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Focus on
Emergency and
Disaster Nursing
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Emergency Nursing
 Patients- with life-threatening/potentially lifethreatening problems enter hospital through
the emergency department (ED).
•Triage
Process of rapidly determining patient
acuity
Represents a critical assessment skill
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Emergency Nursing
 Triage system: categorizes patients so most
critical treated first
 Emergency Severity Index:
Five-level triage system that incorporates
illness severity and resource utilization
Emergency System
Index Triage
Algorithm
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Who to see first?
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Emergency Nursing
 Primary survey- focus on airway,
breathing, circulation, and disability,
exposure (ABCDE)
 Identifies life-threatening conditions
 If life-threatening conditions related
to ABCD identified during primary
survey interventions started immediately before procede to next step of
survey.
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Primary Survey
 Airway with cervical spine stabilization and/or
immobilization
 Signs/symptoms compromised airway
 Dyspnea
 Inability to vocalize
 Presence of foreign body in airway
 Trauma to face or neck
•Maintain airway: least to most invasive method
Open airway using jaw-thrust maneuver.
Suction and/or remove foreign body.
Insert nasopharyngeal/oropharyngeal airway.
Provide endotracheal intubation
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Primary Survey
 Rapid-sequence intubation

Preferred procedure for unprotected
airway- Involves sedation or
anesthesia and paralysis
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Jaw-Thrust
Maneuver
Fig. 69-2. Jaw-thrust maneuver is the recommended
procedure for opening the airway of unconscious patient with
a possible neck or spinal injury. Patient should be lying
supine with rescuer kneeling at top of the head. Rescuer
places one hand on each side of patient’s head, resting his or
her elbows on the surface. Rescuer grasps the angles of
patient’s lower jaw and lifts the jaw forward with both hands
without tilting the head.
Cricoid Pressure
Fig. 69-3. Cricoid pressure. Firm downward pressure on
the cricoid ring pushes the vocal cords downward toward
the field of vision while sealing the esophagus against
vertebral column
.
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Primary Survey
 Stabilize/immobilize cervical spine.

Face, head, or neck trauma and/or
significant upper torso injuries
•Breathing
Assess for dyspnea, cyanosis, paradoxic/
asymmetric chest wall movement, dec/absent
breath sounds, tachycardia, hypotension
•Adm high-flow O2 via a non-rebreather
mask; Bag-valve-mask (BVM) ventilation
with 100% O2 and intubation for lifethreatening conditions
•Monitor patient response.
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Primary Survey
 Circulation
Check central pulse (peripheral pulses may
be absent dt injury or vasoconstriction).
Insert two large-bore IV catheters.
 Initiate aggressive fluid resuscitation using
normal saline or lactated Ringer’s solution
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Primary Survey
 Disability: measured by patient’s level of
consciousness
 AVPU
 A = alert
 V = responsive to voice
 P = responsive to pain
 U = unresponsive
 Glasgow Coma Scale
 Pupils
 Exposure/environmental control
 Remove clothing to perform physical
assessment.
 Prevent heat loss.
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Secondary Survey
 Brief, systematic process to identify all injuries
 Full set of vital signs/Five interventions/
Facilitate family presence
 Complete set of vital signs
 Blood pressure (bilateral)
 Heart rate
 Respiratory rate
 Oxygen saturation
 Temperature
 Initiate ECG monitoring.
 Insert indwelling catheter.
 Insert orogastric/nasogastric tube.
 Collect blood for laboratory studies.
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Secondary Survey
 Full set of vital signs/Five
interventions/Facilitate family presence (cont’d)
 *Family presence: family members who wish
to be present during invasive
procedures/resuscitation view themselves as
participants in care-Their presence should be
supported.
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Secondary Survey
 Give comfort measures.
Pain management strategies— combination
of
 Pharmacologic measures
 Nonpharmacologic measures
 History -head-to-toe assessment
Obtain history of event, illness, injury from
patient, family, and emergency personnel.
Perform head-to-toe assessment to obtain
information about all other body systems

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Secondary Survey
 Inspect the posterior surfaces.

Logroll patient (while maintaining cervical
spine immobilization) to inspect posterior
surfaces.
 Evaluate need for tetanus prophylaxis.
 Provide ongoing monitoring, and evaluate
patient’s response to interventions.
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Secondary Survey
 Prepare to



Transport for diagnostic tests (e.g., x-ray)
Admit to general unit, telemetry, or intensive
care unit
Transfer to another facility
Must recognize importance of hospital rituals
in preparing the bereaved to grieve (e.g.,
collecting belongings, viewing the body)
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Death in the Emergency
Department
 Determine if patient-a candidate for non–
heart beating donation.
 Tissues and organs (e.g., corneas, heart
valves, skin, bone, kidneys) can be
harvested from patient after death.
UNOS
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Gerontologic Considerations:
Emergency Care
 Elderly-at high risk for injury—esp from falls.
 Causes


Generalized weakness
Environmental hazards
Orthostatic hypotension
 Important- determine if physical findings may
have caused fall or may be due to fall

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Heat Exhaustion
 Prolonged exposure to heat
over hours or days
•Tachycardia
 Leads to heat exhaustion
•Dilated pupils
 Clinical syndrome characterized
•Mild confusion
by
•Ashen color
Fatigue
•Profuse diaphoresis
Light-headedness
Nausea/vomiting
•Hypotension
Diarrhea
•Mild to severe temp
Feelings of
inc (99.6º to 104º F
impending doom
[37.5º to 40º C]) due
Tachypnea
to dehydration
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Heat Exhaustion
 Place patient in cool area and remove






constrictive clothing.
Place moist sheet over patient to dec core
temperature.
Provide oral fluid.
Replace electrolytes.
Initiate normal saline IV solution if oral
solutions are not tolerated.
*Salt tablets not used dt potential gastric
irritation and hypernatremia.
Potential hospital admission if not improved in
3-4 hrs
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Heatstroke
 Failure of hypothalamic thermoregulatory




processes
Vasodilation, inc sweating, respiratory rate
>deplete fluids/electrolytes esp sodium.
Sweat glands stop functioning, and core
temperature inc (>104º F [40º C]).
Treatment: stabilize ABCs/rapidly reduce temp
Cooling methods
 Remove clothing; cover with wet sheets.
 Place patient in front of large fan.
 Immerse in ice water bath.
 Administer cool fluids or lavage with cool
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fluids.
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Heatstroke
 Shivering: inc core temperature, complicates
cooling efforts, treated with IV chlorpromazine
 Aggressive temperature reduction until core
temperature reaches 102º F (38.9º C)
 Monitor for signs of rhabdomyolysis,
myoglobinuria, and disseminated intravascular
coagulation.
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Hypothermia
 Core temperature <95º F (<35º C)
 Risk factors
Elderly; Certain drugs
 Alcohol; Diabetes
 Core temperature <86º F (30º C)-potentially
life-threatening.
 Mild hypothermia (93.2º to 96.8º F
[34º to 36º C])
 Shivering; Lethargy; Confusion
 Rational to irrational behavior
 Minor heart rate changes

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Hypothermia
 Moderate hypothermia (86º to 93.2º F [30º to
34º C])
 Rigidity
 Bradycardia, bradypnea
 Blood pressure by Doppler
 Metabolic and respiratory acidosis
 Hypovolemia
 Shivering disappears at temperature
86º F (30º C).
 Severe hypothermia (<86º F [30º C])-person
appears dead.
 Bradycardia
 Asystole
 Ventricular fibrillation
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Hypothermia
 Warm patient to at least 90º F (32.2º C) before
pronouncing dead.
 Cause of death—refractory ventricular
fibrillation
 Treatment of hypothermia
 Manage and maintain ABCs.
 Rewarm patient.
 Correct dehydration and acidosis.
 Treat cardiac dysrhythmias.
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Hypothermia
 Mild hypothermia: passive/active external re-warming
Passive external rewarming: Move to warm, dry
place; remove damp clothing; apply warm blankets
Active external re-warming: body-to-body contact,
fluid- or air-filled warming blankets, radiant heat
lamps
Moderate to severe hypothermia
 Use heated, humidified oxygen; warmed IV fluids
 Peritoneal, gastric, colonic lavage with warmed fluids
Consider cardiopulmonary bypass or continuous
arteriovenous rewarming in severe hypothermia.
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Hypothermia
 Risks of rewarming
Afterdrop, a further drop in core temperature
 Hypotension
 Dysrhythmias
 Rewarming should be discontinued
once core temperature reaches 95º F (35º C).

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Submersion Injury
 Results when person becomes hypoxic as result
of submersion in substance, usually water
 Drowning: death from suffocation after
submersion in fluid
 Immersion syndrome occurs with immersion
in cold water > leads to stimulation of vagus
nerve and potentially fatal dysrhythmias.
 Near-drowning: survival from potential
drowning
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Aggressive resuscitation efforts
and the mammalian diving reflex
improve survival of near-drowning
victims.
Treatment of submersion injuries
Correct hypoxia.
Correct acid-base/fluid
imbalances.
Support basic physiologic
functions.
Rewarm if hypothermia
present.
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Submersion Injury
 Initial evaluation: ABCD
 Mechanical ventilation with PEEP or CPAP to
improve gas exchange when pulmonary
edema is present
 Deterioration in neurologic status: cerebral
edema, worsening hypoxia, profound acidosis
 Observe for minimum of 4 to 6 hours.
 Secondary drowning-a concern with
patients who are essentially symptom-free-
pulmonary complications.
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Animal Bites
 Children at greatest risk
 Animal bites from dogs and cats- most common,
followed by bites from wild or domestic rodents.
 Complications
 Infection
 Mechanical destruction of skin, muscle,
tendons, blood vessels, bone
 Dog bites-usually occur on extremities
 May involve significant tissue damage
 Deaths are reported, usually children
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Animal Bites
 Cat bites: deep puncture wounds that can
involve tendons and joint capsules
 Greater incidence of infection
 Septic arthritis
 Osteomyelitis
 Tenosynovitis

Result in puncture wounds or lacerations
 High risk of infection
 Oral bacterial flora
 Hepatitis virus
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Animal and Human Bites
 Initial treatment: clean with copious irrigation,
debridement, tetanus prophylaxis, and
analgesics
 Prophylactic antibiotics for bites at risk for
infection
 Wounds over joints
 Wounds less than 6 to 12 hours old
 Puncture wounds
 Bites on hand or foot
 Puncture wounds left open
 Lacerations loosely sutured
 Wounds over joints splinted
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Animal and Human Bites
 Rabies prophylaxis essential in mgt of
animal bites
 Initial injection: rabies immune
globulin
 Series of five injections of human
diploid cell vaccine: days 0, 3, 7,
14, and 28
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Poisonings
 Chemicals that harm the body accidentally,
occupationally, recreationally, or intentionally
 Severity depends on type, concentration, and
route of exposure.
 Management
 Dec absorption.
 Enhance elimination.
 Implement toxin-specific interventions per
poison control center.
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Poisonings
 Dec absorption


Gastric lavage
 Intubate before lavage if altered level of consciousness
or diminished gag reflex
 Perform lavage within 2 hours of ingestion of most
poisons.
 Contraindicated
 Caustic agents
 Co-ingested sharp objects
 Ingested nontoxic substances
Activated charcoal
 Most effective intervention: adm orally or via gastric
tube within 60 minutes of poison ingestion
 Contraindications
 Diminished bowel sounds
 Paralytic ileus
 Ingestion of substance poorly absorbed by charcoal
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Poisonings



Activated charcoal
Charcoal can absorb/neutralize antidotes: do
not give immediately before, with, or shortly
after charcoal
Dermal cleansing/eye irrigation
 Skin/ocular decontamination: removal of
toxins from skin/eyes using water or saline
 With the exception of mustard gas, toxins
can be removed with water/saline.
 Water mixes with mustard gas and
releases chlorine gas .
 **Decontamination takes priority over all
interventions except basic life support
measures.
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Poisonings
 Enhance elimination.
Cathartics (e.g., sorbitol)
 Give with first dose of charcoal to
stimulate intestinal motility/increase
elimination.
 Whole-bowel irrigation
 Hemodialysis/hemoperfusion
 Reserved for severe acidosis
 Urine alkalinization
 Chelating agents
 Antidotes

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Violence
 Acting out of emotions (e.g., fear or anger) to
cause harm to someone or something
 Organic disease
 Psychosis
 Antisocial behavior
 Pattern of coercive behavior in a relationship;
involves fear, humiliation, intimidation,
neglect, and/or intentional physical,
emotional, financial, or sexual injury
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Family and Intimate
Partner Violence
 Found in all professions, cultures,
socioeconomic groups, ages, and genders
 Most victims are women, children, elderly
 Screening for domestic violence is required in
ED.
 Appropriate interventions
 Make referrals.
 Provide emotional support.
 Inform victims about options
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Terrorism
 Involves overt actions for expressed purpose of
causing harm
 Disease pathogens (e.g., bioterrorism)
 Chemical agents
 Radiologic/nuclear, explosive devices
 Anthrax, plague, and tularemia: trt with
antibiotics, assuming sufficient supplies/
nonresistant organisms
 Smallpox-can prevent or ameliorated by
vaccination even when first given after exposure.
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Chemical Agents of Terrorism
 Categorized by target organ or effect


Sarin: toxic nerve gas >cause death within
minutes of exposure
 Enters body through eyes/skin
 Acts by paralyzing respiratory muscles
Antidotes for nerve agents: atropine,
pralidoxime chloride
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Chemical Agents of
Terrorism


Phosgene: colorless gas normally used in
chemical manufacturing
 If inhaled at high concentrations for long
enough period >severe respiratory distress,
pulmonary edema >death
Mustard gas: yellow to brown in color with
garlic-like odor
 Irritates eyes and causes skin burns/blisters
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Radiologic/Nuclear Agents of Terrorism
 Radiologic dispersal devices (RRDs) (“dirty bombs”):
mix of explosives and radioactive material
 When detonated, blast scatters radioactive dust,
smoke, and other material into
environment>radioactive contamination.
 Main danger from RRDs: explosion
 Ionizing radiation (e.g., nuclear bomb, damage to
nuclear reactor): serious threat to safety of casualties
and environment
 Exposure may or may not include skin contamination
with radioactive material.
 Initiate decontamination procedures
immediately if external radioactive
contaminants are present.
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Explosive Devices as Agents of
Terrorism
 Result in one or more of following types of injuries:
blast, crush, or penetrating
 Blast injuries from supersonic overpressurization
shock wave that results from explosion
 Damage to lungs, middle ear, gastrointestinal
tract
 Emergency: any extraordinary event that requires
a rapid and skilled response and can be managed
by a community’s existing resources
 Mass casualty incident (MCI)
 Manmade or natural event or disaster that
overwhelms community’s ability to respond
with existing resources
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46
American Red Cross
Fig. 69-8. American Red Cross.
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Emergency and Mass Casualty
Incident Preparedness
 When an emergency or MCI occurs, first responders
(e.g., police, emergency medical personnel)
are dispatched.
 Triage of casualties differs from usual ED triage-is
conducted in <15 seconds.
 System of colored tags designates both seriousness of
injury and likelihood of survival.
 Green (minor injury)
 Yellow (urgent tag-noncritical injury.
 Red tag- life-threatening injury.
 Blue tag indicates those who are expected to die.
 Black tag identifies the dead.
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Emergency and Mass Casualty
Incident Preparedness
 Casualties need to be treated/stabilized.
If known or suspected contamination,
decontaminate at scene, then transport to
hospitals.
 Many casualties will arrive at hospitals on their
own (i.e., “walking wounded”).
 Total number of casualties a hospital can
expect-est by doubling #casualties that arrive
in 1st hour.
 Generally, 30%-require admission to
hospital, 1/2 will need surgery within 8
hours.

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Emergency and Mass Casualty
Incident Preparedness
 Communities have initiated programs to
develop community emergency response
teams (CERTs).
 CERTs-partners in emergency
preparedness-training helps citizens to
understand their personal responsibility in
preparing for natural/manmade disaster.
 All health care providers have role in
emergency and MCI preparedness.
 Knowledge of the hospital’s emergency
response plan
 Participation in emergency/MCI
preparedness drills is required
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Emergency and Mass Casualty
Incident Preparedness
 Response to MCIs often requires aid of federal agency such as
the National Incident Management System (NIMS).
 Section within U.S. Department of Homeland Securityresponsible for coordination of federal medical response to
MCIs
 National Disaster Medical System: organizes and trains
volunteer disaster medical assistance teams (DMATs)
 DMATs: categorized according to ability to respond to an
MCI
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Question
While performing triage in the emergency department, the
nurse determines that which of the following patients should
be seen first?
1. A patient with a deformed leg indicating a fractured tibia;
blood pressure 110/60 mm Hg, pulse 86 beats/min,
respirations 18 breaths/min.
2. A patient with burns on the face and chest; blood pressure
120/80 mm Hg, pulse 92 beats/min, respirations 24
breaths/min.
3. A patient with type 1 diabetes in ketoacidosis; blood
pressure 100/60 mm Hg, pulse 100 beats/min,
respirations 32 breaths/min.
4. A patient with a respiratory infection with a cough
productive of greenish sputum; blood pressure 128/86
mm Hg, pulse 88 beats/min, respirations 26 breaths/min.
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52
Question
Assessment of the patient during the primary survey
indicates that the patient has delayed capillary refill of the
extremities and cannot explain the events prior to
admission to the emergency department. The nurse should
first:
1. Insert one or two large-bore IV catheters to start
intravenous fluid resuscitation.
2. Continue the primary survey to complete it with a brief
neurologic examination.
3. Apply leads for electrocardiogram (ECG) monitoring.
4. Initiate pulse oximetry.
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Question
Several patients are admitted to the emergency
department after exposure to an aerosolized agent that is
believed to be a hemorrhagic fever virus used as a
bioterrorism agent. The nurse plans care for the patients
with the knowledge that:
1. No known treatment is available for this disease.
2. A vaccine is available to prevent the disease in those
who have been exposed.
3. The disease can be spread from person to person only
by vectors such as mosquitoes or fleas.
4. Ciprofloxacin (Cipro) is the treatment of choice and is
stockpiled by government agencies for use against the
virus.
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54
Case Study
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55
Case Study
 32-year-old female arrives to ED via
paramedics.
 A neighbor found her lying on the rocks in the
rock garden. She had fallen off the roof while
fixing the shingles on her house.
 A large stick is protruding through the skin at
lower leg.
 The paramedics report that she was found in
large pool of blood. Unresponsive, BP 60/42,
HR 168
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Discussion Questions
1. What potential life-threatening injuries does
she have?
2. What is the priority of care?
3. What interventions are needed immediately?
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