertness, response to voice, responses to pain, unresponsiveness, pupil size and reaction. Remove the patient's clothing and provide sheet to prevent hypothermia. Normal GCS is 15/15, if GCS less than 10, its indicate CT brain.

Strategy in Patients with Head Injury Understand impaired cerebral autoregulation: In healthy individuals, the brain automatically maintains a steady blood flow despite changes in blood pressure. With severe head injury, this mechanism is often lost, making the brain's blood flow directly dependent on systemic blood pressure. Maintaining adequate blood pressure is therefore critical to prevent cerebral ischemia (inadequate blood flow). Regional anesthesia risks: Regional anesthesia causes a sympathetic block, which can lower a patient's overall blood pressure. This reduction in systemic blood pressure can dangerously lower cerebral blood flow in patients whose cerebral autoregulation is already impaired, risking further brain damage. Thus, careful hemodynamic monitoring is needed if regional anesthesia is considered.

Prioritize life-saving procedures: For a patient with a severe head injury, initial management must focus on immediate, life-saving interventions based on the "ABC" (Airway, Breathing, Circulation) principles of trauma care. This includes securing an airway, ensuring adequate breathing, controlling any external hemorrhage, and maintaining stable circulation. Other less urgent surgical procedures should be delayed until the patient's neurological condition and vital signs are stable. Secondary survey : It should be done after primary survey, patient's vital sign also stable. Secondary survey performs from head-to-toe assessment and re-examination of all vital signs, and level of consciousness by Glasgow coma score and neurological examination.

Management of Life-threatening Orthopedic Injuries All poly trauma patients required 0 hour fixation with injuries of other organs like depressed skull fractures, spleen, kidney, liver, major blood vessels tear, and pelvic fractures. All fractures sites should be immobilized by splinted, Backboard, and scoop stretcher used. Spinal injuries: Stabilization of spine is mandatory. Radiological investigations are essential to confirm the spinal injury. Spinal injury immobilized by apply cervical collar and spine board. Prevent bed sore, early mobilization and rehabilitation.

Pelvic injuries: Pelvic X-ray is mandatory to confirm the pelvic injury. It can lead to life threatening hemorrhage. Urethral injury managed by suprapubic catheter or transurethral catheter. Severe pelvic bleeding managed by pelvic binders, it helps to reduce the pelvic volume, allow for auto transfusion, allows clot formation. Its disadvantages are skin necrosis & compartment syndrome( Compartment syndrome is a painful and potentially dangerous condition caused by increased pressure within a muscle compartment. Compartments are groups of muscles, nerves, and blood vessels in the arms and legs that are enclosed by a tough, fibrous membrane called fascia. ). Damage control orthopedics: It required rapid emergency surgery to save limb and life, it is managed by without complex reconstructive surgery, decompress cranium, control bleeding, thorax, pericardium, abdomen and limbs. Maintain the wound decontamination and ruptured viscera, splint fractures by traction, cast, pelvic binder and external fixation.

DOG BITE Dog bite cause dog rabies potently life threatening. Poor people are at a higher risk. Dog bite spread the rabies virus from the leg to spinal cord, the brain and throughout the body. Pathophysiology Virus inoculation from a rabid dog bite or a rabid animal Transmission: A bite from a rabid animal, such as a dog, is the most common route of infection in many countries. Source of virus: The rabies virus is carried in the infected animal's saliva and is deposited into the wound during the bite.

Virus replicates in the muscle Initial phase: After entering the body, the virus may stay and replicate in the muscle cells at or near the bite site for some time. This stage is often considered part of the incubation period, and during this time, the virus may evade the host's immune system. Variable incubation: The duration of this incubation period can be highly variable (weeks to months), depending on factors such as the amount of virus inoculated, the severity of the wound, and its proximity to the central nervous system (CNS). Virus binds to nicotinic acetylcholine receptors at neuromuscular junctions Entering the nervous system: To invade the nervous system, the virus binds to specific receptors. The nicotinic acetylcholine receptor (nAChR), located at the neuromuscular junction (where nerve cells meet muscle cells), is a key entry point. Initiating uptake: This binding interaction initiates the uptake of the virus into the peripheral motor nerve endings.

Virus travels within axons in peripheral nerves through axonal transport Retrograde transport: Once inside the peripheral nerve endings, the virus uses the nerve cell's internal transport system, specifically the retrograde axonal transport pathway, to move toward the cell body. Molecular motors: The virus uses cellular motor proteins called dyneins to "walk" along microtubules within the axon, effectively moving backward from the nerve ending toward the spinal cord. Replications take place in the motor neuron of spinal cord and ganglia travels to brain Spinal cord infection: The virus reaches the spinal cord and the dorsal root ganglia (containing sensory neurons), where it begins to replicate. Rapid CNS spread: From the spinal cord, the virus rapidly spreads throughout the CNS, including the brain.

Infection of brain neurons leading to fatal inflammation Brain infection: Widespread viral replication in the brain's neurons follows. Neurotoxicity without extensive damage: Although the virus multiplies extensively, it does not typically cause widespread inflammation or damage to the neurons themselves. Instead, rabies is thought to cause a neurotoxic effect by interfering with neurotransmitters, leading to the dramatic neurological symptoms. Fatal outcome: The combination of neurological dysfunction and inflammation leads to coma and ultimately death. Encephalitis is a condition where there is inflammation of the brain, this is caused by rabies viral infection.

Virus enters salivary glands and other organs of the victim Centrifugal spread: After reaching the brain, the virus spreads centrifugally (away from the CNS) along the nerves to various peripheral organs, including the salivary glands. Transmission potential: The replication of the virus in the salivary glands allows it to be shed in the saliva, ready to be transmitted to another host through a bite.

Category of bites as per WHO Categories Type of contact with rabid animal Recommended treatment Category I Contact of intact skin with secretions, excretions of rabid animal, human case Feeding and touching of animals Licks on intact skin No exposure, so prophylaxis not required if history is reliable Category II Nibbling of uncovered skin Minor abrasions and scratches without bleeding Use vaccine alone Category III Licks on mucous membrane Single and multiple transdermal bites or scratches, licks on broken skin, contamination of mucous membrane with saliva (licks) and suspect contacts with bats Use immunoglobulin plus vaccine

Signs and Symptoms Fever, headache, sore throat Hallucinations Hydrophobia is fear of water due to spasms in the throat. Nervousness, confusion Pain or tingling at the site of the bite Paralysis-unable to move parts of the body Coma and death

Management Stop bleeding by apply direct pressure Gently clean bite site with soap and warm water, rinse for several minutes or 1% povidone-iodine or 70% alcohol Apply antibiotic to decrease the risk of infection and cover with a sterile bandage Consult a doctor immediately. Verify the dog is immunized with animal's rabies shots from its owner. Make sure the wound is clean thoroughly and prescribe antibiotics. If any risk of rabies infection, treat with anti-rabies and tetanus shot or booster. Administered pain relievers as ordered.

If animal shows sign of rabies or dies within 10 days of observation. In general, if a biting dog does not die within 10 days, rabies is unlikely. If the biting animal cannot be traced or identified. Antibiotic and anti-tetanus measures. Vaccination-human rabies immune globulin and equine rabies immune globulin. Active immunization-human diploid cells vaccine (HDCV)-number of doses-0, 3, 7, 14 and 28, 1 mL, intramuscular in arms. WHO recommended PEP (Post-Exposure Prophylaxis) schedule-essential intramuscular regimen-rabies immunoglobulin-one dose into deltoid on each of the day 0, 3, 7, 14 and 28 day

Passive immunization immune globulin-human rabies immune globulin-dose 01 as soon as possible, 20 IU/kg, half dose intramuscular and half dose subcutaneously around the bite site. For example: If person having weight 60 kg-human rabies immune globulin-20 IU/kg; 20 x 60 = 1,200 IU; 600 IU IM and 600 IU subcutaneous around the bite site. Equine rabies immune globulin-dose 01 as soon as possible, 40 IU/kg, half dose intramuscular (arm) and half dose subcutaneously around the bite site after test dose. For example, if person having weight 60 kg equine rabies immune globulin-40 IU/kg; 40 x 60 = 2,400 IU; 1,200 IU IM and 1,200 IU subcutaneously around the bite site.

Indications for use of Rabies Immunoglobulins All category III bites Categories II and III bites in case AIDS patient with grossly reduced CD4 + T cell count Licks on mucous membranes by wild or pet animals Patients on long term corticosteroids Long term chemotherapy Radiation therapy Varicella-it can cause transient immunodeficiency in children Wound suturing Rabies Immunoglobulins Side Effects Local side effects-pain, tenderness may occur at injection site, and cutaneous reactions (Cutaneous reactions are any undesirable changes in the structure or function of the skin, its appendages, or mucous membranes) . Systemic effects-headache, fever, chills, backache, nausea.

Prevention All pet animals should be vaccinated against rabies Educate to the children not to play with stray animals Avoid to touch and handle sick or injured animals Avoid to keep wild animals as pets Avoid approach to an unaware animal. Avoid run, panic, and make loud noises with dog. If an unaware dog approach, do not run, avoid scream, avoid direct eye contact, and remain motionless.

Avoid disturb a dog at the time of they are sleeping, eating, and while dog involved to care their puppies. Allow a dog to sniff and smell before try to pet it. Scratch the animal under the chin, avoid touching on the head. If observed any abnormal strange behavior with the strays' dogs report to local animal control. Avoid to play with the dog aggressively. Never use the personal hands to break up a dog fight. Wear protective glove while administering medicine to a dog.

Pathophysiology of Snake Bite There are two separate fang marks present half an inch distance between each other at the bite site. It may or may not bleed, some cases present only one fang mark. Generally, after bite within five minutes appear severe burning pain, and swelling around the fang marks, but occasionally taking 4 hours to develop, and swelling may affect the entire arm or leg. After bite within 2 to 10 hours, appear purplish discoloration, blood filled blister around the bite, and numbness around the bite.

Diagnostic Evaluation History collection about incident and snake features to identify the poisonous or nonpoisonous snake. Physical examinations Arrhythmias/bradycardia/tachycardia Blistering, swelling, necrosis at the site of the bite and its extension Hypotension Hemorrhage Neuroparalytic manifestations (Neuroparalytic manifestations are symptoms of neurological dysfunction, often seen in conditions like neurotoxic snakebites, characterized by progressive weakness or paralysis) Shock

Whole blood clotting test Complete blood count Urine examination for proteinuria, RBCs, hemoglobinuria, and myoglobinuria Oxygen saturation and arterial blood gas (ABG)

Complications of snake bite Cardiac complications AV blockage, cardiac rhythm disturbance, coronary artery thrombosis, hypotension, myocardial infraction, and pulmonary edema Hematological complications Affect the blood clotting, anticoagulant activity, promote excessive bleeding cause cerebral hemorrhages,patients more vulnerable to strokes, hemorrhagic pericardial effusion Neuro-complications Convulsions, delayed sensory neuropathy, ophthalmoplegia, locked in syndrome, paralysis, ptosis, respiratory failure, and stroke.

Delayed sensory neuropathy a condition where damage to peripheral nerves causes delayed onset of symptoms like pain, tingling, or numbness, often starting in the hands and feet and progressing to loss of sensation, balance issues, and muscle weakness. Locked-in syndrome (LIS) is a neurological disorder where a conscious person is paralyzed and unable to speak or move, except for limited vertical eye movements and blinking, which allows for communication Renal complications Acute renal failure, albuminuria, hematuria, oliguria, prolonged bleeding time, prolonged prothrombin time, low hemoglobin and high total bilirubin Local complications Chronic ulceration, corneal ulceration due to spray, compartment syndrome, gangrene, infection, pain, necrosis, limb loss, swelling

Hospital Management Assess airway, breathing, circulation Assess state of level of consciousness Administer-fresh frozen plasma, fresh whole blood, and platelet concentrate Antibiotics CPR based on requirement Dialysis IV fluid infusion Oxygen administration Mechanical ventilation Pain management Prophylaxis against tetanus and gangrene Specific treatment based on complication Surgical debridement if required

WHO recommend, administration of monospecific ASV is most effective treatment for snake bite. Administered ASV 2 mL/minutes through intravenous slowly. Antivenom diluted in 5 to 10 mL per kg body weight of normal saline and infused over 1 hour. Keep ready epinephrine always before administration of antivenom. Because to manage anaphylactic reaction if occurred. After administration of ASV, observed the patient for any anaphylactic reaction.

Preventions of Snake Bite Ask help to those who know how to catch a snake Avoid tall grassy areas. Wear protective shoes/boots Clean backyards Avoid make snakes as pet Avoid live near the forest Avoid touch snake Keep storage areas clear of rodents Remove rubbish, woodpiles and low brush from around the home. Keep the food material in rodent-proof containers. Beds level above floor surface area and Sleep with mosquito nets strongly under sleeping mats within the home.

INSECT STINGS Generally, bee, wasp and hornet stings are very painful than dangerous. But multiple stings are very dangerous. After insect stings, the person feels sharp pain, develop mild swelling and soreness. It managed by first aid. If person allergic to stings, its causes the serious anaphylactic reaction rapidly. There can be developed swelling and airway obstruction if the stings in the mouth and throat.

Bee, Wasps, Scorpion and Ant Stings Symptoms Affected site the person feels severe pain Develops local swelling and redness Present itchy rash over skin Appear puffy eyelids, facial and limb swelling Patient suffering from difficulty in breathing and wheezing Nausea, vomiting, diarrhea and in severe condition cause collapse

Management Assess the primary survey After stung, remove the person's rings, watch, bangle to avoid injury due to swelling Remove sting with fingernail or blunt edge of an object. Cold application on the affected area for 10-15 minutes to stop the pain and swelling Avoid apply ice directly on the sting area to prevent frostbite. If the pain and swelling is not subsided, consult the casualty doctor. If the person with signs and symptoms of allergic reactions, seek medical attention immediately

Precautions Practice insect repellants Use to wear long pants and T-shirt to avoid stings If the approach insect stings area, always cover face and run in a straight line as quickly as possible during attack. Clutch a coat, net, towel or anything it will give temporary relief. Try to find shelter like a house, tent, and car with windows and door closed during escape.

Common Sea Creatures Jellyfish and Fish Signs and Symptoms Cardiac arrest Breathing difficulty/stops Pain in lymph glands Red rash Stinging sensation and severe pain at affected site Shock Unconsciousness

Management Maintain primary survey of airway, breathing, circulation and Immobilize and reassure casualty and monitor closely Avoid rub sting area If the person feels breathing difficulty, reduce the consciousness, pain persist in sting area immediately seek urgent medical care. Apply cold pack to reduce pain on affected area Pick of tentacles with fingers if possible and necessary If sting occurs within tropics pour vinegar over sting area

POISON Any substance which creates harmful effect to the human body is poison. It may be by the human through ingestion, inject, inhale and absorb in the skin. Any substance become poison by taking high quantity such as overdoses medications, consume laundry powder, carbon monoxide from gas appliances, pesticides, furniture polish, lead, plants and mercury. There are two types of exposure, (i) Acute exposure : Acute exposure is single duration of exposure may be lasts for hour, minutes and seconds, several exposures over approximately a day. (ii) Chronic exposure : Chronic exposure is multiple duration of exposure may be lasts for many year, months, and days.

Risk Factors There are several factors that can increase the risk of developing a Risk for Poisoning nursing diagnosis. These include: 1. Age: Children and elderly individuals are most vulnerable to poisoning and mistaking toxic substances as food or drinks. 2. Overmedication: When a patient takes more than the prescribed dose of any medication, they are at an increased risk of experiencing side effects and potentially fatal drug reactions. 3. Alcohol Abuse: Regularly drinking raises the risk of fatal poisonings due to alcohol overdose or mixing alcohol with certain medications. 4. Substance Abuse: Chemicals used in illicit drugs can result in serious poisoning with long-term health risks.

5. Improper Storage of Toxic Substances: Leaks from open containers of hazardous substances or improper storage of toxins can lead to accidental poisonings. 6. Occupational Hazards: Workers exposed to hazardous materials in their workplace may experience occupational poisoning.

Types of poison In regard to poisoning, chemicals can be divided into three broad groups: agricultural and industrial chemicals, drugs and health care products, and biological poisons—i.e., plant and animal sources. Common types of poison exposures in adults: 1. Pain medicines, both prescription and over-the-counter (OTC) 2. Sedatives, hypnotics, antipsychotics 3. Antidepressants 4. Cardiovascular drugs 5. Cleaning substances 6. Alcohols 7. Pesticides 8. Bites and envenomations (ticks, spiders, bees, snakes) 9. Anticonvulsants 10. Cosmetics and personal care products

Symptoms of poisoning The effects of poisoning depend on the substance, amount, and type of contact. The age, weight, and state of health also affect your symptoms. Possible symptoms of poisoning include: 1. Nausea and vomiting 2. Diarrhea 3. Rash 4. Redness or sores around the mouth 5. Dry mouth 6. Foaming at the mouth 7. Trouble breathing 8. Dilated pupils or constricted pupils 9. Confusion 10. Fainting 11. Shaking or seizures

INGESTED POISONING Ingested poisoning results from swallowing of toxic products/poisons. Etiology 1. Many common household and industrial chemicals, medications, improperly prepared foods, petroleum products and agricultural products (made specifically to control rodents, insects and crop disease). 2. In adults, caustic ingestions are frequently intentional ingestions, whereas in children, it happens accidentally.

Risk Factors 1. Easy availability of household chemicals, medicines, and pesticides predisposes to accidental poisoning in pediatric population. 2. Homicide attempt as result of failure in life. 3. Drug poisonings are generally more frequent. 4. Children with psychological impairment are also at high risk for infesting foreign bodies.

Pathophysiology 1. When toxic chemicals are ingested, causes burn in upper gastrointestinal tract tissues, sometimes resulting in esophageal or gastric perforation. 2. Acids cause coagulation necrosis; This happens because acids denature and destroy the proteins in cells and tissues. A defining feature of acid burns is that the coagulation process creates a thick, tough eschar (a scab-like layer of dead tissue) that limits how deeply the acid can penetrate. Acids tend to affect the stomach more than the esophagus. 3. Alkaline cause rapid liquefaction necrosis (a form of cell death where tissue is transformed into a viscous, liquid mass because the dead cells are completely digested by hydrolytic enzymes.) and damage continues until the alkali is neutralized or diluted.

4. Alkalis tend to affect the esophagus more than the stomach, but ingestion of large quantities severely affects both. 5. Solid products tend to leave particles that stick to and burn tissues, discouraging further ingestion and causing localized damage. 6. Liquids may also be aspirated, leading to upper airway injury.

Clinical Manifestations 1. Esophageal perforation may result in mediastinitis, with severe chest pain, tachycardia, fever, tachypnea, and shock. 2. Gastric perforation may result in peritonitis. 3. Esophageal or gastric perforation may occur within hours, after weeks, or any time in between. 4. Others: a. Burns or stains around the patient's mouth. b. Unusual breath odors, body odors at the scene. c. Abnormal breathing. d. Dilated or constricted pupils. e. Foaming at the mouth. f. Abdominal tenderness, sometimes with distention. g. Vomiting, diarrhea, seizures. h. Altered states of consciousness.

Diagnostic Evaluation 1. Medical history and clinical examination. 2. Endoscopy is done to rule out perforation. Management Medical Management 1. Avoid gastric emptying (Inducing vomiting or performing gastric lavage (stomach pumping) is dangerous for patients who have ingested strong acids or alkalis (e.g., drain cleaner). The substance can cause further damage to the esophagus and airway as it is brought back up, increasing the risk of perforation, hemorrhage, and airway obstruction.)

2. Dilute with oral fluids. Dilution should be avoided, if patients have nausea, drooling, stridor, or abdominal distention. 3. Esophageal or gastric perforation is treated with antibiotics and surgery. 4. Foreign bodies that are lodged in the esophagus are most commonly removed by endoscopy. Surgical Management 1. Incase of esophageal or gastric perforation, surgical management may be required. 2. Gastric surgery may be done through laparoscopy or open surgery. 3. Wedge resection or graham patch repair are opted. A Graham patch is a straightforward procedure designed to quickly and effectively seal a small perforation, usually in the duodenum. A wedge resection is a more extensive procedure that involves removing the entire perforated ulcer, not just patching it.

Nursing Management 1. Check level of consciousness. 2. Maintain an open airway and check respiration. 3. For conscious patients, dilute the poison by having the patient drink one or two glasses of water or milk or as directed by the physician. 4. Monitor vital signs. 5. Don't give anything by mouth, if the patient is having a seizure. 6. Position the conscious patient in a semi-recumbent position and monitor closely for vomiting. 7. Keep suction equipment ready. 8. If the patient is unconscious, place him/her in lateral recumbent position to prevent aspiration of vomitus. 9. In hospital, observe the vomitus for color, volume, odor and send it to laboratory as early as possible.

Complications 1. Esophageal/gastric perforation 2. Pneumothorax 3. Pressure necrosis 4. Bleeding 5. Infection

FOOD POISONING Food poisoning is a food borne illness caused by eating food or drinking water contaminated with bacteria, viruses, parasites, or their toxins. The onset of symptoms of food poisoning starts within a few hours of eating contaminated food includes nausea, vomiting, and diarrhea. Etiology 1. Bacteria, viruses and parasites or their toxins are the most common causes of food poisoning. 2. It generally occurs in summer.

3. It occurs due to the following: a. Cooking of food at inappropriate temperature or inadequate cooking. b. Chilling of food at incorrect temperature. c. Touching the food with dusty hand. d. Eating the food which is expired in its use by date. e. Using contaminated water for cooking. f. Unboiled and uncleaned vegetables, contaminated milk and cream products.

Risk Factors 1. Generally, it occurs in summer. 2. Elderly are more prone to food poisoning due to poor immune system. 3. During pregnancy, changes in metabolism and circulation may increase the risk of food poisoning. 4. People with weak immune system are at high risk. For example; cancer patients and diabetes mellitus.

Pathophysiology The pathogenesis of diarrhea in food poisoning is classified broadly into either non-inflammatory or inflammatory types: 1. Non-inflammatory diarrhea is caused by the action of enterotoxins on the secretory mechanisms of the mucosa of the small intestine, without invasion. This leads to large volume watery stools in the absence of the following: a. Blood b. Pus c. Severe abdominal pain. 2. Inflammatory reaction: Ingestion of contaminated food by an infectious organism or toxins in GI tract causes cytotoxic action. The cytotoxic actions of the mucosa leading to invasion and destruction. a. It affects small and large intestine. b. It may results in bloody diarrhea.

2. Inflammatory reaction: Ingestion of contaminated food by an infectious organism or toxins in GI tract causes cytotoxic action( any process or mechanism that causes damage or death to living cells.). The cytotoxic actions of the mucosa leading to invasion and destruction. a. It affects small and large intestine. b. It may results in bloody diarrhea. Clinical Manifestation 1. Nausea and vomiting. 2. Abdominal cramps and pain. 3. Diarrhea 4. Headache 5. Fever 6. Patient may collapse. Diagnostic Evaluation 1. Patient history and physical examination. 2. Stool test is done to confirm presence of pathogens.

Management Medical Management 1. Identify and treat the underlying cause. 2. Encourage patient to take plenty of fluids to manage mild diarrhea. 3. Antibiotics are prescribed for bacterial infection. 4. Antidiarrheal drugs are also prescribed. 5. In case of severe diarrhea, start IV fluids.

Nursing Management 1. Eliminate the source of poison in order to avoid their absorption. 2. Monitor vital signs. 3. Ask patient about episodes of vomiting and diarrhea. 4. Give plenty of fluids such as water, diluted fruit juice. 5. Sometimes with constant vomiting and diarrhea, the water and electrolyte balance of the body gets disturbed, which result into the weakness and conditions of shock arises. 6. Administer prescribed medicines. 7. Advice patient to eat properly cooked food. 8. Avoid eating street foods in rainy season. 9. Reassure the patient and provide psychological support.

Complications 1. Irritable bowel syndrome (a common, chronic disorder that affects the large intestine.) 2. Anemia 3. Kidney failure

INHALED POISONING Inhaled poison is that poisoning that are present in the atmosphere and person is at high risk of breathing in. Carbon monoxide poisoning is a common inhaled poisoning. Carbon monoxide poisoning occurs when person is exposed to carbon monoxide in environment to such an extent that it reaches to blood through inhalation. This can lead to serious tissue damage, or even death.

Etiology 1. Inhalation of following gases: a. Chlorine gas b. Ammonia c. Methyl Isocyanate (MIC) d. Smoke conditions 2. Many inhaled poisons can also be absorbed through the skin. 3. Carbon monoxide (CO) poisoning occurs particularly during winter as a result of leak from stove or water heater, or as a result of inhalation during a fire.

Risk Factors 1. Improper mixing of household substances or chemicals, prolonged use of strong cleaning products or malfunctioning household appliances can result in exposure to potentially hazardous fumes. 2. Carbon monoxide (CO) poisoning may occur, if running a car engine in an enclosed space. 3. Burning charcoal in closed homes produce CO gas. 4. Blocked flues and chimneys can stop CO from escaping.

Pathophysiology 1. CO gas is readily absorbed and is unchanged by the lungs. 2. After absorption, CO reacts with oxygen; it binds to hemoglobin, creating Carboxy Hemoglobin (COHb), which leads to tissue hypoxia. Patient may find difficulty in breathing and suffocation. 3. In addition, it has direct effect of causing cellular damage. 4. Cardiac injury, neurological and perivascular injuries (type of tissue damage that occurs in the area surrounding blood vessels) were hypoxic as result of oxidative stress (reoxygenation) secondary to CO exposure. 5. Damage to Central Nervous System (CNS) as result of hypoxia may lead to cardiovascular insufficiency; effect of high doses of CO on smooth muscle may result in hypotension. 6. Long exposure, even very low levels of the gas, can cause drastic effects. Death may occur due to severe hypoxia.

Clinical Manifestations For Carbon Monoxide Poisoning 1. Headache 2. Dizziness 3. Breathing difficulties 4. Chest pain 5. Nausea 6. Cyanosis 7. Unconsciousness 8. Neurological symptoms, such as: a. Difficulty thinking or concentrating. b. Frequent emotional changes. For examples, becoming easily irritated, depressed, or making impulsive or irrational decisions.

For a Inhaled Poisons 1. Dizziness, shortness of breath, coughing, rapid or slow pulse rate, irritated or burning eyes, burning sensations in the mouth, nose, throat or chest, nausea and vomiting. 2. Changes in skin color. 3. Unconsciousness or altered behavior. Diagnostic Evaluation 1. Patient history and medical examination. 2. Monitor COHb in blood test.

Management Medical Management 1. Assess level of consciousness. 2. Administer oxygen. 3. Provide high fowler's positioned respiratory assessment. 4. Check signs of cyanosis. 5. Assess fluid and electrolyte balance and maintain hydration status. 6. Reassure the patient. 7. Administer fluids in case of hypovolemia.

Nursing Management 1. Remove the patient from the source of the inhaled poison. 2. Avoid touching contaminated clothing. 3. Oxygen is antidote for CO poisoning. It is administered through a mask. 4. Provide fowler's position. 5. Maintain an open airway and do assessment of respiration. 6. Check oxygen saturation. 7. Provide needed basic life support measures and administer a high concentration of O2. 8. Remove contaminated clothing and jewellery. 9. Check level of consciousness. 10. Administer oxygen in order to maintain breathing. 11. Have IV access and administer fluids to maintain fluid electrolyte balance. 12. Encourage patient for deep breathing exercises and respiratory rehabilitation. 13. Provide psychological support.

Complications Long exposure to CO gas may lead to following disease: 1. Coronary heart disease 2. Memory problem 3. Difficulty in concentration. 4. Vision loss 5. Hearing loss

INJECTED POISONING Poisons that enters the body tissues through stings, injections. Etiology Insect stings, spider bites, scorpion stings and snake bites are typical sources of injected poisons. Commonly seen insect stings are those of wasps, bees and ants. Risk Factors 1. Living in areas where insects (spiders) live and disturbing their natural hábitats. 2. Snake bite is common in summer days. 3. Farming, forestry and construction workers are most commonly affected.

Clinical Manifestations 1. Altered states of awareness. 2. Blotchy skin / mottled skin (a patchy, web-like pattern of reddish-blue or purple discoloration on the skin, also known as livedo reticularis ) 3. Localized pain 4. Burning sensation 5. Swelling or blistering at the site. 6. Abnormal pulse rate 7. Profuse sweating 8. Nausea and vomiting. Diagnostic Evaluation 1. Patient history and clinical examination. 2. Blood test reveals biochemistry and hematology findings.

Management Nursing Management 1. Keep the patient calm. a. Treat for shock and conserve body heat. b. Locate the fang marks and clean this site with soap and water. c. Remove any rings, bracelet or other constricting items on the bitten extremity. d. Apply a light constricting band above and below the wound. The purpose of the constricting band is to restrict the flow of lymph, not to blood. Monitor for a pulse at the wrist or ankle, depending on the extremity involved. e. Continuously, monitor vital signs. f. Assess the patient for signs and symptoms of anaphylaxis. 2. The patient is assessed for signs of increasing edema and respiratory distress. 3. Inform physician and preparation for initiation of emergency measures (e.g. intubation, insertion of intravenous lines, administration of oxygen) are important to reduce the severity of the reaction and to restore cardiovascular function.

THERMAL EMERGENCIES Thermal emergencies are the emergencies which result from exposure to extreme temperature. It includes heat stroke and frost bite. HEAT STROKE It is life threatening emergency that occurs when the body's temperature regulating mechanisms fail during exposure to heat. It is also known as sun stroke. Heat stroke often occurs as a progression from milder heat-related illnesses such as; 1. Heat cramps 2. Heat syncope (fainting) 3. Heat exhaustion

Etiology 1. Excessive exposure to heat is the main cause of heat stroke. 2. E xternal heat stroke, more common in physically active individuals. Risk Factors 1. Age: Infants and children up to age 4, and adults over age 65, as they adjust to heat more slowly than other people. 2. Medical disorders associated heart, lung, or kidney disease, obesity or underweight, high blood pressure, diabetes, mental illness, sickle cell, alcoholism, sunburn, and any conditions that cause fever.

3. Medications: a. Antihistamines b. Diuretics c. Sedatives d. Tranquilizers e. Stimulants f. Anticonvulsants g. CVS medications such as beta-blockers and vasoconstrictors. h. Antidepressants and antipsychotics. i. Cocaine and methamphetamine also are associated with increased risk of heat stroke.

Pathophysiology 1. Body exposure to hot objects can result in different physiological or pathological outcomes. 2. Heat-related illnesses: It develops when the pathological effects of heat load are not prevented. 3. Activation of autonomic heat defense effectors affects the regulation of homeostatic systems other than thermoregulation. When autonomic heat defense effectors, like sweating and skin vasodilation, are activated to lower body temperature, they create significant side effects that stress other homeostatic systems, particularly the cardiovascular and fluid balance systems.

4. Increased cutaneous vasodilation and decreased venous tone reduce ventricular filling, which, in an orthostatic position, may lead to low brain perfusion, unconsciousness and fluid electrolyte imbalance. When body gets heated, body widens blood vessels in your skin (vasodilation) and relaxes the veins to cool down. This causes blood to pool in legs, especially when standing (orthostatic position). With less blood returning to the heart, blood pressure drops, which means less blood reaches the brain. This can cause dizziness, fainting (unconsciousness), and an imbalance of fluids and salts due to heavy sweating. 5. Excessive heat denatures proteins, destabilizes phos-pholipids and lipoproteins, and liquefies membrane lipids, leading to cardiovascular collapse, multi-organ failure, and ultimately, death. Excessive heat causes the body's essential proteins to break down and cell membranes to melt. This cellular damage triggers a collapse of the circulatory system and multiple organ systems, which ultimately leads to death.

Clinical Manifestations 1. Core body temperature above 104 degrees Fahrenheit. 2. Fainting 3. Deep then shallow breathing. 4. Tachycardia, hot and dry skin. 5. Throbbing headache (migraine) 6. Dizziness and light-headedness. 7. Lack of sweating despite the heat. 8. Red, hot, and dry skin. 9. Muscle weakness or cramps. 10. Nausea and vomiting. 11. Behavioral changes such as confusion, disorientation, or staggering. 12. Seizures 13. Uncoordinated movements.

Diagnostic Evaluation 1. Medical history and physical examination. 2. Body temperature Management Medical Management 1. Identify and treat the underlying cause. 2. Monitor vital signs. 3. Provide well ventilated room. 4. Encourage patient for fluid intake. 5. Monitor urine output. 6. Reassure the patient.

Nursing Management 1. Assess the level of consciousness. 2. Monitor body temperature. 3. Cooling: Quickly moves the patient to a cool environment. 4. Place cool compresses or ice packs on the head, neck, axilla and groin. 5. Rapid cooling for heat stroke is recommended. 6. Fluids: Patients with heat cramps or heat exhaustion should be given fluids containing electrolytes. 7. Large volumes are usually required to prevent heat exhaustion from deteriorating into heat stroke. 8. Observe for signs and symptoms of heat stroke. 9. Assess level of anxiety and provide information about heat stroke and its prevention.

Complications 1. Acute renal failure. 2. Disseminated intravascular coagulation. It is a life-threatening blood clotting disorder that causes widespread clotting and bleeding throughout the body. 3. Rhab-do-myolysis. Rhabdomyolysis is a serious medical condition that occurs when severely damaged skeletal muscle breaks down rapidly. It releases its contents, like the protein myoglobin, into the bloodstream, which is harmful to the kidneys and can cause kidney failure. 4. Acute respiratory distress syndrome. 5. Acid-base disorders. (Imbalance in the body's pH level) 6. Electrolyte disturbances.

FROST BITE Frost bite is an injury caused by exposure to extreme cold temperature which causes freezing of the skin and underlying tissues. Damage to tissues from freezing due to the formation of ice crystals within cells, rupturing the cells and may lead to cell death. Degree of Frost Bite There are three degrees of frost bite: Incipient frostbite (Frostnip) Superficial frostbite (Simply frost bite) Deep frostbite (Freezing)

Frostnip: It is the first stage of frostbite brought about by direct contact with a cold object or exposure of a body part to cold air. Chilled wind and chill water also can be major factors. This condition is not as serious as tissue damage. It is minor and the response to care is good. The tip of the nose, tips of the ear, the upper cheeks, and the fingers are most susceptible to frostnip. Frost bite and freezing: The skin and subcutaneous layers are involved. Frost bite develops, if frostnip goes untreated. In freezing, the subcutaneous layers and the deeper structures of the body are affected. Muscles bones, deep blood vessels and organ membranes can become frozen.

Etiology Three types of individual, physical and health factors can contribute to frost bite. 1. Excessive heat loss: a. The excessive intake of alcohol, causing capillary dilation, flushing and dissipation of heat. b. Wet clothing, permitting outward heat conduction. c. Exposed skin. d. Fever, with radiation of heat. e. Injury, with hemorrhage, anoxia and shock, causing general body cooling. f. Overexercise, as in forced survival marches, draining unreplaced calories and heat. g. Working with equipment that uses coolant such as liquid nitrogen or carbon dioxide. 2. Mechanical or physical impedance of circulation to the extremities: a. Tight boots, gloves, or clothing. b. Vascular diseases or injuries that diminish the flow of blood to the extremities. c. Vasoconstriction as a result of drug action.

3. Problems that decrease the ability of a person to cope with the cold: a. Underweight or fatigue. b. Dehydration. c. Neuromuscular disease. d. Previous freezing or non-freezing cold injury, with resultant sensory loss, predisposing to further cold injury. Risk Factors 1. Alcohol or drug abuse 2. Smoking 3. Previous frost bite or cold injury

Pathophysiology Frost bite occur when a part of the body is exposed to intensely cold air or liquid Blood flow to that particular part is limited by the constriction of blood vessels. Tissues do not receive enough warmth to prevent freezing. As a result of icing there will be mechanical Leads to damage to cells from ice. If not relieved, these conditions Leads to In the most severe cases gangrene can occur Leads to Most Commonly affected areas: Ears Nose Hand Feet Disruption of the blood corpuscles Thrombosis formation Ischemia Tissue gangrene Tissue dehydration Local oxygen depletion Dry gangrene Loss of the body part

Clinical Manifestations Frostnip 1. Initially, the affected area of the skin reddens, then blenches (became white). Once blenching begins, the color change can take place very quickly. 2. Patient has numbness feeling at affected area. Frostbite 1. Affected area of the skin appears white and waxy. 2. Affected area feels frozen, but only on the surface. 3. The tissue below the surface must still be soft and have its normal resilience or bounce. Freezing 1. The skin turns mottled or blotchy. The color will turn on white, than greyish yellow and finally a grayish blue. 2. The tissue feel frozen to the touch, without the underlying resilience characteristics of superficial frost bite. 3. There is no sensation of pain, and the victim may not even know that he/she has been frost bitten.

Diagnostic Evaluation 1. Patient history and thorough physical examination. 2. Magnetic Resonance Angiography to identify thrombosis. Management Medical Management 1. Goal is to restore body temperature to normal level as early as possible. 2. In general, the patient should be moved out of the wind, provided with shelter and be given warm fluids. 3. In hospitals setting, do thorough patient assessment in order to identify underlying unstable co-morbidities, trauma or hypothermia. 4. Remove jewellery from affected area as swelling can occur. 5. Administer IV fluids to restore hydration.

6. Rewarming is done with whirlpool bath set at 38 ° C with added antiseptic solution (povidone iodine or chlorhexidine). 7. It should continue until a red/purple color appears and the extremity tissue becomes pliable. 8. Non-steroidal anti-inflammatory drugs or opiates are prescribed to control pain. 9. Antibiotics are prescribed to manage infection, blisters and cellulitis. 10. Dressing of the area is done. Nursing Management 1. Bring patient out of the cold environment. 2. Warm the affected area, with the help of blanket, blow warm air on the site. 3. During recovery from frostnip, the patient may complain about tingling or burning sensations, which is normal. 4. Administer prescribed NSAIDs/opioids. 5. In order to prevent infection, administer antibiotics.

6. Keep the patient indoors and keep him/her warm. 7. Do not allow the patient to smoke. 8. Rewarming frozen parts. Remove jewellery from affected digits as swelling can occur 9. In order to restore fluid volume, provide warm liquids to patient. 10. In case of severe dehydration, administer warm IV fluids. 11. Thawing of the hands or feet in warm water baths is done. 12. Continue rewarming until a red or purple color appears and the extremity tissue becomes pliable. 13. Rewarming the extremities can become extremely painful, so use of non-steroidal anti-inflammatory drugs or opiates should be administered. 14. Administer antibiotics as prescribed.

15. Note the type of any blisters that form. 16. Apply jelly or cream (topically) on thawing area before putting dressing. 17. Splinting, elevating and wrapping the affected part in a loose, protective dressing with padding between affected patient's digits are ideal. 18. Constant digital exercises are performed to preserve joint motion. 19. Provide psychological support to patient. Complications 1. Infection and tissue death. 2. Persistent deep pain 3. Arthritis and limitation of joint motion, and nail-bed changes. 4. Joint deformity 5. Arthritic changes in bone. 6. Increased sensitivity to cold.

Principles of emergency management Comprehensive Emergency managers consider and take into account all hazards, all phases, all stakeholders and all impacts relevant to critical emergency. Progressive Emergency nurses anticipate future disasters and take preventive and preparatory measures to control and handle emergency. Risk-assessment There must be understanding of the basic concepts of risk assessment and sustainable development.

Risk-driven Emergency nurse managers use sound risk management principles (hazard identification, risk analysis, and impact analysis) in assigning priorities and resources. Emergency managers are responsible for using available resources effectively and efficiently to manage risk which means that the setting of policy and programmatic priorities should be based upon measured levels of risk to lives, property, and the environment. Integrated Emergency nurse managers ensure unity of effort among all levels of hospital. They work like team.

Collaborative Emergency nurse managers create and sustain broad and sincere relationships among individuals and organizations to encourage trust, advocate a team atmosphere, build conse consensus, and facilitate communication. Coordinated Emergency nurse managers synchronize the activities of all relevant stakeholders to achieve a common purpose. Flexible Emergency nurse managers use creative and innovative approaches in solving emergency challenges. Professional Emergency nurse managers value a science and knowledge based approach based on education, training, experience, ethical practice, public stewardship and continuous improvement. They update their knowledge and apply it in practice.

Body of knowledge Emergency nurse must be able to integrate the four phases of emergency management into business, government, non-profit organizations. She should have ability to locate and identify potential emergency management related to job opportunities. Emergency nurse should have understanding of all hazards and emergency management of natural disasters and manmade hazards and also have Body of Knowledge for emergency management in future.

MEDICO LEGAL ASPECTS Registered nurses may find themselves in a difficult predicament. When they are called upon to respond in times of mass casualty or when the nature of their work puts them at risk for exposure-such as corona disease pandemics. It is reassuring to know that because of their compassionate nature and the nature of their role as caregiver, registered nurses are typically willing to respond. But many other registered nurses struggle with the call to respond Nurses should know in advance that they may be called upon, and will need to make arrangements with their families for communication, and even for care of children or dependents during their absence incase of mass casualty. Nurses have a commitment to help care for and protect their patients while also protecting their own right to self-preservation and self-care. Nurses need to be proactive to address such issues.

Registered nurses: Registered nurses need to be aware of the ethical situations they may encounter, especially in times of scarce resources and supplies when they may face unimaginable patient care decisions. There may be times when a registered nurse must make a choice between duties based on moral grounds. These choices are an important part of disaster planning and preparedness. Each nurse must know what line s/he will or will not cross when it comes to maintaining professional integrity. Effective communication regarding a nurse's ability to commit to providing any level of care to patients is essential, if disaster occur.

Nurses and other health care personnel can find themselves operating in altered standards of care environments during a disaster. There is no clear consensus about mitigating ethical considerations, and continued uncertainty about applying altered standards of care. Nurses must be professionally and personally prepared. Policy makers need to advocate for systems and protocols that protect their ethical obligations as nurses, as well as ensure equity and fairness in disaster medical care planning. Disaster management includes an integrated and interdisciplinary approach to mitigate the effects of disasters affecting the masses.

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NSG MGNT of PT. in EMERGENCY & DISASTER SITUATION.pptx