Emergency and Disaster Nursing &

Biologic Crisis

Principle of emergency care

Triage (French “trier”) (to sort, to choose)

Sort patient into groups based on severity of health problems & immediacy of tx

Mgt of priorities

Levels of acuity

Highest acuity

Receive quickest eval, tx, prioritized resource utilization (Xrays, labs, CT scan)

Three general approaches to emergency /disaster care

Hospital triage

Disaster triage

Emergency medical services

Hospital triage

3–tiered model triage

(under usual conditions)

Hospital triage:

Emergent triage

Urgent triage

Non urgent triage

Emergent triage

Seen & treated immediately

Poses immediate threat to life/ limb

Ex:

Critically injured

Substernal chest pain (Unstable angina)

Active bleeding

Shock

Airway obstruction

Urgent triage

Immediate threat to life does not exist at the moment

Major injuries that require immediate tx

Reassessment done by Triage RN if MD not available within 30mins-1 hr

Treated within 30mins-1 hr

Ex:

New onset of pneumonia with no RF

Abd pain

Renal colic

Complex lacerations with no major bleeding

Displaced fxs/ dislocations

Hx seizure prior to ER

Temp over 102 F (38 C)

Non urgent triage

Minor injuries or problems which do not pose threat to life or limb

Does not require immediate tx

Treated within 2-24hrs w/o up morbidity (clinical deterioration)

Ex:

Sprains (ligaments), strain (tendons, muscles)

Simple fxs

Simple laceration/ soft tissue injuries

Viral / “cold” symptoms

Skin rashes

Mass casualty / Disaster triage

Triage under Mass casualty conditions (Disaster Triage)

Disaster situation

# of casualties exceed resource capabilities

Emergent (class I / red tag)

Airway compromise, hemorrhagic shock

Urgent (class II/ yellow tag)

Needs tx w/in 30-2hrs

Open fxs, large wounds

Non urgent (class III/ green tag)

Tx delayed >2 hrs

Closed fxs, sprain/ strains, contusions, abrasions

“walking wounded”

Expectant (class IV / black tag)

Expected & allowed to die; dead

Massive head trauma, high cervical SCI, extensive burns

Psychological Reactions 2ndary to disaster

Panic

Hysteria

Depression

Emergency medical services

Certifications for Emergency Nursing

BCLS / BLS (Basic Cardiac Life Support)

Noninvasive assessment & mgt skills for airway maintenance & CPR
ACLS (Advanced Cardiac Life Support)

Invasive airway mgt skills, pharmacology & electrical tx, special resuscitation (AED) Automatic External
Defibrillator

PALS (Pediatric Advanced Life Support)

Neonatal & pedia resuscitation

Certified Emergency Nurse (CERN)

Validates core emergency nursing knowledge base

Emergency medical services

EMT( “E” medical technicians)

BLS (Basic Life Support) certified

Prerequisite to paramedics

200hrs training

Paramedics

ACLS ( Advanced Cardiac Life Support) certified

>1K hrs training

ER nurse

ER doctor

Principles of emergency nursing

Principles of emergency nursing

Triage

Primary survey & resuscitation interventions

2ndary survey & resuscitation interventions

Care of the ER patient

Disposition

Case management

Patient / Family health teaching

Primary survey

Initial assessment

Rapid identification + intervention techniques

To address most immediate life threats

ABC + DE

(used in trauma)

Disability

Exposure

Priorities of Primary Survey

Airway / cervical spine

Breathing

Circulation

Disability

Exposure

Primary survey & resuscitation interventions

Airway / cervical spine

Patent airway

Jaw thrust maneuver (cervical spine injury)

Neutral neck alignment

Check resp status

Suction , O2 PRN

GCS <8 = ET intubation + mech ventilation

Breathing

Assess breath sounds, resp effort

Chest wall trauma, abnormality

Prepare for chest compression PRN

Primary survey & resuscitation interventions

Circulation

Monitor VS, esp BP, pulse

Vascular access w/ LARGE bore cath

Direct pressure for external bleeding

Disability (trauma)

Monitor LOC

AVPU (Alert; responsive to Voice; responsive to Pain; Unresponsive) or GCS

Exposure (trauma)

Remove all clothing for accurate assessment

Prevent hypothermia

Blankets

Heat lamps

Infusion warm IVF

2ndary survey

Done post patient stabilized

Immediate threats to life had been addressed

Comprehensive head to toe assessment

To identify other injuries or med issues

Care of ER patient

Privacy

Dignity

Confidentiality of info

HIPAA (Health Insurance Portability and Accountability Act 2003)

Disposition

Admitted to hospital

Discharged to home

w/ instruction for continued care, ff up

Case management

Arrange appropriate referral & ff-up

Disposition for homeless pts

Safe environment for victims of violence (domestic, elder abuse)

Info on community resources

Low cost RX plan, health insurance

Patient / Family health teachings

Discharge teachings

Prevention

Health teachings

Mass casualty principles

Principles of Mass casualty principles

Triage

System of notification/ activation of “E” preparedness

group paging systems, instant electronic based alert messages, TV flash alerts

Hospital “E” preparedness: Personnel roles & responsibilities

hosp incident commander, medical command physician, triage officer, public info officer

Event resolution

Deactivating “E” response plan

Resume normal operations

Debriefing
Promote effective coping strategies

Review of staff & system performance

Modifications for improvement

Mass evacuation (hospital)

Ambulatory 1st

Wheelchair next

Bed bound last

Unit manager

can authorize pt evacuation

Common reasons for going to ER

Chest pain

Abd pain

Headache

Fever

Common “Codes” used in the hospital setting

Code blue

Members (MD, floor / unit RN, Resp therapist, Pharmacist, ICU RN)

Code pink

Deactivated ONLY by head of security and dept unit manager

Code gray

Code red

Deactivated ONLY by head of security

Code black

Bioterrorism / Bio Crisis

Bomb threat
Rapid Response Team

Same members as in code blue team

Prevent “code blue”

Mandated by JCAHO / JCI / The Joint Commission in 2001

Ex:

Decreasing O2 sat

Decreasing CBG/ FSBS despite interventions

Worsening VS

“gut feeling” that something wrong with patient but can’t pin point exactly what & why

Crash cart

“E” cart; “E” kit

Contents

Inside

Outside

Daily check

Defibrillator

Plastic lock with security # tag

Suction apparatus

O2 tank

Stat pads

Fire extinguisher

P-A-S-S method

Pull the pin

Aim the spout

Squeeze the handle

Sweep the fire

DO NOT use in BIG fire

Monthly inspection by the fire dept / security dept

Check expiration date

Label

Color of foam

Fire drill

Q 6-12mons

Search for fire

Wet linens, towels

Door , windows

Appliances

Fire wall door

Safety preparedness manual

Clinical pathways

Mandated by JCAHO

Care Pathways, Critical Pathways, Integrated Care Pathways, Care Maps

mgt tool based on evidence-based practice for specific group of pts with predictable clinical course

Different medical emergencies

shock

cardiopulmonary emergencies

neurological/neurosurgical emergencies

abdominal emergencies

genitourinary emergencies

ocular emergencies
musculoskeletal emergencies

poisoning and overdoses

environmental/temperature emergencies

multiple system trauma

Environmental/temperature “E”

Heat stroke

Heat exhaustion

Hypothermia

Frostbite

High altitude

Near drowning

Snake bites

Heat related illnessess

Heat exhaustion

Heat stroke

Risks :

Meds

Beta blockers, anticholinergics, ACE inhibitors, diuretics, amphetamines

Dehydration

Lack of sleep

Fatigue

Obesity

Strenuous exercise

Burns ( all degrees)

Seizures
Heat exhaustion

Syndrome caused by dehydration during heat exposure over hrs-days

Precursor to heat stroke

Not true medical “E”

s/s:

Flu like s/s + diaphoresis + GI s/s

Temp not significantly up (normal or subnormal)

Moist clammy skin

Heat exhaustion: Mgt

Bedrest in cool place; legs & feet up 12-18 inches

Constrictive clothing removed

ORS / sports drink (Gatorade) if alert

Cold packs ( neck, arm pits, chest, abd, groin)

Abundant blood supply

Soak person in cool water

Fan while spraying person’s skin

Crushed Na tabs dissolved in adeq H20

Prevent GI s/s

Prevent sun exposure (10a-4p); use suncreen SPF >15

If no improvement in 30 mins>= seek medical attention

Heat stroke

Failure of heat regulatory mechanism

Body temp exceeds 40.5 C (105 F)

>= organ dysfunction>= death

Risk factors:
Strenuous physical activity/ wearing thick clothing

in hot humid conditions

Chronic exposure to hot humid weather

s/s:

Dry, hot skin ; Neuro changes

Presence of sweat DOES NOT rule presence of heat stroke

Very high temp (>40.5)

Heat stroke: TX

Patent airway

Rapid cooling measures

Ice packs (neck, groins, arm pits)

Cold water immersion

Wet body with tepid H20 + rapid fanning

Stop cooling till temp drops to 102 F ( 38.8 C)

Prevent hypothermia

No ice immersion

>=shivering

Keep head , shoulders elevated

DO NOT give ASA / antipyretics

VS monitoring

Hydration

Monitor for seizure

Seek medical help ASAP

Hypothermia

Body temp is < 35 C (95 F) as a result to exposure to cold

TX:

Monitoring ABC

Rewarming

Supportive

Frost bite

Cold-related injury that may or may not be associated with hypothermia

Cause :

Inadequate insulation against cold

Skin exposed to cold

Insufficient clothing

Risk:

Smokers, ETOH, PVD

Early s/s:

White waxy areas on nose, cheeks, ears

High altitude illnesses

Elevations > 5K ft

>= O2 decreased

>= hypoxia

Acclimatization

Compensation to high altitude

3 conditions resulting from high altitude

Acute mountain sickness (AMS)

High altitude cerebral edema (HACE)

High altitude pulmo edema (HAPE)

Acclimatization
Compensation to high altitude

>= up RR rate

>= hypocapnia ( decreased C02)

>= resp alkalosis

>=limits further up in RR

>= hypoxia

>= pulmo constriction

>= up pulmo artery pressure

>= excrete excess bicarb (kidneys) (24-48hrs in hi altitude)

>=ph to normal

>= up RBC (up hgb concentration)

High altitude illness : TX

First aid:

Descent to lower altitude areas

1600 ft- 3300 ft

Rest

O2

Hosp tx:

Patent airway; O2

Carbonic anhydrase inhibitors (Acetazolamide<Diamox>)

Bicarb diuresis>= metabolic acidosis>= up RR

Dexamethasone

Furosemide

Decrease pulmo edema

Keep warm
Cold>= up pulmo artery pressure

Weakness , fatigue persist for 2 wks (expected)

Near drowning

Recovery post submersion

Leads to death by suffocation from submersion in the liquid medium (water)

Prevention:

No swimming alone

Test H20 depth before diving head 1st; never dive in shallow water

No ETOH

Enough H20 rescue equipment readily available

ANAPHYLACTIC REACTION

Acute systemic hypersensitivity reaction within few seconds/ minutes

Ex : meds, other agents (insect sting, bees), food

s/s:

resp s/s,

drop BP ( massive vasodilation)

TX:

patent airway

epinephrine SQ injection ffd by antiH2 drug

Poisoning

Swallowed poisons (corrosive)

Alkaline ( detergent, bleach, button batteries)

Acid (bowl cleaners, rust removers)

TX:

Offer 3 glasses of milk / water

to dilute poison

Bring unused poison to hospital for identification

Do not induce vomiting just keep on NPO

*** if not sure of cause of poisoning = CALL poison Call Center

Overdose

Ipecac (Ipecacuanha plant)

TX:

Ipecac to induce vomiting EXCEPT in corrosive substances

Gastric lavage

Send contents to lab for toxicology test

Activated Charcoal administration

Snake bites

Pit vipers (Crotalidae)

most frequent poisonous snake bites (triangular head)

Can cause multiple organ failure esp NEURO

TX:

immobilize injured part below the heart

Cleanse cover wound

DO NOT USE ice / tourniquet, heparin, corticosteroids during ACUTE stage (6-8 hrs)

No ETOH , caffeine

Up venom absorption

Never LEAVE patient; bring snake to hosp

Observe for 6 hrs

Shock

s/s: cool moist skin, falling BP, up HR, delayed capillary refill
TX :

ABC

Patent airway & maintain breathing

Determine cause

IVF & blood transfusion using LARGE bore cath

Monitoring

Lightning injuries

Single lightning stroke= >1M volts

High voltage= >1K volt

Produce injury by:

Direct striking

Splashing nearby strike area

Travel via ground (“step voltage)

Prevention : (during thunder storm)

Seek shelter

No use phone

Stay away from H20, metal objects, windows

Stay away from high powered voltage plants

Bio Crisis: Bioterrorism

Decontamination team wears special, protective gear

patients who were exposed are separated from others in emergency dept.

Decontamination team decontaminates the patients who were exposed

Bio crisis agents

Anthrax ( Bacillus anthracis)

Cutaneous (direct contact); GI; inhalation (pulmo)

Tx: Doxycycline ; Ciprofloxacin

SARS

Cause:Coronavirus: N95 mask

Bird flu (Avian influenza)

Tamiflu

Small pox

Cause: virus Variola

Mgt: Cidofovir

Bioterrorism