Nursing Management: Emergency and Disaster Nursing

Most patients with life-threatening or potentially life-threatening problems arrive at the hospital
through the emergency department (ED).

Triage refers to the process of rapidly determining the acuity of the patient’s problem, and it represents
one of the most important assessment skills needed by the emergency nurse.
 The triage process is based on the premise that patients who have a threat to life, vision, or limb
should be treated before other patients.
o A triage system categorizes patients so that the most critical ones are treated first.
o The Emergency Severity Index (ESI) is a 5-level triage system that incorporates
concepts of illness severity and resource utilization to determine who should be treated
first.

After the initial assessment to determine the presence of actual or potential threats to life,
appropriate interventions are initiated for the patient’s condition.

 The primary survey focuses on airway, breathing, circulation, and disability and serves to identify
life- threatening conditions so that appropriate interventions can be initiated.
 If life-threatening conditions related to airway, breathing, circulation, and disability are
identified at any point during the primary survey, interventions are started immediately and
before proceeding to the next step of the survey.
 Airway with cervical spine stabilization and/or immobilization:
▪ Primary signs and symptoms in a patient with a compromised airway include
dyspnea, inability to vocalize, presence of foreign body in the airway, and trauma
to the face or neck.
▪ Airway maintenance should progress rapidly from the least to the most invasive
method and includes opening the airway using the jaw-thrust maneuver,
suctioning and/or removal of foreign body, insertion of a nasopharyngeal or
oropharyngeal airway, and endotracheal intubation.
▪ The cervical spine must be stabilized and/or immobilized in any patient with face,
head, or neck trauma and/or significant upper torso injuries.
 Breathing:
▪ Breathing alterations are caused by many conditions (e.g., fractured ribs,
pneumothorax, allergic reactions, pulmonary emboli, asthma) resulting in dyspnea,
paradoxical or asymmetric chest wall movement, decreased or absent breath
sounds, cyanosis, tachycardia, and hypotension.
▪ High-flow oxygen (100%) via a non-rebreather mask should be administered and
the patient’s response monitored. Life-threatening conditions may require bag-
valve-mask ventilation with 100% oxygen and intubation.
 Circulation:
▪ A central pulse is checked because peripheral pulses may be absent as a result of
direct injury or vasoconstriction.
▪ Skin is assessed for color, temperature, and moisture.
▪ Altered mental status and delayed capillary refill are the most significant signs of shock.
▪ Two large-bore IV catheters should be inserted and aggressive fluid resuscitation
initiated using normal saline or lactated Ringer’s solution.
 Disability:
▪ The degree of disability is measured by the patient’s level of consciousness.
 ▪ A simple mnemonic can be used: AVPU: A = alert, V = responsive to
voice, P = responsive to pain, and U = unresponsive.
▪ The Glasgow Coma Scale is used to further assess the arousal aspect of the
patient’s consciousness.
▪ Pupils are assessed for size, shape, response to light, and equality.

 The secondary survey is a brief, systematic process that is aimed at identifying all injuries.
 Exposure/environmental control. All trauma patients should have their clothes removed so
that a thorough physical assessment can be performed.
 Full set of vital signs/five interventions/facilitate family presence:
▪ A complete set of vital signs, including blood pressure, heart rate, respiratory
rate, and temperature, is obtained after the patient is exposed.
▪ Five interventions: 1) ECG monitoring is initiated; 2) pulse oximetry is initiated; 3)
an indwelling catheter is inserted; 4) an orogastric or a nasogastric tube is inserted;
5) blood for laboratory studies is collected.
▪ Family presence: family members who wish to be present during invasive
procedures and resuscitation view themselves as active participants in the care
process and their presence should be supported.
 Give comfort measures. Pain management strategies should include a
combination of pharmacologic and nonpharmacologic measures.
 History and head-to-toe assessment:
▪ A thorough history of the event, illness, injury is obtained from the patient, family,
and emergency personnel.
▪ A thorough head-to-toe assessment is necessary.
 Inspect the posterior surfaces. The trauma patient should be logrolled (while maintaining
cervical spine immobilization) to inspect the posterior surfaces.

All patients should be evaluated to determine their need for tetanus prophylaxis.

Ongoing patient monitoring and evaluation of interventions are critical and the nurse is
responsible for providing appropriate interventions and assessing the patient’s response.

Depending on the patient’s injuries and/or illness, the patient may be (1) transported for diagnostic tests
such as x-ray or CT scan; (2) admitted to a general unit, telemetry, or intensive care unit; or (3)
transferred to another facility.

DEATH IN THE EMERGENCY DEPARTMENT

The emergency nurse should recognize the importance of certain hospital rituals in preparing the bereaved
to grieve, such as collecting the belongings, arranging for an autopsy, viewing the body, and making
mortuary arrangements.

Many patients who die in the ED could potentially be a candidate for non–heart beating donation;
certain tissues and organs such as corneas, heart valves, skin, bone, and kidneys can be harvested
from patients after death.

GERONTOLOGIC CONSIDERATIONS: EMERGENCY CARE

 Elderly people are at high risk for injury primarily from falls.

The three most common causes of falls in the elderly are generalized weakness, environmental
hazards, and orthostatic hypotension.

When assessing a patient who has experienced a fall, it is important to determine whether the physical
findings may have actually caused the fall or may be due to the fall itself.

HEAT EXHAUSTION
 Prolonged exposure to heat over hours or days leads to heat exhaustion, a clinical syndrome
characterized by fatigue, light-headedness, nausea, vomiting, diarrhea, and feelings of impending
doom.
 Tachypnea, hypotension, tachycardia, elevated body temperature, dilated pupils, mild
confusion, ashen color, and profuse diaphoresis are also present.
 Hypotension and mild to severe temperature elevation (99.6º to 104º F [37.5º to 40º C]) are
due to dehydration.

 Treatment begins with placement of the patient in a cool area and removal of constrictive clothing.

 Oral fluid and electrolyte replacement is initiated unless the patient is nauseated; a 0.9% normal
saline IV solution is initiated when oral solutions are not tolerated.

 A moist sheet placed over the patient decreases core temperature.

HEATSTROKE

Heatstroke results from failure of the hypothalamic thermoregulatory processes.

Increased sweating, vasodilation, and increased respiratory rate deplete fluids and electrolytes,
specifically sodium.
 Eventually, sweat glands stop functioning, and core temperature increases (>104º F (40º C).
 Altered mentation, absence of perspiration, and circulatory collapse can follow.
 Cerebral edema and hemorrhage may occur as a result of direct thermal injury to the brain.

Treatment focuses on stabilizing the patient’s ABCs and rapidly reducing the temperature.

Various cooling methods include removal of clothing, covering with wet sheets, and placing the patient in
front of a large fan; immersion in an ice water bath; and administering cool fluids or lavaging with
cool fluids.

Shivering increases core temperature, complicating cooling efforts, and is treated with IV chlorpromazine.

Aggressive temperature reduction should continue until core temperature reaches 102º F (38.9º C).
 Patients are monitored for signs of rhabdomyolysis, myoglobinuria, and disseminated intravascular
coagulation.

HYPOTHERMIA

Hypothermia is defined as a core temperature <95º F (35º C).

The elderly are more prone to hypothermia, and certain drugs, alcohol, and diabetes are considered risk
factors for hypothermia.
Core temperature below 86º F (30º C) is a severe and potentially life-threatening situation.
 Patients with mild hypothermia (93.2º to 96.8º F [34º to 36º C]) have shivering,
lethargy, confusion, rational to irrational behavior, and minor heart rate changes.
 Shivering disappears at temperatures below 92º F (33.3º C). Moderate hypothermia (86º to
93.2º F [30º to 34º C]) causes rigidity, bradycardia, slowed respiratory rate, blood pressure
obtainable only by Doppler, metabolic and respiratory acidosis, and hypovolemia.
 Coma results when the core temperature falls below 82.4º F (28º C), and death usually
occurs when the core temperature is below 78º F (25.6º C).
 Profound hypothermia (below 86º F [30º C]) makes the person appear dead.
Profound bradycardia, asystole, or ventricular fibrillation may be present.

Every effort is made to warm the patient to at least 90º F (32.2º C) before the person is pronounced dead.
The cause of death is usually refractory ventricular fibrillation.

Treatment of hypothermia focuses on managing and maintaining ABCs, rewarming the patient, correcting
dehydration and acidosis, and treating cardiac dysrhythmias.
 Passive or active external rewarming is used for mild hypothermia.
▪ Passive external rewarming involves moving the patient to a warm, dry
place, removing damp clothing, and placing warm blankets on the
patient.
▪ Active external rewarming involves body-to-body contact, fluid- or air-
filled warming blankets, or radiant heat lamps.
 Active core rewarming is used for moderate to profound hypothermia and refers to the
use of heated, humidified oxygen; warmed IV fluids; and peritoneal, gastric, or colonic
lavage with warmed fluids.

Rewarming places the patient at risk for afterdrop, a further drop in core temperature, and can result in
hypotension and dysrhythmias.

Rewarming should be discontinued once the core temperature reaches 95º F (35º C).

SUBMERSION INJURY

Submersion injury results when a person becomes hypoxic due to submersion in a substance, usually water.

Drowning is death from suffocation after submersion in water or other fluid medium. Near-drowning is
 defined as survival from potential drowning. Immersion syndrome occurs with immersion in cold
water, which leads to stimulation of the vagus nerve and potentially fatal dysrhythmias.

Aggressive resuscitation efforts and the mammalian diving reflex improve survival of near-drowning
victims even after submersion in cold water for long periods of time.

Treatment of submersion injuries focuses on correcting hypoxia, acid-base imbalances, and fluid
imbalances; supporting basic physiologic functions; and rewarming when hypothermia is present.
 Initial evaluation involves assessment of airway, cervical spine, breathing, and circulation.
 Mechanical ventilation with positive end-expiratory pressure or continuous positive
airway pressure may be used to improve gas exchange across the alveolar-capillary
membrane when
significant pulmonary edema is present.

Deterioration in neurologic status suggests cerebral edema, worsening hypoxia, or profound acidosis.

All victims of near-drowning should be observed in a hospital for a minimum of 4 to 6 hours. Delayed
pulmonary edema (also known as secondary drowning) can occur and is defined as delayed death
from drowning due to pulmonary complications.

ANIMAL BITES
Children are at greatest risk for animal bites, and the most significant problems associated with animal
bites are infection and mechanical destruction of the skin, muscle, tendons, blood vessels, and bone.

Animal bites from dogs and cats are the most common, followed by bites from wild or domestic rodents.

Cat bites cause deep puncture wounds that can involve tendons and joint capsules and result in a
greater incidence of infection. Septic arthritis, osteomyelitis, and tenosynovitis are common.

Human bites also cause puncture wounds or lacerations and carry a high risk of infection from oral
bacterial flora and the hepatitis virus.
 Hands, fingers, ears, nose, vagina, and penis are the most common sites of human
bites and are frequently a result of violence or sexual activity.
 Boxer’s fracture, fracture of the fourth or fifth metacarpal, is often associated with an
open wound when the knuckles strike teeth.

Initial treatment for animal and human bites includes cleaning with copious irrigation, debridement, tetanus
prophylaxis, and analgesics as needed.
 Prophylactic antibiotics are used for animal and human bites at risk for infection such as
wounds over joints, those more than 6 to 12 hours old, puncture wounds, and bites of the
hand or foot.
 Puncture wounds are left open, lacerations are loosely sutured, and wounds over
joints are splinted.
 Consideration of rabies prophylaxis is an essential component in the management of
animal bites. An initial injection of rabies immune globulin is given, followed by a
series of five injections of human diploid cell vaccine on days 0, 3, 7, 14, and 28 to
provide active immunity.
POISONINGS
A poison is any chemical that harms the body, and poisoning can be accidental, occupational, recreational,
or intentional.

Severity of the poisoning depends on type, concentration, and route of exposure.

Specific management of toxins involves decreasing absorption, enhancing elimination, and

implementation of toxin-specific interventions per the local poison control center
 Options for decreasing absorption of poisons include gastric lavage, activated
charcoal, dermal cleansing, and eye irrigation.
▪ Patients with an altered level of consciousness or diminished gag reflex must be
intubated before lavage.
▪ Lavage must be performed within 2 hours of ingestion of most poisons and is
contraindicated in patients who ingested caustic agents, co-ingested sharp
objects, or ingested nontoxic substances.
▪ The most effective intervention for management of poisonings is
administration of activated charcoal orally or via a gastric tube within 60
minutes of poison ingestion.
 Contraindications to charcoal administration are diminished bowel
sounds, ileus, or ingestion of a substance poorly absorbed by charcoal.
 Charcoal can absorb and neutralize antidotes, and these should not be
given immediately before, with, or shortly after, charcoal.
 Skin and ocular decontamination involves removal of toxins from eyes and skin using
copious amounts of water or saline. With the exception of mustard gas, most toxins can
be safely removed with water or saline.
▪ Water mixes with mustard gas and releases chlorine gas.
▪ Decontamination takes priority over all interventions except basic life
support techniques.
 Elimination of poisons is increased through administration of cathartics, whole-bowel
irrigation, hemodialysis, hemoperfusion, urine alkalinization, chelating agents, and
antidotes.
▪ A cathartic such as sorbitol is given with the first dose of activated
charcoal to stimulate intestinal motility and increase elimination.
▪ Hemodialysis and hemoperfusion are reserved for patients who develop
severe acidosis from ingestion of toxic substances.

VIOLENCE
 Violence is the acting out of the emotions of fear or anger to cause harm to someone or something.
 It may be the result of organic disease, psychosis, or antisocial behavior.
 Violence can take place in a variety of settings, including the home, community, and
workplace. EDs have been identified as high-risk areas for workplace violence.

 Domestic violence is a pattern of coercive behavior in a relationship that involves fear,

humiliation, intimidation, neglect, and/or intentional physical, emotional, financial, or sexual
injury.
 It is found in all professions, cultures, socioeconomic groups, ages, and both genders;
although men can be victims of domestic violence, most victims are women, children, and
the elderly.
 It has been reported that 1.5 million women and 834,000 men treated at EDs have been battered
(assaulted) by spouses, significant others, or individuals known to them.
  Screening for domestic violence is required for any patient who is found to be a victim of abuse.
Appropriate interventions should be initiated, including making referrals, providing emotional
support, and informing victims about their options.

AGENTS OF TERRORISM
 Terrorism involves overt actions such as the dispensing of disease pathogens (bioterrorism) or other
agents (e.g., chemical, radiologic/nuclear, explosive devices) as weapons for the expressed purpose of
causing harm.
 The pathogens most likely to be used in a bioterrorist attack are anthrax, smallpox,
botulism, plague, tularemia, and hemorrhagic fever.
▪ Those agents that cause anthrax, plague, and tularemia can be treated effectively
with commercially available antibiotics if sufficient supplies are available and the
organisms are not resistant.
▪ Smallpox can be prevented or ameliorated by vaccination even when first given after
exposure.
▪ Botulism can be treated with antitoxin.
▪ There is no established treatment for viruses that cause hemorrhagic fever.
 Chemicals used as agents of terrorism are categorized according to their target organ or effect.
▪ Sarin is a highly toxic nerve gas that can cause death within minutes of exposure.
Sarin enters the body through the eyes and skin and acts by paralyzing the
respiratory muscles; antidotes for nerve agent poisoning include atropine and
pralidoxime chloride.
▪ Phosgene is a colorless gas normally used in chemical manufacturing. If inhaled at
high concentrations for a long enough period, it causes severe respiratory distress,
pulmonary edema, and death.
▪ Mustard gas is yellow to brown in color and has a garlic-like odor. The gas
irritates the eyes and causes skin burns and blisters.
 Radiologic/nuclear agents represent another category of agents of terrorism.
▪ Radiologic dispersal devices, (RRD) also known as “dirty bombs,” consist of a
mix of explosives and radioactive material.
▪ When the device is detonated, the blast scatters radioactive dust, smoke, and
other material into the surrounding environment resulting in radioactive
contamination.
▪ The main danger from an RRD results from the explosion. The radioactive materials
used in an RRD do not usually generate enough radiation to cause immediate serious
illness, except to those casualties who are in close proximity to the explosion.
▪ Since radiation cannot be seen, smelled, felt, or tasted, measures to limit
contamination and decontamination should be initiated.
 Ionizing radiation (e.g., nuclear bomb, damage to a nuclear reactor) represents a serious
threat to the safety of the casualties and the environment.
▪ Exposure to ionizing radiation may or may not include skin contamination with
radioactive material; if external radioactive contaminants are present,
decontamination procedures must be initiated immediately.
▪ Acute radiation syndrome develops after a substantial exposure to ionizing
radiation and follows a predictable pattern.
 Explosive devices used as agents of terrorism result in one or more of the following
types of injuries: blast, crush, or penetrating.
▪ Blast injuries result from the supersonic over-pressurization shock wave that
occurs following the explosion, causing damage to the lungs, middle ear, and
gastrointestinal tract.
 ▪ Crush injuries often result from explosions that occur in confined spaces and result
from structural collapse.
▪ Some explosive devices contain materials that are projected during the explosion,
leading to penetrating injuries.

EMERGENCY AND MASS CASUALTY INCIDENT PREPAREDNESS

The term emergency usually refers to any extraordinary event that requires a rapid and skilled response and
that can be managed by a community’s existing resources.

An emergency is differentiated from a mass casualty incident (MCI) in that an MCI is a manmade (e.g.,
biologic warfare) or natural (e.g., hurricane) event or disaster that overwhelms a community’s ability
to respond with existing resources.
 MCIs usually involve large numbers of casualties, involve physical and emotional
suffering, and result in permanent changes within a community.
 MCIs always require assistance from people and resources outside the affected
community (e.g., American Red Cross, Federal Emergency Management Agency
[FEMA]).
When an emergency or MCI occurs, first responders (i.e., police, emergency medical personnel) are
dispatched to the scene.
 Triage of casualties of an emergency or MCI differs from the usual triage that occurs in
the ED and must be conducted in less than 15 seconds.
 A system of colored tags is used to designate both the seriousness of the injury and the
likelihood of survival.
▪ A green (minor injury) or yellow (non–life-threatening injury) tag is used to
indicate a non-critical injury.
▪ A red tag indicates a life-threatening injury requiring immediate intervention.
▪ A black tag is used to identify those casualties who are deceased or who are
expected to die.
 Casualties need to be treated and stabilized, and if there is known or suspected
contamination, decontaminated at the scene, and then transported to hospitals.
 Many casualties will arrive at hospitals on their own (i.e., walking wounded).
 The total number of casualties a hospital can expect is estimated by doubling the
number of casualties that arrive in the first hour.
 Generally, 30% of casualties will require admission to the hospital, and 50% of these will
need surgery within 8 hours.

 Many communities have initiated programs to develop community emergency response teams (CERTs).
 CERTs have been recognized by FEMA as important partners in emergency preparedness,
and the training helps citizens to understand their personal responsibility in preparing for a
natural or manmade disaster.
 Citizens are taught what to expect following a disaster and how to safely help themselves,
their family, and their neighbors.
 Training includes the teaching of life-saving skills, with an emphasis on decision-
making and rescuer safety.

All health care providers have a role in emergency and MCI preparedness, and knowledge of the hospital’s
emergency response plan and participation in emergency/MCI preparedness drills are required.
 Response to MCIs often requires the aid of a federal agency such as the National Disaster Medical
System (NDMS), which is a division within the U.S. Department of Homeland Security that is
responsible for the coordination of the federal medical response to MCIs.
 One component of the NDMS is to organize and train volunteer disaster medical
assistance teams (DMATs).
▪ DMATs are categorized according to their ability to respond to an MCI. A Level-1
DMAT can be deployed within 8 hours of notification and remain self-sufficient for
72 hours with enough food, water, shelter, and medical supplies to treat about 250
patients per day.
▪ Level-2 DMATs lack enough equipment to be self-sufficient but are used to
replace a Level-1 team, using and supplementing the equipment left on site.
Many hospitals and DMATs have a critical incident stress management unit that arranges group discussions to
allow participants to verbalize and validate their feelings and emotions about the experience to facilitate psychologic
recovery.