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Focus onEmergency and Disaster Nursing
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
2
Emergency Nursing
Patients- with life-threatening/potentially life-threatening problems enter hospital through the emergency department (ED).
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
•TriageProcess of rapidly determining patient acuity Represents a critical assessment skill
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Emergency Nursing
Triage system: categorizes patients so most critical treated first
Emergency Severity Index: Five-level triage system that incorporates illness severity and resource utilization
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Emergency System Index Triage Algorithm
4Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Who to see first?
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Emergency Nursing
Primary survey- focus on airway, breathing, circulation, and disability, exposure (ABCDE)
Identifies life-threatening conditions If life-threatening conditions related
to ABCD identified during primary survey-
interventions started immediately -before procede to next step of survey.
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Primary Survey Airway with cervical spine stabilization and/or
immobilization Signs/symptoms compromised airway
Dyspnea Inability to vocalize Presence of foreign body in airway Trauma to face or neck
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•Maintain airway: least to most invasive method Open airway using jaw-thrust maneuver.Suction and/or remove foreign body.Insert nasopharyngeal/oropharyngeal airway.Provide endotracheal intubation
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Primary Survey
Rapid-sequence intubation Preferred procedure for unprotected
airway- Involves sedation or anesthesia and paralysis
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Jaw-Thrust Maneuver
Fig. 69-2. Jaw-thrust maneuver is the recommended procedure for opening the airway of unconscious patient with a possible neck or spinal injury. Patient should be lying supine with rescuer kneeling at top of the head. Rescuer places one hand on each side of patient’s head, resting his or her elbows on the surface. Rescuer grasps the angles of patient’s lower jaw and lifts the jaw forward with both hands without tilting the head.
Fig. 69-3. Cricoid pressure. Firm downward pressure on the cricoid ring pushes the vocal cords downward toward the field of vision while sealing the esophagus against
vertebral column.
Cricoid Pressure
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Primary Survey
Stabilize/immobilize cervical spine. Face, head, or neck trauma and/or
significant upper torso injuries
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•Breathing Assess for dyspnea, cyanosis, paradoxic/ asymmetric chest wall movement, dec/absent breath sounds, tachycardia, hypotension •Adm high-flow O2 via a non-rebreather mask; Bag-valve-mask (BVM) ventilation with 100% O2 and intubation for life-threatening conditions •Monitor patient response.
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Primary Survey
CirculationCheck central pulse (peripheral pulses may
be absent dt injury or vasoconstriction).Insert two large-bore IV catheters. Initiate aggressive fluid resuscitation using
normal saline or lactated Ringer’s solution
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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 Pupils
Exposure/environmental control Remove clothing to perform physical
assessment. Prevent heat loss.
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Secondary Survey
Brief, systematic process to identify all injuries Full set of vital signs/Five interventions/ Facilitate
family presence Complete set of vital signs
Blood pressure (bilateral) Heart rate Respiratory rate Oxygen saturation Temperature Initiate ECG monitoring. Insert indwelling catheter. Insert orogastric/nasogastric tube. Collect blood for laboratory studies.
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Secondary Survey Full set of vital signs/Five
interventions/Facilitate family presence (cont’d) *Family presence: family members who wish
to be present during invasive procedures/resuscitation view themselves as participants in care-Their presence should be supported.
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Study Supports Allowing Family Members i
n ED During Critical Care
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Secondary Survey Give comfort measures.
Pain management strategies— combination of
Pharmacologic measures Nonpharmacologic measures
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
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Secondary Survey
Inspect the posterior surfaces. Logroll patient (while maintaining cervical spine
immobilization) to inspect posterior surfaces.
Evaluate need for tetanus prophylaxis.
Provide ongoing monitoring, and evaluate patient’s response to interventions.
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Secondary Survey Prepare to
Transport for diagnostic tests (e.g., x-ray) Admit to general unit, telemetry, or intensive
care unit Transfer to another facility
Must recognize importance of hospital rituals in preparing the bereaved to grieve (e.g., collecting belongings, viewing the body)
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Death in the Emergency Department Determine if patient-a candidate for non–
heart beating donation. Tissues and organs (e.g., corneas, heart
valves, skin, bone, kidneys) can be
harvested from patient after death.
UNOS
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Gerontologic Considerations: Emergency Care
Elderly-at high risk for injury—esp from falls. Causes
Generalized weakness Environmental hazards Orthostatic hypotension
Important- determine if physical findings may have caused fall or may be due to fall
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Heat Exhaustion
Prolonged exposure to heat over hours or days
Leads to heat exhaustion Clinical syndrome characterized
by FatigueLight-headednessNausea/vomitingDiarrheaFeelings of impending doom Tachypnea
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•Tachycardia•Dilated pupils•Mild confusion•Ashen color•Profuse diaphoresis •Hypotension•Mild to severe temp inc (99.6º to 104º F [37.5º to 40º C]) due to dehydration
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Heat Exhaustion
Place patient in cool area and remove constrictive clothing.
Place moist sheet over patient to dec core temperature.
Provide oral fluid. Replace electrolytes. Initiate normal saline IV solution if oral
solutions are not tolerated. *Salt tablets not used dt potential gastric
irritation and hypernatremia. Potential hospital admission if not improved in
3-4 hrs
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Heatstroke
Failure of hypothalamic thermoregulatory processes
Vasodilation, inc sweating, respiratory rate >deplete fluids/electrolytes esp sodium.
Sweat glands stop functioning, and core temperature inc (>104º F [40º C]).
Treatment: stabilize ABCs/rapidly reduce temp Cooling methods
Remove clothing; cover with wet sheets. Place patient in front of large fan. Immerse in ice water bath. Administer cool fluids or lavage with cool fluids.
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Heatstroke
Shivering: inc core temperature, complicates cooling efforts, treated with IV chlorpromazine
Aggressive temperature reduction until core temperature reaches 102º F (38.9º C)
Monitor for signs of rhabdomyolysis, myoglobinuria, and disseminated intravascular coagulation.
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Hypothermia Core temperature <95º F (<35º C) Risk factors
Elderly; Certain drugs Alcohol; Diabetes
Core temperature <86º F (30º C)-potentially life-threatening.
Mild hypothermia (93.2º to 96.8º F [34º to 36º C]) Shivering; Lethargy; Confusion Rational to irrational behavior Minor heart rate changes
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Hypothermia Moderate hypothermia (86º to 93.2º F [30º to 34º
C]) Rigidity Bradycardia, bradypnea Blood pressure by Doppler Metabolic and respiratory acidosis Hypovolemia Shivering disappears at temperature
86º F (30º C). Severe hypothermia (<86º F [30º C])-person
appears dead. Bradycardia Asystole Ventricular fibrillation
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Hypothermia Warm patient to at least 90º F (32.2º C) before
pronouncing dead. Cause of death—refractory ventricular
fibrillation Treatment of hypothermia
Manage and maintain ABCs. Rewarm patient. Correct dehydration and acidosis. Treat cardiac dysrhythmias.
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Hypothermia Mild hypothermia: passive/active external re-warming
Passive external rewarming: Move to warm, dry place; remove damp clothing; apply warm blankets
Active external re-warming: body-to-body contact, fluid- or air-filled warming blankets, radiant heat lamps
Moderate to severe hypothermia Use heated, humidified oxygen; warmed IV fluids Peritoneal, gastric, colonic lavage with warmed fluidsConsider cardiopulmonary bypass or continuous
arteriovenous rewarming in severe hypothermia.
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Hypothermia
Risks of rewarming Afterdrop, a further drop in core temperature Hypotension Dysrhythmias
Rewarming should be discontinued once core temperature reaches 95º F (35º C).
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Submersion Injury
Results when person becomes hypoxic as result of submersion in substance, usually water
Drowning: death from suffocation after submersion in fluid Immersion syndrome occurs with immersion
in cold water > leads to stimulation of vagus nerve and potentially fatal dysrhythmias.
Near-drowning: survival from potential drowning
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Aggressive resuscitation efforts and the mammalian diving reflex improve survival of near-drowning
victims.
Treatment of submersion injuriesCorrect hypoxia.Correct acid-base/fluid imbalances.Support basic physiologic functions.Rewarm if hypothermia present.
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Submersion Injury
Initial evaluation: ABCD Mechanical ventilation with PEEP or CPAP to
improve gas exchange when pulmonary edema is present
Deterioration in neurologic status: cerebral edema, worsening hypoxia, profound acidosis
Observe for minimum of 4 to 6 hours. Secondary drowning-a concern with patients
who are essentially symptom-free- pulmonary
complications.
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Animal Bites Children at greatest risk Animal bites from dogs and cats- most common,
followed by bites from wild or domestic rodents. Complications
Infection Mechanical destruction of skin, muscle,
tendons, blood vessels, bone Dog bites-usually occur on extremities
May involve significant tissue damage Deaths are reported, usually children
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Animal Bites
Cat bites: deep puncture wounds that can involve tendons and joint capsules Greater incidence of infection
Septic arthritis Osteomyelitis Tenosynovitis
Result in puncture wounds or lacerations High risk of infection
Oral bacterial flora Hepatitis virus
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Animal and 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
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Animal and Human Bites
Rabies prophylaxis essential in mgt of animal bites Initial injection: rabies immune globulin Series of five injections of human diploid
cell vaccine: days 0, 3, 7, 14, and 28
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Poisonings
Chemicals that harm the body accidentally, occupationally, recreationally, or intentionally
Severity depends on type, concentration, and
route of exposure. Management
Dec absorption. Enhance elimination. Implement toxin-specific interventions per
poison control center.
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Poisonings Dec absorption
Gastric lavage 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 Ingested nontoxic substances
Activated charcoal Most effective intervention: adm orally or via gastric tube within
60 minutes of poison ingestion Contraindications
Diminished bowel sounds Paralytic ileus Ingestion of substance poorly absorbed by charcoal
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Poisonings Activated charcoal Charcoal can absorb/neutralize antidotes: do not
give immediately before, with, or shortly after charcoal
Dermal cleansing/eye irrigation Skin/ocular decontamination: removal of toxins
from skin/eyes using water or saline With the exception of mustard gas, toxins can be
removed with water/saline. Water mixes with mustard gas and releases
chlorine gas . **Decontamination takes priority over all
interventions except basic life support measures.
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Poisonings
Enhance elimination. Cathartics (e.g., sorbitol)
Give with first dose of charcoal to stimulate intestinal motility/increase elimination.
Whole-bowel irrigation Hemodialysis/hemoperfusion
Reserved for severe acidosis Urine alkalinization Chelating agents Antidotes
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Violence
Acting out of emotions (e.g., fear or anger) to cause harm to someone or something Organic disease Psychosis Antisocial behavior
Pattern of coercive behavior in a relationship; involves fear, humiliation, intimidation, neglect, and/or intentional physical, emotional, financial, or sexual injury
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Family and Intimate Partner Violence 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 Make referrals. Provide emotional support. Inform victims about options
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Terrorism
Involves overt actions for expressed purpose of causing harm Disease pathogens (e.g., bioterrorism) Chemical agents Radiologic/nuclear, explosive devices
Anthrax, plague, and tularemia: trt with antibiotics, assuming sufficient supplies/ nonresistant organisms
Smallpox-can prevent or ameliorated by vaccination even when first given after exposure.
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42Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
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Chemical Agents of Terrorism
Categorized by target organ or effect Sarin: toxic nerve gas >cause death within
minutes of exposure Enters body through eyes/skin Acts by paralyzing respiratory muscles
Antidotes for nerve agents: atropine, pralidoxime chloride
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Chemical Agents of Terrorism
Phosgene: colorless gas normally used in chemical manufacturing
If inhaled at high concentrations for long enough period >severe respiratory distress, pulmonary edema >death
Mustard gas: yellow to brown in color with garlic-like odor
Irritates eyes and causes skin burns/blisters
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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>radioactive contamination.
Main danger from RRDs: explosion Ionizing radiation (e.g., nuclear bomb, damage to nuclear
reactor): serious threat to safety of casualties and environment Exposure may or may not include skin contamination with
radioactive material.
Initiate decontamination procedures immediately if external radioactive contaminants are present.
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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 lungs, middle ear, gastrointestinal
tract Emergency: any extraordinary event that requires a
rapid and skilled response and can be managed by a community’s existing resources Mass casualty incident (MCI)
Manmade or natural event or disaster that overwhelms community’s ability to respond with existing resources
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American Red Cross
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Fig. 69-8. American Red Cross.
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Emergency and Mass Casualty Incident Preparedness
When an emergency or MCI occurs, first responders (e.g., police, emergency medical personnel) are dispatched. Triage of casualties differs from usual ED triage-is
conducted in <15 seconds. System of colored tags designates both seriousness of
injury and likelihood of survival. Green (minor injury) Yellow (urgent tag-noncritical injury. Red tag- life-threatening injury. Blue tag indicates those who are expected to die. Black tag identifies the dead.
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Emergency and Mass Casualty Incident Preparedness
Casualties need to be treated/stabilized. If known or suspected contamination,
decontaminate at scene, then transport to hospitals.
Many casualties will arrive at hospitals on their own (i.e., “walking wounded”).
Total number of casualties a hospital can expect-est by doubling #casualties that arrive in 1st hour. Generally, 30%-require admission to
hospital, 1/2 will need surgery within 8 hours.
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Emergency and Mass Casualty Incident Preparedness
Communities have initiated programs to develop community emergency response teams (CERTs). CERTs-partners in emergency preparedness-
training helps citizens to understand their personal responsibility in preparing for natural/manmade disaster.
All health care providers have role in emergency and MCI preparedness. Knowledge of the hospital’s emergency
response plan Participation in emergency/MCI preparedness
drills is required
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51
Emergency and Mass Casualty Incident Preparedness
Response to MCIs often requires aid of federal agency such as the National Incident Management System (NIMS). Section within U.S. Department of Homeland Security-
responsible for coordination of federal medical response to MCIs
National Disaster Medical System: organizes and trains volunteer disaster medical assistance teams (DMATs) DMATs: categorized according to ability to respond to an MCI
While performing triage in the emergency department, the nurse determines that which of the following patients should be seen first?
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.
Question
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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:
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.
Question
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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:
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.
Question
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Case Study
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Case Study
32-year-old female arrives to ED via paramedics. A neighbor found her lying on the rocks in the
rock garden. She had fallen off the roof while fixing the shingles on her house.
A large stick is protruding through the skin at lower leg.
The paramedics report that she was found in large pool of blood. Unresponsive, BP 60/42, HR 168
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Discussion Questions
1. What potential life-threatening injuries does she have?
2. What is the priority of care?
3. What interventions are needed immediately?
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