Emergency Preparedness

A. Direct the clients to the decontamination area.

A group of people arrived at the emergency unit by a private car with complaints of periorbital swelling, cough, and tightness in the throat. There is a strong odor emanating from their clothes. They report exposure to a "gas bomb" that was set off in the house. What is the priority action? A. Direct the clients to the decontamination area. B. Direct the clients to the cold or clean zone for immediate treatment. C. Measure vital signs and auscultate lung sounds. D. Immediately remove other clients and visitors from the area. E. Instruct personnel to don personal protective equipment.

B) Reallocate staff according to mass casualty plan of action

A major hospital has received notification of a mass casualty event in the area. Which of the following actions should a charge nurse of an inpatient neurovascular floor do FIRST? A) Expedite discharge of appropriate clients B) Reallocate staff according to mass casualty plan of action C) Initiate paper charting methods for consistency D) Reduce vital sign frequency to every 8 hours for patients currently on the unit

DELIBERATE RELEASE OF VIRUSES, BACTERIA, OR OTHER MICROBES AS WEAPONS -Emerging infection SARS Novel Influenza A -Bioterrorism Category A, B, and C -Chemical incidents Explosions and blast events PRIMARY AGENTS: BACILLUS ANTHRACIS (ANTHRAX) CLOSTRIDIUM BOTULINUM TOXIN (BOTULISM) YERSINIA PESTIS (PLAGUE) VIRAL HEMORRHAGIC FEVERS VARIOLA MAJOR (SMALLPOX) FRANCISELLA TULARENSIS (TULAREMIA IMMEDIATE TREATMENT IS LIMITED STRATEGIC NATIONAL STOCKPILE MANAGED BY CDC, DEPARTMENT OF HOMELAND SECURITY PREASSEMBLED "PUSH PACKAGES" LOCATIONS PERMIT DELIVERY WITHIN 12 HOURS AFTER ATTACK VENDOR-MANAGED INVENTORY PACKAGES, SHIPPED WITHIN 24-36

Examples of Bioterrorism

MITIGATION BOTH BEFORE AND AFTER EMERGENCY OCCURS WARNING SYSTEMS, INSURANCE PREPAREDNESS BEFORE EMERGENCY OCCURS NURSES GAIN UNDERSTANDING OF EXPECTED ROLES IN EMERGENCY DEVELOP EMERGENCY PLAN DESIGNATE MEETING PLACES EMERGENCY RESPONSE IMPLEMENTATION OF PREPAREDNESS PLANS VICTIMS TRIAGED, TREATED AS SOON AS POSSIBLE SEARCH AND RESCUE OPERATIONS, SHELTER FOR SURVIVORS, REPAIRING UTILITY INFRASTRUCTURES RECOVERY DESIGNED TO RETURN COMMUNITY TO NORMAL OR CREATE NEW, SAFER NORMAL REBUILDING, REEMPLOYMENT, REPAIR, RECONSTITUTION OF

FOUR PHASES OF EMERGENCY RESPONSE (know these + components)

4-20

For every person physically injured in a disaster, there are __-__ psychological victims

D) Brief neurologic assessment

In conducting a primary survey on a MCI trauma patient, which of the following is considered one of the priority elements of the primary survey? A) Initiation of pulse oximetry. B) Complete set of vital signs. C) Client's allergy history. D) Brief neurologic assessment.

Being aware of the agency's emergency response plan.

In the work setting, what is the primary responsibility of the nurse in preparation for disaster management, that includes natural disasters and bioterrorism incidents? Being aware of the signs and symptoms of potential agents of bioterrorism. Making ethical decisions regarding exposing self to potentially lethal substances. Being aware of the agency's emergency response plan. Being aware of what and how to report to the Centers for Disease Control and Prevention.

Nuclear/radiological events Exposures to radiation may be accidental or deliberate in origin Radiation Ionizing radiation; Alpha radiation; Beta radiation; Gamma radiation Means of exposure Irradiation Contamination Radiation effects Adverse health effects of exposure may not be apparent for many years 2 types of radiation injury Local radiation injury and acute radiation syndrome

Radiation

This victim is seriously hemorrhaging, one of the reasons to treat during triage. Respirations elevated and perfusion impaired. You use your unskilled male helper to apply pressure by placing his hands on the bleeding and applying pressure, preferably using his shirt or bandanna as a "dressing". Tag RED. As the patient is already RED, you don't really have to assess mental status. You and your female helper move on.

Treatment Level: Teenage girl bleeding heavily from her right thigh, respirations 32, pulse thready, CRT 2.5 seconds, follows commands

Triage and acuity are based on ABCD priorities: See Table 70.1 pg. 1544 -Airway with C-spine precautions- airway is inspected for obstruction or injuries -Breathing- assess for ineffective breathing patterns -Circulation with hemorrhage control- include pulses, heart rate, skin color, blood pressure, capillary refill, and any obvious signs of bleeding -Disability and resource management- includes a brief neurological assessment that measures the patients LOC. -Exposure/Environment- complete assessment of the patient; prevent hypothermia

Triage and acuity based on:

Emergent (Immediate)-Life threatening issues that require prompt treatment and care. Stabilization of the patient's condition is critical Urgent (Delayed)- Serious health conditions in which delay of treatment and care would result in life-threatening situations. Non-urgent (Minor)- Minor issues that do not require prompt care. Can ambulate and are stable in their conditions.

Triage: Emergent (Immediate)- Urgent (Delayed)- Non-urgent (Minor)-

"DO THE GREATEST GOOD FOR THE GREATEST NUMBER OF PEOPLE RATHER THAN DOING EVERYTHING POSSIBLE TO SAVE EVERY LIFE." MASS CASUALTIES CALL FOR REVERSE TRIAGE THE MOST SEVERELY INJURED OR ILL VICTIMS ARE TREATED LAST TO ALLOW THE GREATEST NUMBER OF VICTIMS TO ALLOW FOR MEDICAL TREATMENT DESIGNED TO BE COMPLETED IN 60 SECONDS OR LESS. BASED ON THREE OBSERVATIONS: RESPIRATIONS, PERFUSION, AND MENTAL STATUS

What is reverse triage?

Decontamination Three goals for hospital decontamination: 1) Hospitals must not allow contaminated patients to enter the facility, if the patient cannot be decontaminated at the on-incident scene a decontamination site should be set up just outside of ED 2) hospitals should decontaminate patients as rapidly as possible 3) hospitals must plan to protect the decontamination team from secondary exposure and injury.

the reduction or removal of contaminating material from a person or equipment by water and mechanical processes.

RESPIRATIONS, PERFUSION, AND MENTAL STATUS *DESIGNED TO BE COMPLETED IN 60 SECONDS OR LESS.

Reverse triage is based on what 3 observations?

Selection of appropriate PPE is a complex process based on a hazard assessment that: 1) identifies the hazards or suspected hazards 2) identifies the routes of entry of the potential hazard (inhalation, skin absorption, ingestion, and eye/skin contact) 3) defines the performance of the PPE materials in providing a barrier to these hazards. Educate staff that no single PPE will protect against all hazards.

Selection of appropriate PPE is a complex process based on a hazard assessment that:

Obviously in dire straits, you use your shirt as a tourniquet and sacrifice your remaining helper to apply pressure on the bleeding area. Tag RED, move on.

Treatment Level: Elderly woman, bleeding profusely from an amputated right arm (level of forearm), respirations 36, pulse on left wrist absent, CRT 3 seconds, unresponsive.

Obviously injured, this young woman is otherwise stable and communicating. With assistance, she is able to stand up, and can walk by herself. She becomes another of the walking wounded, tag GREEN. Point her to the GREEN area you previously assigned and move on.

Treatment Level: Female in her 20s, burns on neck and face, respirations 22, pulse present, CRT 1 second, asks to get up and can walk, although with a limp.

This victim has a significant head injury, but is stable from the standpoint of respirations and perfusion. As her mental status is impaired, tag RED (immediate). Move on.

Treatment Level: Female in her 50s, bleeding from nose, ears, and mouth. Trying to sit up but can't, respirations 20, pulse present, CRT 1 second, not responding to your commands.

You initially think this child is deceased, but you follow protocol and reposition his airway by tilting his head back. A Mass Casualty Incident is one of the few circumstances where you don't worry about cervical spine injuries in making your assessment. He starts breathing even without an oral airway, so you tag him RED. If he is bleeding heavily from his injuries, you apply pressure and wait for the additional help.

Treatment Level: Male child, multiple penetrating injuries, respirations absent. Airway repositioned, starts breathing. Radial pulse absent, CRT 2 seconds, unresponsive.

If not breathing, you will reposition his head and place an airway. In this case, this fails to restart breathing. This patient is deceased for all intents and purposes. Tag BLACK, move on.

Treatment Level: Male in his 20s, head wound, respirations absent. Airway repositioned, still no breathing.

Respirations are within acceptable range (less than 30), pulse and CRT normal. Complains of pain, and is communicating where it hurts, so mental status probably normal. This patient is tagged YELLOW: needs care but will not die if there is a reasonable (2-4 hour) delay. Move on.

Treatment Level: Male in his 30s, complains of pain in his left leg (obviously fractured), Respirations 24, pulse strong, CRT 1 second, no excessive bleeding.

This victim has significant burns on large areas, but is breathing well and has normal perfusion. Mental status is unimpaired, so you tag YELLOW and move on.

Treatment Level: Male in his 40s, burns on face, chest, and arms. Respirations 22, pulse 100, CRT 1.5 seconds, follows commands.

This victim doesn't look so bad but is having trouble breathing and has questionable perfusion. Mental status is unimpaired, but he likely has other issues, perhaps internal bleeding. You tag RED (respirations over 30, impaired perfusion) and move on.

Treatment Level: Teenage boy, multiple cuts and abrasions but not hemorrhaging, says he can't breathe, respirations 34, radial pulse present, CRT 2.5 seconds.

C. A deviated trachea.(A deviated trachea is a symptom of tension pneumothorax, which will result in respiratory distress if left untreated.)

A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. Which of the following assessment should take the highest priority to take? A. Irregular pulse. B. Ecchymosis in the flank area. C. A deviated trachea. D. Unequal pupils.

A deviated trachea

A client arrives at the emergency department who suffered multiple injuries from a head-on car collision. Which of the following assessment should take the highest priority to take? Irregular Pulse Ecchymosis in the flank area A deviated trachea Unequal Pupils

Drainage of a clear fluid from the client's nose.

A client was brought to the emergency department after suffering a closed head injury and lacerations around the face due to a hit-run accident. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessment findings if observed after few hours, should be reported to the physician immediately? Bleeding around the lacerations Withdrawal of the client in response to painful stimuli. Bruises and minimal edema of the eyelids Drainage of a clear fluid from the client's nose.

1. Event of destructive magnitude. 2. Kills, injures or causes human suffering to a significant number of people. 3. Requires need for external assistance.

Disaster events are defined by what 3 characteristics?

Treat the most seriously ill or injured first.

During disaster, what is the goal of triage?

C) 4, 3, 1, 2 4. An irritable infant with a fever, petechiae, and nuchal rigidity. 3. An ambulatory dazed 25-year-old male with a bandaged head wound. 1. A 50-year-old female with moderate abdominal pain and occasional vomiting. 2. A 35-year-old jogger with a twisted ankle, having a pedal pulse and no deformity.

Michael works as a triage nurse, and four clients arrive at the emergency department at the same time. List the order in which he will assess these clients from first to last. 1. A 50-year-old female with moderate abdominal pain and occasional vomiting. 2. A 35-year-old jogger with a twisted ankle, having a pedal pulse and no deformity. 3. An ambulatory dazed 25-year-old male with a bandaged head wound. 4. An irritable infant with a fever, petechiae, and nuchal rigidity. A) 1, 2, 3, 4 B) 2, 1, 3, 4 C) 4, 3, 1, 2 D) 3, 4, 2, 1

-Disaster preparedness, response, and recovery -Mass casualty triage, helping to ensure patients get the most appropriate level of care -Putting disaster response plans into action -Evacuation -Decontamination NURSES MAY ALSO BECOME LEADERS AS THEIR COMMUNITIES PREPARE FOR POTENTIAL DISASTERS BY CREATING OR REVISING EMERGENCY PREPAREDNESS AND CONTINGENCY PLANS

Nurses role in disasters

A homeless person who is a poor historian; has altered mental status, poor muscle coordination, and hot, dry ashen skin; and whose duration of heat exposure is unknown.

The following clients are presented with signs and symptoms of heat-related illness. Which of them should be seen first? A relatively healthy homemaker who reports that the air conditioner has been broken for days and who manifest fatigue, hypotension, tachypnea, and profuse sweating An elderly person who complains of dizziness and syncope after standing in the sun for several hours to view a parade. A homeless person who is a poor historian; has altered mental status, poor muscle coordination, and hot, dry ashen skin; and whose duration of heat exposure is unknown. A marathon runner who complains of severe leg cramps and nausea, and manifests weakness, pallor, diaphoresis, and tachycardia.

C. 5, 1, 3, 2, 4

The following clients come at the emergency department complaining of acute abdominal pain. Prioritize them for care in order of the severity of the conditions. 1. A 27-year-old woman complaining of lightheadedness and severe sharp left lower quadrant pain who reports she is possibly pregnant. 2. 43-year-old woman with moderate right upper quadrant pain who has vomited small amounts of yellow bile and whose symptoms have worsened over the week. 3. A 15-year-old boy with a low-grade fever, right lower quadrant pain, vomiting, nausea, and loss of appetite for the past few days. 4. A 57-year-old woman who complains of a sore throat and gnawing midepigastric pain that is worse between meals and during the night. 5. A 59-year-old man with a pulsating abdominal mass and sudden onset of persistent abdominal or back pain, which can be described as a tearing sensation within the past hour. A. 2, 5, 3, 4, 1 B. 3, 1, 4, 5, 2 C. 5, 1, 3, 2, 4 D. 2, 5, 1, 4, 3

B. Securing the airway, applying O2, stopping excessive bleeding, performing a quick neurological assessment, undressing the patient Rationale: Airway/breathing should always be first. The priority is making sure all tissue receives adequate oxygenation. If the airway is not treated, there will not be effective breathing, which will affect oxygenation before circulation affects tissue oxygenation. Circulation needs to be treated immediately after your AB in order to maintain circulating blood to profuse tissues. Disability is next because it may provide clues that ABC may still be affected or there is a head injury that will in turn affect the ABCs. Exposure comes last (or if you have a large enough trauma team it can happen simultaneously while others are assessing ABCDs); this is to prepare the patient for the secondary exam.

The nurse caring for a patient who has been involved in a high-speed MVC understands that the priorities of care include which of the following? A. Securing the airway, applying O2, undressing the patient, stopping excessive bleeding, performing a quick neurological assessment B. Securing the airway, applying O2, stopping excessive bleeding, performing a quick neurological assessment, undressing the patient C. Undressing the patient, securing the airway, applying O2, stopping excessive bleeding, performing a quick neurological assessment D. Stopping excessive bleeding, securing the airway, applying O2, performing a quick neurological assessment, undressing the patient

D. Assessing the patient using ABCs, treating life-threatening conditions, then transport to the hospital Rationale: A pre-hospital provider's priority is to quickly assess using ABCs and stabilize/treat the life threatening conditions and quickly transport to the appropriate facility. The appropriate facility most likely is the nearest trauma center; however, if the patient is too unstable, the closest local emergency department may be the most appropriate facility in order to further stabilize the patient, then transport to a trauma center. Prehospital providers should not be treating all injuries found, only immediate life threatening injuries. They should notify any hospital that they are transporting, but should do an assessment and needed interventions route. The other answers are incomplete.

The nurse understands priority prehospital interventions include which of the following? A. Transporting the patient as quickly as possible to the nearest trauma center B. Treating all injuries found on primary survey and then transporting the patient C. Notifying the local hospital of the transport of a trauma patient and transporting the patient quickly D. Assessing the patient using ABCs, treating life-threatening conditions, then transport to the hospital

Yellow tags -(delayed)

These tags are for those who require observation. They do have life threatening injuries, but their condition is stable for the moment and, they are not in immediate danger of death.

Green tags - (minor)

These tags are reserved for the "walking wounded" who will need medical care at some point, after more critical injuries have been treated.

Black tags - (expectant)

These tags are used for the deceased and for those whose injuries are so extensive that they will not be able to survive given the care that is available.

Red tags - (immediate)

These tags are used to label those who cannot survive without immediate treatment but who have a chance of survival. Includes compromises to patients ABC's

Probable spinal injury but otherwise stable and can communicate. Tag YELLOW. Move on.

Treatment Level: Another teenage girl, small laceration on forehead, says she can't move her legs. Respirations 20, pulse strong, CRT 1 second.

Your goal is to identify who will need help most urgently (red tags). You will be assessing RPMs (Respirations, Perfusion, and Mental Status): Respirations: Is your patient breathing? If not, use jaw thrust method, or insert an oral airway. If you have an open airway and no breathing, that victim is tagged BLACK. If the victim breathes once an airway is restored or is breathing more than 30 times a minute, tag RED. If the victim is breathing normally, move to perfusion. Perfusion: Check for a radial pulse and/or capillary refill. If no radial pulse or it takes longer than 2 seconds for nail bed color to return to pink, tag RED. If a pulse is present and CRT is normal, move to mental status. Mental Status: Can the victim follow simple commands ("open your eyes", "what's your name")? If the patient is breathing <30/minute and has normal perfusion but is unconscious or can't follow your commands, tag RED. If your breathing, normally perfused victim can follow commands, tag YELLOW if they can't get up or GREEN if they can.

When doing START triage (Simple Triage and Rapid Treatment) what is the goal? What are you assessing?

ANSWER B- All mass casualty events are disasters. Rationale: A disaster is an event that results in significant damage to life, property, or the environment. When a disaster causes injuries and death that overwhelm the local medical resources, then that event is call a mass casualty incident. Not all disasters result in human casualties, but all mass casualty incidents are caused by disasters.

Which of the following best explains the relationship between an MCI and a disaster? A. All disasters are mass casualty events. B. All mass casualty events are disasters. C. Mass casualty events are natural disasters. D. Mass casualty events are man-made disasters.

HOT ZONE -INITIAL SITE OF INCIDENT -ONLY PERSONNEL WITH APPROPRIATE PROTECTIVE EQUIPMENT ALLOWED IN HOT ZONE WARM ZONE -DECONTAMINATION COLD ZONE -WHERE DECONTAMINATED VICTIMS ARE TRIAGED AND TREATED

Zones of Safety