focus on emergency and disaster nursing copyright © 2011, 2007 by mosby, inc., an affiliate of...

Focus onEmergency and Disaster Nursing

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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Emergency Nursing

Patients- with life-threatening/potentially life-threatening problems enter hospital through the emergency department (ED).


•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


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


•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


•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.

Google

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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.


Study Supports Allowing Family Members i

n ED During Critical Care

http://www.aap.org/en-us/about-the-aap/aap-press-room/pages/Study-Supports-Allowing-Family-Members-in-ED-During-Critical-Care.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3A+No+local+token

http://www.aap.org/en-us/about-the-aap/aap-press-room/pages/Study-Supports-Allowing-Family-Members-in-ED-During-Critical-Care.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3A+No+local+token

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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.


http://www.adhb.govt.nz/trauma/t_guidelines/secondary_survey.htm

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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

http://www.unos.org/

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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


•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


Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 29

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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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


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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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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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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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


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


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


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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