Emergency and Disaster Nursing
Healthcare Provider's Role in Emergency Situations
-Emergency response plan includes individual roles and responsibilities of members of the response team and participation in emergency/MCI preparedness drills on a regular basis. -Drills include hospital disaster drills, computer simulations, and tabletop exercises.
Violence
-Acting out of emotions (e.g., fear or anger) to cause harm to someone or something -Organic disease -Psychosis -Antisocial behavior
Goals of Primary Survey
-Airway with cervical spine stabilization and/or immobilization -Maintain airway: least to most invasive method
Bioterrorism
-Anthrax, plague, and tularemia: treated with antibiotics, assuming sufficient supplies and nonresistant organisms -Smallpox can be prevented or ameliorated by vaccination even when first given after exposure.
Primary Survey: Breathing
-Assess for dyspnea, cyanosis paradoxic/asymmetric chest wall movement, decreased/absent breath sounds, tachycardia, hypotension. --- Many conditions, including fractured ribs, pneumothorax, penetrating injury, allergic reactions, pulmonary emboli, and asthma attacks, cause breathing alterations. 1. Administer high-flow O2 via a non-rebreather mask. 2. Bag-valve-mask (BVM) ventilation with 100% O2 and intubation for life-threatening conditions -Monitor patient response. -Life-threatening conditions, such as tension pneumothorax and flail chest, can severely and quickly compromise ventilation.
Additional Bioterrorism Methods
-Botulism is treated with antitoxin. -No treatment has been established for most viruses that cause hemorrhagic fever.
Secondary Survey
-Brief, systematic process to identify all injuries -Full set of vital signs/Five interventions/Facilitate family presence -Give comfort measures. -History and head-to-toe assessment -Inspect the posterior surfaces. -Evaluate need for tetanus prophylaxis. -Provide ongoing monitoring, and evaluate patient's response to interventions.
Triage System
-Categorizes patients so most critical are treated first -5 level system
Poisonings
-Chemicals that harm the body accidentally, occupationally, recreationally, or intentionally. -Severity depends on type, concentration, and route of exposure. -Management -Decreasing absorption -Dermal cleansing/eye irrigation -Enhance elimination -Hemodialysis/hemoperfusion
Animal Bites
-Children at greatest risk -Animal bites from dogs and cats are most common, followed by bites from wild or domestic rodents.
Emergency and Mass Casualty Incident Preparedness (More)
-Communities have initiated programs to develop community emergency response teams (CERTs). -All health care providers have a role in emergency and MCI preparedness. -Response to MCIs often requires the aid of a federal agency such as the National Incident Management System (NIMS). -National Disaster Medical System: organizes and trains volunteer disaster medical assistance teams (DMATs)
Hypothermia
-Core temperature <95º F (<35º C) -Risk factors -Mild hypothermia (93.2º to 96.8º F [34º to 36º C]) -Moderate hypothermia (86º to 93.2º F [30º to 34º C]) -Severe hypothermia (<86º F [30º C]) makes the person appear dead.
Treatment of Submersion Injuries
-Correct hypoxia. -Correct acid-base and fluid imbalances. -Support basic physiologic functions. -Rewarm if hypothermia is present. -Initial evaluation: ABCD. Mechanical ventilation with PEEP or CPAP to improve gas exchange when pulmonary edema is present. -Ventilation and oxygenation are the primary techniques for treating respiratory failure.
Gastric Lavage
-Decreases absorption -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 and ingested nontoxic substances
Signs/Symptoms of Compromised Airway
-Dyspnea -Inability to vocalize -Presence of foreign body in airway -Trauma to face or neck
Gerontologic Considerations: Emergency Care
-Elderly are at high risk for injury—primarily from falls. -Causes-Generalized weakness,Environmental hazards, Orthostatic hypotension, Important to determine whether physical findings may have caused fall or may be due to fall
Emergency Nursing: Primary Survey
-Focuses on airway, breathing, circulation, and disability, exposure (ABCDE) -Identifies life-threatening conditions -Interventions are started immediately and before proceeding to the next step of the survey (if ABCDE is identified)
Additional Methods of Poisoning Treatments
-Hemodialysis is reserved for patients who develop severe acidosis from ingestion of toxic substances (e.g., aspirin). -Sodium bicarbonate administration raises the pH (>7.5), which is particularly effective for phenobarbital and salicylate poisoning. -Vitamin C is added to IV fluids to enhance excretion of amphetamines and quinidine. -Chelation therapy is considered for heavy metal poisoning (e.g., edetate calcium disodium [Calcium EDTA] for lead poisoning).
Treatments of Animal/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
Terrorism
-Involves overt actions for the expressed purpose of causing harm -Disease pathogens (e.g., bioterrorism) -Chemical agents -Radiologic/nuclear, explosive devices
Mass Causality Incident
-Manmade or natural event or disaster that overwhelms community's ability to respond with existing resources
Activated Charcoal
-Most effective intervention for poisoning: administer orally or via gastric tube within 60 minutes of poison ingestion -Contraindications: Diminished bowel sounds, paralytic ileus Ingestion of substance poorly absorbed by charcoal -Charcoal can absorb and neutralize antidotes: do not give immediately before, with, or shortly after charcoal.
Death in the Emergency Room
-Must recognize importance of hospital rituals in preparing the bereaved to grieve (e.g., collecting belongings, viewing the body) -Determine if patient could be candidate for non-heart beating donation. -Tissues and organs (e.g., corneas, heart valves, skin, bone, kidneys) can be harvested from patient after death.
Family and Intimate Partner Violence
-Pattern of coercive behavior in a relationship; involves fear, humiliation, intimidation, neglect, and/or intentional physical, emotional, financial, or sexual injury -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
Rapid Sequence Intubation
-Preferred procedure for unprotected airway -Involves sedation or anesthesia and paralysis
Triage
-Process of rapidly determining patient acuity -Represents a critical assessment skill
Heat Exhaustion/Heat Stroke
-Prolonged exposure to heat over hours or days -Leads to heat exhaustion -Clinical syndrome characterized by -Treatment of the patient -Monitor for signs of rhabdomyolysis, myoglobinuria, and disseminated intravascular coagulation.
Rabies:Prophylaxis for Bites
-Rabies prophylaxis essential in management of animal bites -Initial injection: rabies immune globulin -Series of five injections of human diploid cell vaccine: days 0, 3, 7, 14, and 28
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, resulting in radioactive contamination. -Main danger from RRDs: explosion -Ionizing radiation (e.g., nuclear bomb, damage to a nuclear reactor): serious threat to safety of casualties and environment -Exposure may or may not include skin contamination with radioactive material.
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 the lungs, middle ear, gastrointestinal tract
Human Bites
-Result in puncture wounds or lacerations -High risk of infection -Oral bacterial flora and Hepatitis virus -Common Bacteria: Staphylococcus aureus, Streptococcus, and hepatitis virus.
Submersion Injury
-Results when person becomes hypoxic as the result of submersion in substance, usually water -Drowning: death from suffocation after submersion in fluid -Aggressive resuscitation efforts and the mammalian diving reflex improve survival of near-drowning victims. Treatment of submersion injuries
Dermal cleansing/eye irrigation
-Skin and ocular decontamination: removal of toxins from skin and eyes using water or saline -With the exception of mustard gas, toxins can be removed with water or saline. -Water mixes with mustard gas and releases chlorine gas . -Decontamination takes priority over all interventions except basic life support measures.
Primary Survey
-Stabilize/immobilize cervical spine. -Breathing -Circulation -Disability -Exposure/environmental control
Treatment of Heat Exhaustion/Stroke
-Stablize ABCs and rapidly reduce temperature -Place patient in cool area and remove constrictive clothing. -Place moist sheet over patient to decrease core temperature. -Provide oral fluid. -Replace electrolytes. -Initiate normal saline IV solution if oral solutions are not tolerated.
Emergency and Mass Casualty Incident Preparedness
-System of colored tags designates both seriousness of injury and likelihood of survival. -Casualties need to be treated and stabilized. -Many casualties will arrive at hospitals on their own. -Total number of casualties a hospital can expect is estimated by doubling number of casualties that arrive in first hour.
Treatment for Hypothermia
-Warm patient to at least 90º F (32.2º C) before pronouncing dead. -Mild hypothermia: passive or active external rewarming -Moderate to severe hypothermia: active core rewarming
Additional Considerations with Heat Exhaustion/Stroke
-Watch for cardiac dysrthymias (due to electrolyte imbalance) -Cerebral Edema and hemorrhage -Muscle breakdown leading to myoglobinuria which can cause renal damage -No salt tablets to prevent gastric irritation and hypernatremia
Actions to Take in Mass Causality
-When an emergency or MCI occurs, first responders (e.g., police, emergency medical personnel) are dispatched. -Triage of casualties differs from usual ED triage and is conducted in <15 seconds.
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:
Answer: 1 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. Rationale: Only supportive treatment is available. A vaccine is available for Yellow fever only. The disease is carried by rodents and mosquitoes and through direct person-to-person contact with body fluids. Also, the virus can be aerosolized.
While performing triage in the emergency department, the nurse determines that which of the following patients should be seen first?
Answer: 3 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. Rationale: A triage system identifies and categorizes patients so that the most critical are treated first. The Emergency Severity Index (ESI) is a five-level triage system that incorporates concepts of illness severity and resource utilization to determine who should be treated first. Initially, the nurse would assess the patient for any threats to life or the presence of a high-risk situation. Next, evaluate patients who do not meet the criteria for ESI-1 or ESI-2 for the number of anticipated resources they may need. Assign patients to ESI level 3, 4, or 5 based on this determination. Normal vital signs are required for patients assigned to ESI level 3. Patients with abnormal vital signs may be reassigned to ESI level 2. Option 3 is ESI-1; option 1 is ESI-4; option 2 is ESI-5; and option 4 is ESI-2.
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:
Answer: 4 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. Rationale: The primary survey focuses on airway, breathing, circulation, disability, and exposure/environmental control. It serves to identify life-threatening conditions, so that appropriate interventions can be initiated. The nurse may identify life-threatening conditions related to airway, breathing, circulation (ABCs), and disability at any point during the primary survey. When this occurs, the nurse should start interventions immediately and before moving to the next step of the survey. The patient has decreased oxygenation, and further assessment with pulse oximetry is indicated.
An 18-year-old male who fell through the ice on a pond near his farm was admitted to the emergency department with signs and symptoms of severe hypothermia. The nurse should anticipate which of the following interventions?
Answer: A A. Active core rewarming B. Immersion in a hot bath C. Rehydration and massage D. Passive external rewarming Rationale: Active core rewarming involves the application of heat directly to the core and is indicated for severe hypothermia. Passive rewarming is used in mild hypothermia. Immersion in a hot bath, rehydration, and massage are not appropriate interventions in the treatment of severe hypothermia.
Which of the following assessment parameters will the nurse address during the secondary assessment of a patient in triage?
Answer: A A. Blood pressure and heart rate B. Patency of the patient's airway C. Neurologic status and level of consciousness D. Presence or absence of breath sound and quality of breathing Rationale: Vital signs are considered to be a part of the secondary assessment in the triage process. Airway, breathing, and a brief neurologic assessment are components of the primary survey.
A patient has sought care 3 days after experiencing a series of tick bites. Which of the following signs and symptoms would indicate that a patient is experiencing tick paralysis?
Answer: A A. Respiratory distress B. Aggression and frequent falls C. Decreased level of consciousness D. Fever and necrosis at the bite sites Rationale: Classic symptoms of tick paralysis are flaccid ascending paralysis, which develops over 1 to 2 days. Without tick removal, the patient dies as respiratory muscles become paralyzed. Decreased LOC, aggression, fever, and necrosis at the bite sites are not characteristic of the problem.
Which of the following assessment parameters will the nurse address during the secondary?
Answer: A A. Blood pressure and heart rate B. Patency of the patient's airway C. Neurologic status and level of consciousness D. Presence or absence of breath sound and quality of breathing Rationale: Vital signs are considered to be a part of the secondary assessment in the triage process. Airway, breathing, and a brief neurologic assessment are components of the primary survey.
Which of the following guidelines for the assessment of intimate partner violence (IPV) should the emergency nurse follow?
Answer: C A. All female patients and patients under 18 should be assessed for IPV. B. Patients should be assessed for IPV provided corroborating evidence exists. C. Patients should be routinely screened for family and IPV. D. Patients whom the nurse deems high risk should be assessed for IPV. Rationale: Patients should be routinely screened for family and IPV.
An 18-year-old female has been admitted to the emergency department after ingesting an entire bottle of chewable multivitamins in a suicide attempt. The nurse should anticipate which of the following interventions?
Answer: D A. Induced vomiting B. Whole bowel irrigation C. Administration of fresh frozen plasma D. Administration of activated charcoal Rationale: Among the most common treatments for poisoning is the administration of activated charcoal. Induced vomiting is not typically indicated, and there is no need for plasma administration. Whole bowel irrigation may be used as an adjunct therapy later in treatment, but the use of activated charcoal is central to the treatment of poisonings.
Emergency Preparedness
Any extraordinary event that requires a rapid and skilled response and can be managed by a community's existing resources
Secondary Survey: Vital Signs
Blood pressure (bilateral) Heart rate Respiratory rate Oxygen saturation Temperature Initiate ECG monitoring. Initiate pulse oximetry. Insert indwelling catheter. Insert orogastric/nasogastric tube. Collect blood for laboratory studies.
Active external rewarming
Body-to-body contact, fluid- or air-filled warming blankets, radiant heat lamps. -Use of heated, humidified oxygen -Warmed IV fluids -Peritoneal, gastric, or colonic lavage with warmed fluids
Chemical Agents of Terrorism
Categorized by target organ or effect: -Sarin: toxic nerve gas that can cause death within minutes of exposure -Enters body through eyes and skin -Acts by paralyzing respiratory muscles -Antidotes for nerve agents: atropine, pralidoxime chloride -Phosgene: colorless gas normally used in chemical manufacturing -If inhaled at high concentrations for long enough period, causes severe respiratory distress, pulmonary edema, and death -Mustard gas: yellow to brown in color with garlic-like odor -Irritates eyes and causes skin burns/blisters
Additional Complications of Bites
Cellulitis, osteomyelitis, and septic arthritis
Primary Survey: Circulation
Check central pulse (peripheral pulses may be absent because of injury or vasoconstriction). If a pulse is felt, assess the QUALITY & RATE. Assess the skin for color, temperature, and moisture. Altered mental status and delayed capillary refill (longer than 3 seconds) are the most significant signs of shock. Take care when evaluating capillary refill in cold environments because cold delays refill. When someone is losing fluid and potentially becoming hypovolemic shock, you must insert two large-bore IV catheters. Initiate aggressive fluid resuscitation using normal saline or lactated Ringer's solution. Insert intravenous (IV) lines into veins in the upper extremities unless contraindicated, such as in a massive fracture or an injury that affects limb circulation. Apply direct pressure to any obvious bleeding sites with a sterile dressing. Obtain blood samples for typing to determine ABO and Rh group.
Clinical Symptoms of Heat Exhaustion
Fatigue, Light-headedness, Nausea/vomiting, Diarrhea , Feelings of impending doom, Tachypnea, Tachycardia, Dilated pupils, Mild confusion, Ashen color, Profuse diaphoresis, Hypotension and mild to severe temperature elevation (99.6º to 104º F [37.5º to 40º C]) due to dehydration. Failure of the hypothalamic thermoregulatory processes Vasodilation, increased sweating, and respiratory rate deplete fluids and electrolytes, specifically sodium. Sweat glands stop functioning, and core temperature increases (>104º F [40º C]).
Cricoid pressure
Firm downward pressure on the cricoid ring pushes the vocal cords downward toward the field of vision while sealing the esophagus against the vertebral column.
Risk factors of Hypothermia
Elderly, certain drugs, alcohol, diabetes
Family Involvement in Emergency Care
Family members who wish to be present during invasive procedures/resuscitation view themselves as participants in care their presence should be supported.
Passive External Rewarming
Move patient to warm, dry place; remove damp clothing; place warm blankets on patient.
Manifestations of Hypothermia
Hypothermia mimics cerebral or metabolic disturbances causing ataxia, confusion, and withdrawal, so the patient may be misdiagnosed.
Infection & Animal Bites
Individuals at greatest risk of infection are infants, older adults, immunosuppressed patients, alcoholics, diabetic individuals, and those taking corticosteroids.
Complications of Animal Bites
Infection and mechanical destruction of skin, muscle, tendons, blood vessels, bone
Airway Maintenance
Least to most invasive method: -Open airway using the jaw-thrust maneuver. -Suction and/or remove foreign body. -Insert nasopharyngeal/oropharyngeal airway. -Provide endotracheal intubation.
Secondary Survey: Inspect posterior surfaces
Logroll patient (while maintaining cervical spine immobilization) to inspect the posterior surfaces. Inspect the back for ecchymosis, abrasions, puncture wounds, cuts, and obvious deformities. Palpate the entire spine for misalignment, deformity, and pain.
Treatment of Hypothermia
Manage and maintain ABCs, rewarm patient, correct dehydration and acidosis, treat cardiac dysrhythmias.
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 and pupils
Secondary Survey: 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.
Organ procurement organizations (OPOs)
Organizations available to assist in the process of screening potential donors, counseling donor families, obtaining informed consent, and harvesting organs from patients who are on life support or who die in the ED.
Secondary Survey: Comfort Measures
Pain management strategies— combination of pharmacologic measures and nonpharmacologic measures.
Community Emergency Response Teams (CERTs)
Partners in emergency preparedness, and training helps citizens to understand their personal responsibility in preparing for natural/manmade disaster. -Training includes teaching of lifesaving skills with emphasis on decision making and rescuer safety. -CERTs are an extension of first responder services.
Cricothyroidotomy or Tracheotomy
Performed if unable to intubate because of airway obstruction.
Jaw-Thrust Maneuver
Recommended procedure for opening the airway of an unconscious patient with a possible neck or spinal injury. The patient should be lying supine with the rescuer kneeling at the top of the head. The rescuer places one hand on each side of the patient's head, resting his or her elbows on the surface. The rescuer grasps the angles of the patient's lower jaw and lifts the jaw forward with both hands without tilting the head.
Secondary Drowning
Refers to delayed death from drowning due to pulmonary complications.
Primary Survey: Exposure/environmental control
Remove clothing to perform physical assessment. Prevent heat loss.
Emergency Severity Index
Review Table: 69-2 Five-level triage system that incorporates illness severity and resource utilization ESI-1 through ESI-5 Level 1 is Unstable/Most Severe to Level 5-Stable/Least Severe
Risks of Treatment for Hypothermia
Risks of rewarming: -Afterdrop, a further drop in core temperature -Hypotension -Dysrhythmias -Rewarming should be discontinued once the core temperature reaches 95º F (35º C).
AMPLE
Secondary Survey: A: Allergies to drugs, food, environment M: Medication history P: Past health history (e.g., preexisting medical and/or psychiatric conditions, previous hospitalizations/surgeries, smoking history, recent use of drugs/alcohol, tetanus immunization, last menstrual period, baseline mental status) L: Last meal E: Events/environment leading to the illness or injury
Colored Tag System in Emergency Management
System of colored tags designates both seriousness of injury and likelihood of survival. -Green (minor injury) or yellow (non-life-threatening injury) tag indicates noncritical injury. -Red tag indicates life-threatening injury. -Blue tag indicates those who are expected to die. -Black tag identifies the dead.
Secondary Survey: Preparation
Transport for diagnostic tests (e.g., x-ray), admit to general unit, telemetry, or intensive care unit, transfer to another facility. The nurse may accompany critically ill patients on transports. The nurse is responsible for monitoring the patient during transport, notifying the health care team should the patient's condition become unstable, and initiating basic and advanced life-support measures as needed.
Mannitol (Osmitrol) or Lasix (Furosemide)
Used to decrease free water and treat cerebral edema. Deterioration in neurologic status: cerebral edema, worsening hypoxia, profound acidosis.
Emergency Department
Where patients with life-threatening or potentially life-threatening problems enter the hospital.
