EMERGENCY AND DISASTER NURSING
Right Treatment
Scope and Practice of Emergency Nursing
• Emergency management traditionally refers to
urgent and critical care needs;
• however, the ED has increasingly been used for
non-urgent problems, and emergency management
has broadened to include the concept that an
emergency is whatever the patient or family
considers it to be
The emergency nurse has:
• Special training, education, experience, and
expertise in assessing and identifying health care
problems in crisis situations
• Nursing interventions are accomplished
interdependently in consultation with or under the
direction of a physician or nurse practitioner
• The emergency room staff works as a team
Four Basic Emergency Action Principles
• Survey the scene
– If any kind of danger is threatening, do not
approach the casualty, call EMS immediately for
professional help.
• Check the casualty for any for unresponsiveness
• If the person does not respond, Call EMS
• Check the casualty’s airway, breathing and
circulation (ABC’s) : try to the airway without moving
the patient
Priority Emergency Measures for
All Patients
• Make safety the first priority
• Preplan to ensure security and a safe environment
• Closely observe patient and family members in the
event that they respond to stress with physical
violence
• Assess the patient and family for psychological
function
• Patient and family-focused interventions
– Relieve anxiety and provide a sense of security
– Allow family to stay with patient, if possible, to
alleviate anxiety
– Provide explanations and information
– Provide additional interventions depending upon
the stage of crisis
PRINCIPLES OF TRIAGE
What is TRIAGE?
- it is sorting
- from the French word “trier” meaning to choose,
referred to a battlefield
- the rapid focused assessment
What is the purpose of TRIAGE?
- is to sort or classify all incoming ED patients
- the goal is to get the
Right Patient to the
Right Place at the
Right Time for the
Right Reason to receive
How long should the TRIAGE take?
- the common goal is to assess the patient within 2-
5 minutes for adults
(but this time according to ENA caters up to 22%
only of patients per hundred in 8 hours)
- for pediatrics, 7 minutes
Who should perform the ED TRIAGE function?
- the Joint Commission on Accreditation of
Healthcare Organization (JCAHO) doesn’t entails
what are the specifics of the triage nurse
- Emergency Nurses Association (ENA) 1999
established he standards of Emergency Nursing
Practice, states that safe, effective triage can only
be performed by a registered professional nurse,
educated in the principles of triage and has
minimum experience of 6 months in emergency
nursing
- The triage nurse should classify patient 24/7
What are the Essential Components of
Comprehensive TRIAGE?
1. An initial across-the- room look or visualization.
This includes ABCD. For pediatric clients, this may
include critical look, general appearance, work of
breathing and circulation
2. A rapid triage (60secs) of an appropriately elicited
chief complaint, key questions, assessment such as
feeling of the pulse and fracture in the extremities
3. Completion of a focused triage history and
physical assessment. This include vital signs, pulse
oximetry reading, diagnostics and institution’s
protocol
4. The triage decision, in which the triage acuity or
level is assigned. This determines the urgency of the
condition, includes the MSE and additional
assessment.
What should the triage history include?
Medications
Exposure to infection
Allergies Pregnancy
Immunization
LMP
Past medical history
Family history
What are the some examples of Adult
Mnemonics?
PQRST
Pain assessment
P precipitating factors
Q quality
R radiation
S severity
T time
T treatment - Breathing
- Circulation
PHOSPHATE - Disability
For the history of the chief compliant - Systemic before local; life before limb
- Acute before chronic; short term before long
Problem - Central before peripheral
Onset - Actual over Potential
Associated Symptoms - Trending (worsening trend could consist of minor
Previous History symptoms that tend to reoccur repeatedly, increase
Precipitating Factors in severity, or indicate a steady progressive decline)
Alleviating/ Aggravating Factors - Potential for worsening (ex. Drug overdose and
Timing chest tightness)
Etiology

CIAMEDS (from Emergency Nursing Pediatric TOXICOLOGY

Course) (Poisoning and Drug Overdose)
Chief Compliant
Immunization A. General Guidelines
Allergies - maintain adequate airway, breathing and cardiac
Medications output
Past Medical History - Patients who ingested large amounts of TCA may
Events Surrounding require intubation immediately even if mental status
Diets/ Diapers has not yet occurred.
Symptoms Associated with injury or illness - Perform gastric lavage
- Induce emesis for patients with alkali ingestion
SAVE A CHILD (From ENA Hawaii- SAVE Are - Contact local poison control center at UP College of
observations before touching the child, A Medicine 524-1078, 524-5651 loc 2311
CHILD are key history and examination - East Ave Med Ctr 928-0611
components) - Consider possibility of suicide
Skin - All female with chemical ingestion should undergo
Activity pregnancy test
Ventilation -
Eye Contact B. Principles of Decontamination
Abuse External Decontamination
Cry - Wash skin with soap and water
Heat - Remove cloths
Immunization - Keep warm, use blankets
Level of Consciousness
Dehydration Gastric Lavage
- contraindications includes strong ingestion of
What are some tips for better TRIAGE strong acids, alkalis, petroleum and distillates.
- Look at the patient, listen and do not write while - Airway must be protected with endotracheal tube
the patient is talking to you unless awake, alert and has a gag reflex
- Never appear shocked by what the patient tells - Position head on one side of he bed to prevent
you aspiration
- Do not discount the patient’s concern on triage - If the patient has severe DOB stat intubation
- Watch people’s faces - Perform gastric lavage unless overdose with acid
- Ask specifically about drugs recently started - Lavage is useful within two hours of ingestion
- Do not assume patients are taking their Activated Charcoal
medications - Always consider giving charcoal after emesis or
- Use the language of symptoms, feelings, and lavage until specifically contraindicated
thoughts - Multiple doses of charcoal in (+) metamphetamine,
- Remember that he patient’s diagnosis is not phenothiazines, digoxin, theophylline, phenobarb,
necessarily the correct diagnosis and organophosphates
- Exhibit concern for a higher acuity in the presence - Activated charcoal is not effective for alkalis,
of other risks factors, or co-morbidities/ chronic cyanide, mineral acid and ferrous sulfate
illness
- Remember hat alcoholics can be sick and Cathartics
intoxicated at the same time - contraindicated with infants (risk for dehydration),
- Ask the patient at the end of he triage encounter if intestinal obstruction, electrolyte imbalance
here is anything else the patient wants to say - sodium sulfate is contraindicated in HPN and heart
failure
What are the prioritization principles?
- Airway Forced Diuresis
- forced neutral diuresis may be helpful for isoniazid,
bromide and ethanol intoxification
- make sure to monitor electrolytes
- forced alkaline diuresis may be useful for
Phenobarbital, salicylates and lithium using sodium
bicarbonate.
C. Guidelines for Nurses
- when antidotes are ordered, it is meant to be given
immediately or at least reasonably within the hour in
some cases. They are not given when it is the
convenient dosing period for the nurses.
Specific Substance Ingestion
Acid Ingestion
- provide airway control, ventilation, circulatory
support, and fluid resuscitation
- wash the oral cavity (controversial)
- emesis, lavage and charcoal are contraindicated
- secure serial CBC and cros-matching
- maintain NPO
Alkali Ingestion
- immediately rinse oral cavity
- administer oxygen and IVF
- secure serial CBC, CXR, and monitor electrolytes
- esophagoscopy and gastroscopy should be
performed immediately if there is drooling, stridor
and painful swallowing
Amphetamine/ Metamphetamine Toxicity
- start charcoal and cathartics
- emesis has no role
- WOF for seizure, psychosis, agitation, hypertensive
crisis, arrhythmias
- Secure ABG, CBC with PC, PT, PTT, RBS, BUN, Crea,
Na, K, UA
- Diazepam and Phenytoin for seizure
- Beta-blockers, Lidocaine for dysrythmias
Anticoagulant Overdose
- Secure lab results such as CBC with PC, PT, PTT
and Creatinine
- For Heparin: Give protamine sulfate at 1mg iv for
every 50-100 units of heparin infused in the
preceeding 2 hours, dilute in 25-50ml fluid over 10
minutes
- For Warfarin: perform gastric lavage and give
activated charcoal if recently ingested; give vitamin
k 5-10 mg every 8-12 hours; give FFP 2-6units for
severe bleeding
Diazepam Overdose
- Place NGT and do gastric lavage
- Protect airway
- Instill activated charcoal, followed by repeated
doses of 20-25 gm via NGT
- Secure RBS, ABG, ECG and CXR
- Watched out for hypotension, CNS and respiratory
depression and withdrawal syndrome such as
agitation, seizure, restlessness and insomnia.
Digitalis Overdose
- considered NGT insertion and gastric lavage
- secure digitalis assay, CBC, Ca, K, Mg, CXR and
ECG/ cardiac monitor
- the treatment goal would be to correct
hypokalemia. Hypomagnesemia or hypocalecemia.
- The doctor may prescribe charcoal and cathartics
- Watch out for hypotension; fluid challenge my be
instituted
- For arrythmias, lidocaine may be given
Ethanol Toxicity
- maintain adequate airway, ventilation, circulation
and administer oxygen
- Thiamine is useful to protect/ prevent liver damage
- Phynetoin my be given in cases of seizure, but
make sure to give it SIVP and hook the patient to the
cardiac monitor
Narcotic Overdose
- maintain airway, ventilation and circulation
- may start on Naloxone 2mg every 5 minutes , max
10mg IV, IM SQ
- Activated charcoal if (+) for bowel sounds and
cathartics
- Watch out for signs of pneumonia, infections and
rhabdomyolysis
- Watch out for complications such as seizure,
pulmonary edema and hypotension
Hydrocarbon/ Kerosene Ingestion
- Respiratory support
- Treatment is not required in the absence of
symptoms
- Promote gastric emptying
- Remove contaminated clothing and wash affected
skin with soap and water.
- Provide supplemental oxygen
- secure CBC, ABG abd CXR
Isoniazid Overdose
- place an NGT and do gastric lavage is clean
- watch out for seizure, lactic acidosis may give
sodium bicarbonate
- consider mannitol administration for forced diuresis
- secure CBC, RBS, K, ABG
Narcotic Overdose
- maintain airway, ventilation and circulation
- may give naloxone 2.0mg q 5 minutes initially max
of 10mg IV, IM SQ
- start activated charcoal if (+) with BM and
cathartics
- watched out for complications, PNA, hypotension,
and seizures is (+) norpethidine
Insecticides/ Pesticides
Therapeutics
1. Decontamination
- make he patient rinse with alkaline or baking soda
(10gm in 100cc)
- change cloths and wash the patient with gloves
- insert NGT and do gastric lavage wih activate
charcoal
2. Activated charcoal
3. Antidote
4. In cases of seizure; consider Phenytoin
5. wof for hypoglycemia
6. Give mannitol if with good urine output
- secure CBC, RBS, ABG, SGOT and SGPT
Paracetamol Overdose
- Insert NGT
- Activate charcoal about 30-100mg and then
remove via NGT suction prior to acetylcysteine
- Sodium Sulfate to induce vomiting
- Antidote: N-acetylcysteine (NAC) . the initial
administration would be 150mg/kg body weight
infused in 200ml 5% dextrose over 15 minutes
followed by IV infusion of 50mg/kg in 500ml of 5%
dextrose water
- NAC is very effective in preventing paracetamol-
induced hepatotoxicity when administered; when
administered with in 8 hours from the time of
ingestion, the better. But beyond 8 hours, the
protective effect diminishes progressively as the
treatment interval increases
Salicylate Poisoning
Diagnostics:
- CBC, K, RBS, ABG and UA
- PT, PTT, SGOT, SGPT and alk Posh with 48 hours
post ingestion
Therapeutics:
- Stabilize respiratory and cardiac functions
- Avoid diluting the gastric contents since this may
incease gastric absorption
- Consider NGT insertion
- Give activated charcoal 1gm/ kg body weight every
6 hours
- Sodium sulfate 15-30 gm in 100cc H20 orally if
tolerated or with NGT with every other doses of
activated charcoal to prevent charcoal constipation
or fecal impaction
- To increase urine ph, consider sodium bicarbonate
- Glucose and KCl should be infused with other fluids
Treatment Plan
- if with dehydration and hypokalemia, manage with
vigorous and with electrolyte replacement
- Cerebral edema can be best avoided using
hypertonic rehydration solution
- Alkaline diuresis to maintain urinary ph at approx 8
- Monitor urine output
- Assess hydration status
- Watch closely for signs of fluid overload
- Hemodialysis is indicated for initial salicylate level
of >160ml/dl or with profound acidosis of below 7;
or when there is renal failure, severe CNS
dysfunction, pulmonary edema or deterioration
despite supportive therapy
Other Treatments
- Acidemia: NaHCO3
- Seizure: Diazepam
- Pulmo Edema: treat with high concentration of
oxygen, furosemide and PEEP
- Cerebral Edema: treat with hyperventilation and
osmotic diuresis with Mannitol
SHOCK (Multisystem Stressor)
Pathophysiology
- Shock is a multisystem stressor that involves
inadequate tissue perfusion and altered
metabolism.
- Inadequate tissue perfusion can lbe a result of nay
condition that alters heat function (cardiogenic),
blood volume(hypovolemic), blood pressure
(neurogenic) and distribution of blood volume
(septic/ anaphylactic)
- Shock is a very complex clinical syndrome in which
tissue perfusion is inadequate to meet the demands
for oxygen
- It alters cellular functions and eventually impairs
body organ functions
- Multi Organ Dysfunction Syndrome (MODS) is a
term used to describe several impairment of the
human functions
Sepsis and Septic Shock
- Sepsis is an acute systemic clinical syndrome
caused by bacteria, viruses or fungi in the blood,
most commonly gram (-) bacilli
- At an early phase, generalized inflammatory
response is triggered, causing widespread
vasodilation
- The progression to septic shock is due to the toxins
released from the organism involved
- Bacterial endotoxins activates the complement,
coagulation and fibrinolytic system; inceases
vascular permeability and trigger the vasoactive
kinins causing vasodilation and increased capillary
permeability thereby decreasing the vascular
resistance and facilitating fluid shifting from
intravascular to interstitial
- Another response would be due to the histamine
release causing increase in vascular permeability
- This changes are further stimulated by the
catecholamine and prostaglandins that are released
from ischemic tissues
- “COLD SHOCK” is he term used during the stage in
which tissue perfusion becomes severely
compromised and ischemic cellular damage occurs.
- In addition the, fever is present due to the
pyrogens released by the organism
Anaphylactic Shock
- systemic anaphylactic shick is potentially life
threatening situation
- it is he result of an exaggerated hypersensitivity
response to an antigen
- the classic form of anaphylaxis occurs in a
sensitized person usually 1-20 minutes ater the
exposure to the antigenic substance
- the most common substance that can cause
reactions would be, drugs, antibiotics, foods,
anesthetics, antisera and blood products
- hypersensitivity reaction occurs over the surface of
he mast cells which are located primarily in he
lungs, small blood vessels and connective tissues
- it also attacks basophils circulating in the blood
- the antigenic substance triggers the release of
kinins, histamines, prostaglandins, eosinophils,
neutrophils
- “sow reacting substance of anaphylaxis” (SRSA)
such as prostaglandins and leukotrienes produces
deleterious results icluding profound shock
- Histamine is he primary mediator of anaphylactic
attack. Leukotrienes produces vasoconstriction that
is even worst than histamine
- The prostaglandins exaggerate the
bronchoconstriction; kinins increases the vascular
permeability
- The combined effects of the substance causes
respiratory distress and obstruction
Toxic Shock
- it is another syndrome of shock believed caused by
bacterial toxins
- e.g. Staph A enters he blood steam from the site of
infection, commonly the vagina, diffusing across the
mucus membranes. Hey are then circulated
throughout the body
- thise toxins causes massive vasodilatation and
eventually to a shock state
For Septic Shock Assessment
- history and risk factors includes, malnutrition,
immunosuppresion, liver and renal diseases, recent
traumayic injuries, surgical or invasive procedure
- commonly caused by E Coli, Klebsiella,
Enterobacter, Staph A. as well as fungi and viruses
For Anaphylactic Assessment
- recent exposure to pharmacological agents, blood
transfusion and insect bites or stings
- clinical presentation is dependent on several
factors and varies with the portal of antigen entry,
the amount absorbed, rate of absorption, and the
degree of hypersensitivity
- Ingestion: cramping, nausea, vomiting and may
precede systemic shock syndrome
- Inhalation: hoarseness, dyspnea and whezing
- Allergic: urticaria or itching at the site of the sting,
or drug injection
Diagnostic Test/ Procedure
-WBC, serum glucose, GS-CS, ABG, BUN, CT, BT,
Liver studies
Collaborative Management (Septic)
- antibiotic therapy specific to he organism
- Hemodynamic monitoring
- Fluid resuscitation
- Inotropic Agents
- Ventilatory Support
- Alkaline Support
- Nutritional Support
- Steroids
- Antipyretic Agent
- Naloxone
- GI solution
Collaborative Management (Anaphylaxis)
- Airway maintenance
- Epinephrine
- Supplemental Oxygen
- Fluid Resuscitation
- Vasopressors
- Angi-histamine
- Bronchodilator
- Steroids
- Mast cell stabilizer
- Glucagon
- ECG monitoring
Nursing Diagnosis and Intervention (SEPSIS)
1. Fluid volume deficit related to active loss from
vascular compartment secondary to increased
capillary permeability and shifting of intravascular
volume into interstitial spaces
Desired Outcome
Within 4 hours of initiation of therapy, the patient is
normovolemic as eveidenced by good peripheral
pulses, stable body weight, good urine output and
decreased adventitious breath sounds
Intervention
- Monitor hemodynamic pressures
- Administer crystalloid and fluid replacement as
prescribed
- VS hourly
- Maintain proper inotropic administration
- Weigh patient daily
- Monitor specific gravity
- Assess for interstitial edema
- Proper positioning
2. Decreased Cardiac Output related to negative
inotropic changes at the myocardium secondary to
effects of tissue O2 deprivation
Desired Outcome
Within 8 hours of initiation of therapy, patient has a
n adequate cardiac output as evidenced by good BP,
urine output and god peripheral pulses
Intervention
- Assess patient for signs of deceasing CO
- Administer inotropics as prescribed
- Position patient on supine to increase/ optimize
preload and enhance stroke volume
- Monitor cardiac rhythm
- Minimize cardiac oxygen demand by assisting
patient with ADL
3. Altered Cerebral, renal, gastrointestinal tissue
perfusion related to decreased to circulating blood
volume secondary to massive vasodilatation and
interruption of arterio-venous blood flow associated
to vasoconstriction and clot formation
Desired outcome
Within 24 hours after initiating therapy, the patient
has an adequate tissue perfusion as evidenced by
orientation to time, place and person, good bowel
sounds and good urine output
Intervention
- Assess LOC hourly
- Assess signs of decreasing renal perfusion
- Assess/ monitor peripheral vascular resistance
- Assess peripheral pulses
- O2 saturation monitoring
- Assess evidence of decreasing visceral circulation
including bowel sounds
* Other examples of nursing problems…
4. Impaired Gas exchange, related to alveolar-
capillary membrane changes secondary to
interstitial edema, alveolar destruction and
endotoxin release with activation of histamine and
kinins
5. Ineffective breathing pattern related to decreased
lung function secondary to central respiratory
depression occurring in the lat shock
6. Ineffective thermoregulation related to successful
entry bacterial endotoxins, increasing the
hypothalamic termperature regulating center
7. Altered Nutrition less than body requirements
related to increased need secondary to increased
metabolic rate
Nursing Diagnosis and Interventions (Anaphylaxis)
1. Ineffective airway clearance realated to
tracheobronchial obstruction secondary to
bronchoconstriction and increased secretions
associated with histamine response and the
presence of leukotrienes and prostaglandins
Desired Outcome:
Within 2 hours of intervention, the patient has an
adequate airway clearance as evidenced by by a
state of eupnea and the presence of breath sounds
in all lung fields
Interventions:
- Assess patency of airway on a continuing basis.
Auscultate all lung fields
- Stand by Adrenergic agent in case of cardio-
pulmonary arrest
- Maintain intubation set at all times
- If laryngeal edema pevents intubation, prepare
tracheostomy set
- Monitor ABG results
2. Impaired gas exchange related to alveolo-
capillary membrane changes secondary to
increased vascular permeability associated
with histamine response
Desired Outcome:
Within 2hours of initiation of intervention, he patient
has adequate gas exchange as evidenced by
eupnea and O2 sat of more than 90%
Intervention:
- Monitor patient for the presence of SOB
- Secure ABG results as necessary
- Monitor pulse oximetry reading regularly
- Administer steroids as prescribed
- Position patient in a sitting position to enhance
lung expansion
- Remain with the patient, encourage slow, deep
breathing if possible. Help patient alleviate anxiety
by responding calmly and explaining all procedures
before performing to them
3. Decreased cardiac output related to
decreased preload and afterload secondary to
release of vasoactive chemical mediators and
associated vasodilation and increased
capillary permeability
Desired Outcome:
After 4 hours of continuous nursing intervention, the
patient has an adequate cardiac output as
evidenced by a near normal BP of morethan 90/60,
good urine output and normal sinus rhythm
Intervention:
- Assess for physical and hemodynamic parameters
indicating a decreased cardiac ouput
Check for apical pulse
Palpate peripheral for amplitude
Assess BP
Calculate MAP
Measure CVP
- Monitor ECG changes
- WOF signs of edema
- Admisister fluid replacement therapy as prescribed
- Administer vasopessors as prescribed
Multiple Injury
This includes:
1. Major Trauma
2. Craniocerebral Trauma
3. Chest Trauma
4. Abdominal Trauma
5. Renal and Lower Tract Trauma
Mechanisms of Injury:
- Objects Producing Injury (ex. MVA, handgun, glass,
wood, metal)
- Type of Energy (ex. Kinetic, thermal, chemical,
radiation)
- Force of Energy (ex. Velocity, tension force,
shearing force)
- Use of Protective devices (ex. Helmet, airbags, seat
belt)
Types of Injury:
Blunt Injury – occurs without interruption on the skin
integrity
Penetrating – are produced from the motion of the
objects that penetrate the tissue causing direct
damage.
Oxygen Delivery and Consumption
- an oxygen debt is created by a profound imbalance
between oxygen supply and demand brought about
by hypovolemia and inadequate tissue perfusion
- after initial restoration of circulating blood volume,
he body develops a “hyperdynamic circulatory
state”, which is associated with improved survival
and fewer complications
- the hyperdynamic state usually peaks within 48-72
hours and diminishes in 7 -10 days
- inability to achieve this state increases the
mortality
Neuroendocrine Stress Response
- shortly after the trauma, the CNS triggers a series
of reactions that promotes cmpentation including
brain, blood, and bone marrow
- cathecolamines are released
- these hormones mobilizes glycogen stores,
increases glucose availablty, suppresses pancreatic
insulin, resulting in an increase net of glucose
- centrally mediated release of ADH promotes water
absorption, increasing intravascular volume and
diminishes urine output
Systemic Inflammatory Response Syndrome
- the release of cathecolamine triggers massive
amount of WBC at the site of injury
- SIRS is used without he presence of infection;
SEPSIS is termed in the presence of a widespread
inflammation and infection
Multi Organ Dysfunction Syndrome
Coagulopathy
Hypothermia
Psychologic Response
Environmental Emergencies—Heat
Stroke
• A failure of heat regulating mechanisms
• Types
– Exertional: occurs in healthy individuals during
exertion in extreme heat and humidity
– Hyperthermia: the result of inadequate heat loss
• Elderly, very young, ill, or debilitated—and persons
on some medications—are at high risk
• Can cause death
• Manifestations: CNS dysfunction, elevated
temperature, hot dry skin, anhydrosis, tachypnea,
hypotension, and tachycardia
Management of Patients With Heat Stroke
• Use ABCs and reduce temperature to 39° C as
quickly as possible
• Cooling methods
– Cool sheets, towels, or sponging with cool water
– Apply ice to neck, groin, chest, and axillae
– Cooling blankets
– Iced lavage of the stomach or colon
– Immersion in cold water bath
• Monitor temperature, VS, ECG, CVP, LOC, urine
output
• Use IVs to replace fluid losses
– Hyperthermia may recur in 3 to 4 hours; avoid
hypothermia
Environmental Emergencies—Frostbite
• Trauma from freezing temperature and actual
freezing of fluid in the intracellular and intercellular
spaces
• Manifestations: hard, cold, and insensitive to
touch; may appear white or mottled; and may turn
red and painful as rewarmed
• The extent of injury is not always initially known
• Controlled but rapid rewarming; 37° to 40° C
circulating bath for 30- to 40-minute intervals
• Administer analgesics for pain
• Do not massage or handle; if feet are involved, do
not allow patient to walk
Environmental Emergencies—Hypothermia
• Internal core temperate is 35° C or less
• Elderly, infants, persons with concurrent illness,
the homeless, and trauma victims are at risk
• Alcohol ingestion increases susceptibility
• Hypothermia may be seen with frostbite;
treatment of hypothermia takes precedence
• Physiologic changes in all organ systems
• Monitor continuously
Management of Patients With Hypothermia
• Use ABCs, remove wet clothing, and rewarm
• Rewarming
– Active core rewarming
Cardiopulmonary bypass, warm fluid administration,
warm humidified oxygen, and warm peritoneal
lavage
– Passive external rewarming
Warm blankets and over-the-bed heaters
• Cold blood returning from the extremities has high
levels of lactic acid and can cause potential cardiac
dysrhythmias and electrolyte disturbances
Management Patients With
Carbon Monoxide Poisoning
• Inhaled carbon monoxide binds to hemoglobin as
carboxyhemoglobin, which does not transport
oxygen
• Manifestations: CNS symptoms predominate
– Skin color is not a reliable sign and pulse oximetry
is not valid
• Treatment
– Get to fresh air immediately
– Perform CPR as necessary
– Administer oxygen: 100% or oxygen under
hyperbaric pressure
• Monitor patient continuously
Management of Patients With
Chemical Burns
• Severity of the injury depends upon the
mechanism of action of the substance, the
penetrating strength and concentration, and the
amount of skin exposed to the agent
• Immediately flush the skin with running water
from a shower, hose, or faucet
– Lye or white phosphorus must be brushed off the
skin dry
• Protect health care personnel from the substance
• Determine the substance
• Some substances may require prolonged
flushing/irrigation
• Follow-up care includes reexamination of the area
at 24 hours, 72 hours, and 7 days
Management of Patients With
Substance Abuse
• Acute alcohol intoxication: a multisystem toxin
– Alcohol poisoning may result in death
– Maintain airway and observe for CNS depression
and hypotension
– Rule out other potential causes of the behaviors
before it is assumed the patient is intoxicated
– Use a nonjudgmental, calm manner
– Patient may need sedation if noisy or belligerent
– Examine for withdrawal delirium, injuries, and
evidence of other disorders
Crisis Intervention—Rape Victims
• How the patient is received and treated in the ED
is important to his or her psychological well-being
• Crisis intervention begins as soon as the patient
enters the facility; the patient should be seen
immediately
• Goals are to provide support, reduce emotional
trauma, and gather evidence for possible legal
proceedings
• Patient reaction; rape trauma syndrome
• History taking and documentation
• Physical examination and collection of forensic
evidence
• Role of the sexual assault nurse examiner (SANE)
Psychiatric Emergencies
• Overactive, underactive, violent, and depressed or
suicidal patients
• Management
– Maintain the safety of all persons and gain control
of the situation
– Determine if the patient is at risk for injuring
himself or others
– Maintain the person’s self-esteem while providing
care
– Determine if the person has a psychiatric history
or is currently under care to contact the therapist
• Crisis intervention
• Interventions specific to each of the conditions
Roles and Function of the Nurse in Emergency
and Disaster Nursing
• Educator
• Counselor
• Team member
• Facilitator (include triaging)
• Advocate
• Researcher
Terrorism, Mass Casualty, and Disaster
Nursing
Emergency Operations Plan (EOP)
• Health care facilities are required by the Joint
Commission on Accreditation of Healthcare
Organizations to create a plan for emergency
preparedness and to practice this plan twice a year
• Essential components of the plan:
– An activation response
– An internal/external communication plan
– A plan for coordinated patient care
– Security plans
– Identification of external resources
– A plan for people management and traffic flow
• Essential components of the plan:
– A data management strategy
– Deactivation response
– Post-incident response
– A plan for practice drills
– Anticipated resources
– Mass casualty incident planning
– An education for all of the above
Managing Short- and Long-Term Psychological
Effects After a Disaster
• Provide active listening and emotional support
• Provide information as appropriate
• Refer to therapist or other resources
• Discourage repeated exposure to media regarding
the event
• Encourage return to normal activities and social
roles
• Critical incident stress management (CISM)
• Programs that include education, field support,
defusing, debriefing, demobilization, and follow-up
components
• Persons with ongoing stress reactions should be
referred to mental health specialists
Personal Protective Equipment (PPE)
• Purpose: to shield the health care provider from
chemical, physical, biological, and radiologic hazards
that may exist when caring for contaminated
patients
• Categories of protective equipment:
– Level A: self-contained breathing apparatus (SCBA)
and vapor-tight chemical-resistant suit, gloves, and
boots
– Level B: high level of respiratory protection (SCBA)
but lesser skin and eye protection; chemical-
resistant suit
– Level C: air-purified respirator, coverall with splash
hood, and chemical-resistant gloves and boots
– Level D: typical work uniform
Isolation Precautions for
Biological Terrorism Agents
• Biological agents may be delivered or spread in a
number of ways
• Due to modern travel, spread of infection may
occur in areas thousands of miles apart
• Health care providers need to be aware of
potential signs of biological weapon dissemination;
signs and symptoms are similar to those of common
disease process
• Isolation practices depend upon the infecting
agent
• Always use Standard Precautions
• Some agents require Transmission-Based
Precautions
• Terminal disinfection and disposal of wastes
depends on the infecting agent
Chemical Weapons
• Chemical substances that quickly cause injury
and/or death and cause panic and social disruption
• Agents
– Nerve agents
– Blood agents
– Vesicants
– Pulmonary agents
• Agents vary in volatility, persistence, toxicity, and
period of latency
• Limitation of exposure is essential with evacuation
and decontamination as soon possible and as close
to the scene of the incident as possible
Nerve Agents
• Sarin and soman organophosphates
• Inhibit cholinesterase-causing cholinergic
symptoms progressing to loss of consciousness,
seizures, copious secretions, apnea, and death
• Treatment: supportive care, atropine,
benzodiazepine, and pralidoxime
• Decontaminate with copious amounts of soap and
water or saline for at least 20 minutes
• Blot; do not wipe off
• Plastic equipment will absorb sarin gas
Vesicants
• Lewisite, sulfur mustard, nitrogen mustard, and
phosgene
• Cause blistering and burning
• Respiratory effects can be serious and cause
death
• Decontaminate with soap and water; do not scrub
or use hypochlorite solutions
• Eye exposure requires copious irrigation
• Treatment for lewisite exposure: dimercaprol IV or
topically
Radiation Exposure
• Radiation exposure may occur due to nuclear
weapons, nuclear reactor incidents, or exposure to
radioactive samples
• Exposure to radiation is affected by time, distance,
and shielding
• Types of radiation exposure:
– External radiation: all or part of the body is
exposed to radiation; as decontamination is not
necessary, it is not a medical emergency
– Contamination: exposure to radioactive gases
liquids or solids; requires immediate medical
management to prevent incorporation
– Incorporation: uptake of the radioactive material
into the body
Radiation Decontamination
• Triage outside the hospital
• Cover floor and use strict isolation precautions to
prevent the tracking of contaminants
• Seal air ducts and vents
• Waste is double bagged and put in a container
labeled radiation waste
• Staff protection
– Water-resistant gowns, 2 pairs of gloves, caps,
goggles, masks, and booties
– Dosimetry devices
• Patients are surveyed for radiation and directed to
the decontamination area
• Each patient is decontaminated with a shower
outside the ED
• Water, tarps, towels, soap, gowns, all the patient’s
belongings, etc., must be collected and contained
• Patients are surveyed and showered again as
necessary
• Showering should be performed so as not to
contaminate clean areas with runoff from the
showering
• Biologic samples: nasal and throat swabs; blood
• Internal contamination requires additional
treatment: catharsis and gastric lavage with
chelating agents
Radiation Injuries
• Acute radiation syndrome (ARS): dose of radiation
determines if ARS will develop
• All body systems are affected by ARS
• Presenting signs and symptoms determine
predicted survival
• Probable survivors have no initial symptoms or
only minimal symptoms
• Possible survivors present with nausea and
vomiting that persists for 24 to 48 hours
• Improbable survivors are acutely ill with nausea,
vomiting, diarrhea, and shock; neurologic symptoms
suggest lethal dose; and survival time is variable