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Emergency Management
Care that is being given to clients with urgent and critical needs. This is not like
nursing on the floor.
An emergency is whatever the client or their family considers it to be. Not
everyone that comes into the emergency room is an emergency, but you still
have to treat people courteously because this is an emergency to them even if
we don’t think it is.
This type treatment is provided under the direction of a physician or Emergency
Nurse Practitioner. Hopefully you have a real ER doctor with real ER nurses,
however; if you work at many places your ER doctor is a Rent-a-Doctor. If you
are an experienced ER nurse, you may have to step in a save someone’s life
because the Rent-a-Doctor is not trained in emergency medicine.
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have to be able to think and act in a hurry. You also need to know what
you can do also and what is within your scope of practice.
Documentation
o This is “HUGE”. ER documentation frequently ends up in criminal cases.
ER’s are frequently sued. Your documentation could very likely end up in
court.
Technical nursing skills
o Need to have excellent technical clinical skills, you don’t have time to go
slow and try to figure things out. If you are not proficient in your technical
skills, you need to get some experience and then work in the ER.
Ability to think quickly
o Need to be confident enough to think quickly and act on it.
Problem solving skills
o A lot of problem solving goes on in the ER, especially if you are working in
a larger and busier emergency rooms.
Ability to deal with death and dying
o You will see death and dying in the ER. Most families have not had the
time to prepare for a death therefore; there will be a lot of drama, anger
and grief. These things can present themselves in many different ways.
o When you deal with death on a daily basis, need to learn how to cope with
it. Sometimes the ER staff will do things like laughing at things they
shouldn’t, while this is inappropriate, it is a coping method for most of
them.
Special certifications
o ACLS (Advanced Cardiac Life Support)
o CEN (Certified Emergency Room Nurse)
o CCRN (Critical Care Nursing)
o PALS (Pediatric Advanced Life Support)
If you work in the ER, you must know the norms for all age groups. Most
emergency rooms see the client from the womb to the tomb. You need to know
the appropriate pediatric doses, the appropriate pediatric injection sites. You
need to know the vital signs for all of the age groups.
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system came up with 911 for emergency. As a result of this there is much
more emergency access and care.
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Emergency Department (ED) Classifications
Level I Trauma Center – we have one in Mississippi; it is the University Medical
Center. A Level I trauma center has 24/7 nurses and physicians. They have a
24/7 OR. They have a 24/7 diagnostics. You don’t have to wait for them to
call for an x-ray, x-rays are taken right there. They have the capability to
transport critically ill people to their institution. This could simply mean an
ambulance. We would like to think it was a helicopter, but it only needs to be
an ambulance. 24/7 whatever you need. In a Level I trauma center, you have
a bunch of ER physicians.
Level II – not really a trauma center, Level II is an emergency department; they
have 24 hour ER coverage by an RN and a physician. Level II, you may have
an ER physician, it might be a family practice physician. They have to be able
to give specialty consultation within 30 minutes. This means that you come in
with the open femur fracture, there will be a physician there to order some
blood work, x-rays, pain medicine and when they get on the phone, the
orthopedic surgeon can be there in 30 minutes.
Level III – You have 24 hour coverage with an RN and a doctor can get there
within 30 minutes. This is the doctor down the road. About all you can do
here as a nurse is know your ACLS protocol and try to save lives.
Level IV – This is where they have emergency service that offers reasonable
care in determining if an emergency actually exists. In other words, when you
go there, they can decide if they need to call 911. Level IV is going to be
hospitals way out in the rural communities. Level IV is a band aid station. We
are seeing more and more of these.
ED Layout
Triage area – to sort out clients – this is where the first decision is made as to
where you are going to live or die or keep that limb is going to be made. This
is where they sort the patients out and they decide who needs to be seen now
and who has to wait. Many places, you have to get by the guard first.
Trauma Room – this is where the trauma is usually going to go. There is usually
going to be one major trauma room and they have everything in there (trach
trays, they open chests in there). It is almost like a mini OR. It is a major busy
area.
Orthopedic Room – this is where they put on the casts and splints
Suture Room/Spot – good lighting in the room
Observation Area – usually going to be somewhere that they can keep an eye on
the client or if they just want to keep you for 23 hours or something and they
just want to make sure that you are going to be okay.
Clinic Area – big ER’s will have a clinic area or fast track area, this is a busy spot
because 80% of the people that show up in the ER will be getting attention
here.
ENT Room – bigger ER’s will have one of these, this is where they have the
microscopes to look in the ear and suction equipment and such.
Psych Holding – these are good things to have
X ray – bigger ER’s will have one in them
Close proximity to OR – all ER’s should be in close proximity to the OR or at
least should have their own elevator to get them there or at least their own hall
to get them straight from the ER to the OR.
Waiting Room – this is where most ER patients spend most of their time. Most
have a 4 hour wait.
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Triage
Means “to sort”
A systematic approach to assessment that allows the ED nurse determines what
clients need immediate treatment and those who can safely wait.
Places clients in groups based on severity of problems and the immediacy of
needed treatment.
Triage is vastly different between the Emergency Department and in the “field
“(disasters) triage.
Ideally triage happens within 2 to 5 minutes of a person arriving into the
emergency room. Reality triage should happen before they have to go and
give their life history to the lady at the money desk. If they are well enough to
go see the money desk lady, they do not really need to be in the ER. Triage
should happen within 10 minutes of arrival at the emergency room.
Remember privacy is a big issue to day. The triage area is big open area and
questions need to be immediate, discreet and private. The questions should
be immediate and you should know right then if they need to go in to the room.
So be careful what you are asking if it is in an open area. Don’t ask how much
they weigh, when they last had sex and such. Triage should be as private as
possible.
With neonates, they really need to have care and somebody laying their hands
on them to find out what is going on within 10 minutes of their arrival. They
are sick and they can go down in a hurry.
One of the problems in triage is language barriers. If you do not understand, you
need to get someone there that does speak the language or can help you
understand each other. The problem falls in that it takes time to get someone
there to translate these patients. Having their children answer the questions if
the child speaks English is becoming questionable.
ED Triage Categories
Emergent – highest priority (they are fixing to die)
o ER journals and the latest emergency room nursing exams and such are
now saying that there are certain things that are just going to be put here
(emergent). One of the things is that if someone is pregnant with a life
threatening problem to either them or their baby. This person is going to
be bumped up for treatment before someone else that has the same life
threatening situation because two lives are at risk. Another category that
is automatically going to go to emergent are infants that are less than 7
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days old that are symptomatic or any infant that is symptomatic and sick.
With babies it does not take a whole lot of boogers in a nose for them to
get respiratory distress.
Urgent – serious
o This is not immediately life threatening, but they need to be seen within an
hour. They are not going to die right this minute, but in 60 minutes or so, if
they don’t get care they are probably going to die or lose and extremity.
You might can put them off if you have somebody that is sicker, but you
only have an hour to put them off.
Non-urgent –less serious
o Episodic illness that can wait up to 24 hours to get treated. This is your
new onset of nausea, vomiting and diarrhea. You have 24 hours before
you seek care for these.
Fast-Track – first aide or basic care
o This is supposed to be first aid and basic care. They need the scratch
washed out and band aided. They need the Tylenol for their hurt toe.
They need some cough medicine.
There is another group of patients that is going to get priority over someone with
the same thing. If you have someone that was in the ER yesterday and they
were in there for nausea, vomiting and diarrhea. They were given some fluids
and some medicine and it has been 18 hours and they show back up with
worsening nausea, vomiting and diarrhea. They are going to be bumped up
because they had care less than 24 hours ago and it has gotten worse or has not
gotten better. These people will be bumped up in the seriousness of what is
going on.
Usually wherever you work, there may be guidelines that are specific to that
agency. These are very general guidelines, so you have to be aware of the
guidelines of the facility where you are an ER nurse.
(3) We have 60 year old that has vomited for 2 days (might aspirate)
(2) We have a 23 year old that has an obviously twisted right leg, pain is rated at
an 8 (we will see this client second because of the pain)
(4) We have a19 year old that has asthma and says that they are SOB, their O2
sats are 97% - if this person is speaking in sentences and is not in distress I will
see them last
(1) We have a 29 year old with lacerated hand spurting blood. – This person has
blood spurting. This is circulation. Remember ABC’s. With the spurting this
person has cut an artery (pulsing).
Emergency Planning
JACHO requires that every healthcare facility have an emergency plan.
The emergency plan must be practiced twice a year.
Communities also have emergency plans that work in conjunction with the
hospitals. They must work together. They have to actually practice the plan
and make sure that it is going to work.
All nurses should be aware of their employing agencies disaster plan so they can
respond appropriately. As registered nurses, when you go through orientation,
they are going to tell you about their plan. You need to think about putting
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yourself in that situation, because it really could be you in this situation.
Nurses died in Hurricane Katrina.
Need to have an emergency plan and a disaster kit that you could live or take
care of yourself for 3 to 5 days without food, water or medicine. They are now
saying that individuals need to have 7 days worth of food, water and medical
supplies to last them 7 days because of the Katrina disaster.
You find the problem in emergency care and you take care of it, then you go
down to the next one on down the line.
You could call trauma situations systematic chaos. After you have done all of
this, then you can go on to the next step, but you have to take care the A, the B
and the C. Then you can take care of the D and the E.
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Cricothyroidotomy
One thing to remember is that if you are looking at the Glasgow Coma scale and
the patient is at 8 or less, you need to be prepared for intubation. They may
not intubate them, but you need to be prepared for that as a nurse. This client
is getting some pretty significant brain injury and the literature says anywhere
from a 6 to 8 be prepared for intubation. Mrs. Batton says if it is an 8 be
prepared for it.
Most of your big trauma rooms have open crash carts, on the floor you have
close crash carts that have to be changed out and accounted for. In the ER
and critical care units you have open crash carts that are counted every shift.
Remember obstruction is a real common problem with children as far as an
obstructed airway. Make sure you check their C spine and give them an
airway
We have a client that has a severe chest injury, he has severe dyspnea, subq
emphysema is getting worse around the neck, the breathe sounds are
decreasing. What is the priority nursing diagnosis? Ineffective airway
Circulation
Always take care of airway/breathing first
If there is obvious external hemorrhaging – open airway and then control bleed,
especially if arterial bleed because they are going to continue to bleed. If it is
an arterial bleed, until the blood pressure is so low that it is not pumping it out
of the body any more, they are going to continue to bleed.
Make sure to apply pressure and elevate extremity for external bleed. If
someone is alert and oriented, they can apply pressure themselves.
Tourniquet is always last resort unless traumatic amputation has occurred. You
only use a tourniquet if you are willing to lose the limb. Use your direct
pressure, elevation, maybe ice and pressure points first.
Initiation of IV’s to restore volume. If you lose volume, the blood pressure drops
and the heart rate increases until there is no blood and then it is going to go
down pretty rapidly.
Draw blood for cross match. Almost anybody that comes in bleeding from
somewhere is going to have a blood drawn for type and match.
Any time that you have an external bleed and it is spurting or squirting, this is
high priority.
Always if they are bleeding, monitor for shock.
Remember that someone can lose 1500 cc’s of blood before they start showing
major signs of blood loss or shock. It is less than this in children.
People that are losing lots of blood are going to have at least 2 large bore IV’s
(16 – 18 gauge). The rule of thumb in the ER is that if people have medical
problems they are going to give them a fluid like D5W. If the client comes in
for trauma or general fluid replacement, they are going to go with Normal
Saline or Lactated Ringers because these fluids are isotonic and the fluid is
going to stay where they put it. If they have a blood pressure that is dropping
and you are trying to maintain vascular pressure, you want the fluid to stay
where you put it.
In the ER, women of child bearing age will usually receive O negative blood. For
men and post menopausal women, they will get O positive blood. If you are
having to replace large amounts of blood or fluids, they are going to have to be
warm. We don’t lower the core temperature too much.
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Female, sudden onset of left sided chest pain, short of breath, diaphoretic, pale
in acute respiratory distress with no trauma. She has nausea and vomiting. The
blood pressure is 100/60, pulse is 118, and respirations are 36. What is the
primary nursing diagnosis? Impaired Gas Exchange
You cannot take the obvious deformity or problem and assume that it is the
issue.
Disability /Neurological
Assess Mental Status
o Any change is going to be significant. It is going to mean something, but
remember that you can get a change in mental status from something as
simple as sleep deprivation, anxiety, or an intracranial bleed.
Glasgow Coma scale – if you have time, we are going to be prepared to intubate
at 8 or below.
Assess Anxiety level
AVUP
A – alert
V – responsive to voice
U – unresponsive
P – responsive to pain
This is a quick thing that places use in addition to the Glasgow coma scale.
Sometimes this is something that they will use in triage, before they have time
to see what the patient can move for.
If anything is running out of the ears or nose – this is not a good sign, it could be
cerebral spinal fluid. Blood and gray matter is never a good sign to come out
of someone’s ears and nose.
Battle sign (bruising behind the ear) is a sign of basilar skull fracture
DO NOT PUT NG TUBE in someone with a basilar skull fracture – it can go into
the cranial vault.
Raccoon sign – periorbital discoloration usually associated with basilar skull
fractures.
Exposure
This is the final component of the primary survey
Remove all clothing to allow for allow for a thorough assessment
Be aware of potential need for evidence collection
If you have a patient that you have taken off all of their clothes – keep them warm
and keep them covered up.
75% of people with chest trauma – they are going to have some degree of
underlying pulmonary contusions. With pulmonary contusions, you have to
remember the airway is probably going to be an issue.
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Pain
Client's complaining of severe pain should be moved up in priority.
Severe pain is defined as client’s self rating of 8-10 on a scale of 1-10.
Severe pain is moved up as a priority, but it is not going to go above the A, the B
and the C.
We need to take care of their pain. Remember when you are giving pain
medication in the ER, you need to find out what they have already taken,
eaten or had to drink.
Emergency Drugs
Most emergency drugs are given intravenously; we are not going to give people
in trauma PO meds.
O2
o Usually in trauma and ER situations it is going to be given in high
concentrations and possibly through an ET tube
Epinephrine
o Cardiac stimulant – bronchodilator
o We are going to give it to stimulate the heart or for anaphylaxis
Atropine
o Given for bradycardia or PEA (pulseless electrical activity)
Lidocaine
o Given for PVC’s, V Fib, V tach
o Can be given IV or through the endotracheal tube
Amiodarone
o Given for V Fib, unstable V Tach
o Suppresses arrhythmias, don’t give to infants with gasping syndrome
Narcan
o To stop the effects of drugs (narcotics) that they took
o Given so the client will start breathing again
D50W
o This is given for hypoglycemia
NA Bicarb.
o This is given when the patient is acidotic
Magnesium
o Given for hypomagnesaemia, uterine problems and given sometimes for
cardiac arrest
Dopamine
o Is a vasopressor
o It increases the blood pressure, in smaller doses it improves renal function
Dobutamine
o Short term it is given to increase cardiac output
o It is a vasoactive adrenergic drug
o Do not usually use this on children
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Donor agencies are notified
Coroner contacted
Staff debriefing possibly about what could have been done differently.
Documentation in the ED
Document everything
o Assessment data
o History
o Vital Signs
o Allergies
o Medications
o Last meal eaten
o How they arrived
o Pertinent statements from client with quotations
o Make sure that you get all of this documented. Most ER’s have their own
documentation forms and you need to use them according to the policy of
the facility.
Secondary Survey
This is when you already have the client a patent airway, you have them
breathing, the circulation is being taken care of, neurologically they are stable,
now you can get down to the business of the complete health history. The
reality is that most of this is going to occur on the unit.
Complete health history
Head to toe assessment
Diagnostic and Labs
Monitoring, (EKG, Foley, Arterial lines)
Splinting fractures
Clean/dress wounds
Other interventions based on client needs
Remember in the ER, any woman that is of child bearing age that is sexually
active should be considered pregnant until determined otherwise. Even if they
say that they are not having sex and they are of child bearing age and you
look at them and you think that they might be of child bearing age, consider
them pregnant until you know that they are not.
(3) 61 year old with a wound draining purulent foul smelling secretions with a
temp of 101.4°, blood pressure 160/90
(1) 41 year old with bilateral rhonchi, rales and respirations of 36 (airway)
(2) 1 month old with increased ___, 2 diarrhea stools and 2 wet diapers in the
last 2.5 hours (this child has urinated twice in the last 2.5 hours, so it is not
dehydrated)
(4) 23 year old with a lacerated index finger
73 year old diabetic with glucose of 260 and a gangrenous right toe
66 year old cancer patient, painful chem. Port, fatigue and temp of 101° for 3
days
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Scoliosis patient who 2 weeks ago had surgery, now is having a lot of back pain
(1) MVA with chest pain, SOB and unilateral chest movement
If you have a limb that has been cut off in an emergency and you want to try to
save it. Wrap it in sterile gauze, moisten in normal saline, and put it on ice in a
plastic bag.
Abdominal Trauma
ABC first
Goal – Control the bleeding and maintain the blood volume
Assess – nee to know what happened, knife, GSW, hit? When?, How many
times? Stay conscious?
Auscultate – you want to know if they have bowel sounds
Palpate – Rigidity? Guarding? Tenderness?, Measure abdominal girth (is it
getting bigger, if it is getting bigger they might be bleeding into it). If they are
bleeding into the abdomen, the blood pressure is dropping.
ABC always first, get rid of those clothes and see what else you see, control the
bleeding, start the IV, get ready to treat shock, NG tube and a Foley
If it is an evisceration, we are going to cover it, keep sterile and moist
Always an NG Tube with an abdominal trauma unless they have a basilar skull
fracture.
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Labs
Meds
Peritoneal lavage or pericentesis – they are going to do this if there is a question
about intraperitoneal bleeding. Now depending upon where you work, the
frequency of this occurrence. Big centers have CT people there and they can
do a CT scan and look at the bleeding. You go to some of these smaller ER’s
that don’t have CT people there and if they need to know if the client needs to
go to surgery, they are going to do the paracentesis. They are going to cut a
couple of slits in the belly, put in a catheter, they are going to hold up the bag
of normal saline, and let it run in there and then they are going to hold the bag
down and let it sit it on the floor and let all of the fluid run back out. This used
to be all that you could do until they had CT scans. With the lavage, they are
looking to see if it is grossly bloody, if it is grossly bloody obviously there is a
bleed. If they look at it and they can’t decide, if they cannot read a newspaper
through it then they need to go straight to the OR.
Prepare for the OR
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corrosion to the esophagus. It can even go through the esophagus into
the trachea. Activated charcoal is very commonly given.
o Position on Left side
o Going to have an IV
o Treat the signs and symptoms that you see
o Try to find out what it is that they ate or ingested, if it is food and you get
several of them in, it is going to have to be reported
o Monitor Neuro status
o NGT for gastric lavage
o give milk or water to dilute
o do not make vomit if caustic
o If caustic assess for mouth, esophagus burns
o Activated Charcoal (PO- NGT)
o Cathartic (Mg. Citrate)
o Syrup of Ipecac (only if alert and able to swallow) – we seldom use this
any more, it is not something that is recommended, there is a huge risk for
aspiration
Food Poisoning
o ABC’s, V/S, , EKG, muscular activity
o Place on side
o IV
o Treat S/S N/V
o Determine source and type of food
o Reporting may be necessary
Inhaled (Carbon monoxide, gas, smoke, fumes)
o Carbon Monoxide most common
o Carboxyhemoglobin levels
o 100% O2
o Monitor for deterioration of mental status
o Notify Psych if attempted suicide and Health department if in the dwelling
o May cause permanent brain damage
Skin Contamination
o Remove clothes
o Profuse amounts of water to flush all traces of chemical away from body
(unless chemical was Lye or white phosphorus)
o Manage as a burn after removal of agent
Injected
o Insects
o Snakes
Very common in Mississippi. More people die of insect bites than
snake bites.
Pit vipers and coral snakes are the most poisonous
Signs and symptoms can vary. The poisons are injected through
fangs. Just because someone has fang marks does not mean that
they have been invenomated. Usually going to immobilize the
bitten area. Try to find out what type of snake it was.
o Spiders
Brown Recluse is pretty common. Brown recluse bites can be very
bad. They have a cytotoxic venom (kills the cells). Initially the
signs and symptoms may be very mild. There might be a little pain,
but then it starts getting worse over time. Then it becomes
ischemic, dark and hard in several days and then it begins to have
a bull’s eye appearance. The infection can be pretty severe with
fever and chills. There is lots of pain. They have to do
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debridement in surgery. If the client is a diabetic, and it is on an
extremity, this is really bad.
Black Widow spiders have a neurotoxic venom. This affects the
neuromuscular junctions. There is an immediate sharp pain when
you get bitten by a black widow spider. They may have stomach
pain and rigidity.
Disaster Types
Natural
o Tornadoes
o Hurricanes
o Earthquakes
o Blizzards
o Epidemics
Man-Made
o Fires
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o Explosions
o Nuclear Accidents
o Bombings
o Biological
o Chemical
o Radiation
o War
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Child with brain tissue from nose and bleeding from both ears – black tagged
Adult with a traumatic amputation of the hand – red tagged
Pregnant woman with swollen ankles – green tagged
Disaster Levels
Level I – Local emergency response personnel and organizations can contain
and effectively manage the disaster and it’s aftermath
Level ll – Regional efforts and aid from surrounding communities are sufficient to
manage the effects of the disaster
Level III - Local and regional assets are overwhelmed; state wide or federal
assistance is required (Katrina)
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