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INTRODUCTION
Most patients with life-threatening or potentially life-threatening
problems arrive at the hospital through the emergency department
(ED). Many more patients report to the ED for less urgent conditions.
Emergency nurses care for patients of all ages and with a variety of
problems. However, some EDs specialize in certain patient populations
or conditions, such as pediatric ED or trauma ED.
Emergency management of patients with various medical, surgical,
and traumatic emergencies is presented throughout this book. Tables
that highlight emergency management of specific problems

HISTORY OF EMERGENCY NURSING

Emergency nursing was officially recognized as a specialty in 1970.
The national association representing these nurses LS the Emergency
Nurses Association (ENAI. Its current membership comprises more
than 25,000 nurses who have chosen this area of professional nursing.
The ENA is recognized internationally and by 1999 had approximately
400 members from 35 different countries. Emergency nurses
throughout the world have realized both their similarities and
differences through use of the World Wide Web and increasing
international globalization. The ED of the future is being formulated
today. Not only is technology changing, but the day-to-day processes

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that support the ED infrastructure are being challenged and

redesigned. These include concepts such as incorporating multiple
triage stations and bedside or back-end client registration; using
computerized protocols, guidelines, and electronic medical records;
integrating nontraditional health care modalities; initiating wireless
communication technology; and creating virtual EDs.
In addition to the provision of direct client care, other multifaceted roles
exist within emergency nursing. The emergency nurse is involved in
the initial triaging of clients according to illness severity, may perform
as a mobile intensive care nurse (MICN) by directing pre-hospital care
personnel via telecommunication, and frequently provides client care in
the pre-hospital environment. Community clinics use ED nurses, and
many emergency nurses have become active in injury prevention
programs at both national and local levels. Advanced practice roles
such as clinical nurse specialists and nurse practitioners are integrated
into many EDs throughout the United States. Nurses in these
advanced practice roles often have a masters degree level of
education or higher in addition to specialty certification.

SCOPE OF EMERGENCY NURSING

The emergency nurse has had specialized education, training,

and experience to gain expertise in assessing and identifying
patients health care problems in crisis situations.

In addition, the emergency nurse establishes priorities,

monitors and continuously assesses acutely ill and injured
patients, supports and attends to families, supervises allied
health personnel, and teaches patients and families within a

time-limited, high-pressured care environment.

Nursing interventions are accomplished interdependently, in
consultation with or under the direction of a licensed physician
or nurse practitioner. The strengths of nursing and medicine are
complementary in an emergency situation. Appropriate nursing
and medical interventions are anticipated based on assessment

data.
The emergency health care staff members work as a team in
performing the highly technical, hands-on skills required to care

for patients in an emergency situation.

The nursing process provides a logical framework for problem
solving in this environment. Patients in the ED have a wide
variety of actual or potential problems, and their condition may
change constantly. Therefore, nursing assessment must be
continuous, and nursing diagnoses change with the patients
condition. Although a patient may have several diagnoses at a
given time, the focus is on the most life-threatening ones; often,
both independent and interdependent nursing interventions are
required.

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LEGAL AND ETHICAL ISSUES IN EMERGENCY NURSING

A. LEGAL ISSUES
1. FEDERAL ISSUE
a. Past federal legislation has mandated that any client
who presents to an ED seeking treatment must be
rendered aid regardless of financial ability to pay for
services. Since the mid-1980s, additional specific
legislation has been enacted requiring ED personnel
to stabilize the condemn of any client considered
medically unstable before transfer to another health
care facilitythe Consolidated Omnibus Budget
Reconciliation Act (COBRA) of 1985 -and the
Omnibus Budget Reconciliation Act (OBRA) of 1990.
This stabilization mtist occur regardless of the
clients financial ability to pay for services. ED
personnel who transfer clients to another institution
without first providing this initial stabilization can
incur substantial fines and penalties, as can the
hospital administration.
b. Clients have continued to seek health care services
in the ED, even with the proliferation of managed
health care plans and gatekeeping policies. The
financial integrity of the ED has been challenged
over the years due to the legal obligations of the ED
to provide service.

c. Retrospectively, financial reimbursement for

rendered services has been denied to EDs from
managed health care plans following a
determination that the clients problem did not
constitute a true emergency
d. Additional legislation was enacted (Emergency
Medical Treatment and Active Labor Act EMTALA in
1988, 1989, 1990, and 1994) requiring that a
medical screening examination be performed on all
ED clients before solicitation of information about
ability to pay.3 This medical screening examination
must be inclusive enough to determine whether the
client is experiencing an emergency medical
condition requiring treatment or, in the case of a
pregnant woman, is experiencing labor contractions.
An emergency medical condition includes drug
abuse, hemodynamic instability, psychiatric illness,
intoxication, severe pan, and labor.
e. If a client has an emergency medical condition,
stabilization must be rendered. Stabilization is
interpreted to mean that deterioration of the client is
unlikely during possible transfer or discharge of the
client. Continued interpretations of this act have
expanded the facilities that come under EMTALA.
These include not only EDs. but also hospital owned
urgent care centers, anywhere unscheduled clients
appear for medical care, and off site locations that

are within a 250-yard zone of a main hospital that is

covered under the 2001 outpatient prospective
payment system. Violations of this legislation can
again result in fines and penalties.
2. CONSENT TO TREAT
a. Most adult clients seeking treatment in the ED give
voluntary consent to the standard and usual
treatment performed in this setting. In some
instances, however, a client is deemed unable to
give consent for treatment. This inability may be due
to the critical nature of the clients illness or injury or
to other conditions, such as an altered level of
consciousness. In these instances, emergency care
may be rendered to the client under the implied
emergency doctrine. This doctrine assumes that the
client would consent to treatment to prevent death or
disability if the client were so able.
b. Children younger than the age of legal majority must
have the consent of their parent or legal guardian for
medical care to be rendered. Exceptions include (1)
emancipated minors, (2) minors seeking treatment
for communicable diseases, including sexually
transmitted diseases, injuries from abuse, and
alcohol or drug rehabilitation, and (3) minor-aged
females requesting treatment for pregnancy or
pregnancy-related concerns. Some states also allow
the adult caregiver with whom the child resides to

give treatment authorization even though that

caregiver may not be the parent.
c. The issue of informed consent in the ED is the same
as in any other health care setting. Adult clients must
he informed about the necessity of required
treatments, expected outcomes, and potential
complications. Clients must also be mentally
competent and understand the information being
explained. As in any other setting, a mentally
competent adult client always maintains the right to
refuse treatment or withdraw previously given
consent.
3. RESTRAINTS
a. Restraining a client while he or she is in the ED may
at times be necessary. The need for restraints
usually arises because the client is becoming
agitated or potentially violent. Hard leather or
chemical restraints are used in the ED if the client is
in danger of injuring self or others and when
nonphysical methods of controlling the client are not
viable.
b. Restraints may not he used to control a client solely
for convenience or because of staffing issues.
c. When restraints are required, departmental and
hospital guidelines that are in compliance with Joint
Commission and the Centers for Medicare &
Medicaid Services must he followed.
d. A physicians order for applying restraint as well as

the clients behavior mandating the use of restraints

most be documented.
e. The client must be periodically reevaluated both for
the continued need or restraints and the integrity of
distal circulation, motor movement, and sensory
f.

level of the restrained extremities.

The findings must be documented. Offering water to
the client and providing opportunities to urinate or
relieve other body needs are required, as is

documentation of this nursing care.

g. No client may be kept restraints against his or her
will unless the clients behavior indicates the
existence of safety issues.
h. Behavior modification techniques used in an attempt
to release the client from restraints must also be
documented. The ED staff must receive appropriate
education pertaining to dealing with clients requiring
i.

physical restraint.
Clients in the ED who have psychological conditions
that render them a danger to themselves or to
others, or who are unable to provide food or shelter
for themselves, can be placed and held on a legal
psychiatric restraining order. THIs order mandates
that such clients be placed in a locked psychiatric
facility for their protection for a maximum of 72
hours. Within that 72-hour period, the client must be
evaluated by a psychiatrist to determine whether the
legal hold needs to be extended or whether the

client can be released.

4. MANDATORY REPORTING
a. Every state has mandatory reporting regulations that
affect emergency nurses. Incidents and conditions
may need to be reported to federal, state, or local
authorities or to the Department of Public Health,
Department of Motor Vehicles, coroners offices, or
animal control agencies.
b. The types of incidents requiring reporting are
suspected child, sexual, domestic, and elder abuse;
assaults; motor vehicle crashes; communicable
diseases such as hepatitis, sexually transmitted
diseases, chicken pox, measles, mumps, meningitis,
tuberculosis, and food poisoning; first time or
recurrent seizure activity; death; and animal bites.
c. Every ED has written policies regarding these
mandatory reports.
5. EVIDENCE COLLECTION AND PRESERVATION
a. Recognition of unusual circumstances surrounding a
clients injury or death is an important aspect of ED
nursing because of the associated legal implications.
Not only must tile legal authorities be notified, but
also, in many instances, the ED nurse may be
required to collect and preserve evidence taken from
the client. This evidence can include bullets,
weapons, clothing, and body fluid specimens.
b. All collected evidence must be identified by the
clients name, hospital identification number, date

and time of evidence collection, type of evidence

and source e.g. venipuncture, hematoma, aspiration
vomitus, swab), and the initials or signature of the
person collecting the evidence. Once the evidence
has been collected, its preservation and the
maintenance of the chain of custody are extremely
important.

6. VIOLENCE
a. Violence directed against ED personnel has become
an issue of concern throughout the late 1990s and

into the 21st century. The environment inherent in

the ED, the emotional circumstances often
surrounding the illness or injury that affect both
clients and family members, and the increasingly
b.

violent trends all play a role in this phenomenon.

Administrative changes have been made in some
EDs to enhance both public and health care worker
safety. These measures have included the
installation of items such as metal detectors, panic
buttons, bullet-proof glass, and lock- down doors at
public entrances; increasing the visibility of security
guards; using patrol guard dogs; and instituting

visitor control policies.

c. Changing the perception of the ED from one of fear
and isolation for both clients and family members is
also occurring.
d. Instituting family centered practices that recognize
tile importance of family participation and addressing
the emotional needs of clients and families is a trend
in ED management.
Following are areas to address
Recognizing potentially violent clients and

situations
Identifying verbally and physically abusive

signs from clients, family members, or friends

Understanding the importance of instinct or

gut , reactions
Using simple communication strategies to
defuse potentially problematic situations

Requiring clients to completely undress

before physical examination

Minimizing the presence of potential
weapons in client care areas such as
scalpels, needles, excess tubing attached to
oxygen flow meters, scissors, stethoscopes

worn around the neck, and personal jewelry.

Restraining clients, when necessary, using a

team approach.
Avoiding becoming a hostage in a volatile

situation
Having safety committee track all reported

assaults on clients and employees

Ensuring Occupational Safety and Health
Administration violence guidelines are

followed
Encouraging employees to report both verbal
and physical assaults.

B. ETHICAL ISSUES
1. UNEXPECTED DEATH
a. When death occurs in the ED setting, it is usually
sudden and unexpected, even if the client has had a
prolonged illness. I hr unexpected nature of the
death, or impending death, can present ethical
dilemmas for both the family survivors and the ED
personnel.87 One such issue deals with the length
to which resuscitation is performed. This is usually a

physicians decision; however, family members may

at times have input. Allowing family members or
significant others to be present during client
resuscitation is becoming more common. This
practice is not necessarily disruptive to the
resuscitation process, and it can be of comfort to the
survivors and the involved ED personnel.
b. When death does occur, the ED nurse and the ED
physician have important roles in informing the
family:
i. Inform the family of the clients death, and
refer to the deceased client by name.
ii. Provide the family with an explanation of the
course of events related to the death; use
simple explanations.
iii. Offer the family an opportunity to view the
body. If a child has died, allow the parent to
hold the child. Providing the parent with a
lock of the childs hair may be comforting.
iv. Help the family to focus on decisions
requiring immediate attention such as taking
possession of the deceased persons
valuables, arranging postmortem
examination if desired or required, identifying
possible organ or tissue donation, and
selecting a funeral home.
v. Inform family members when they can leave
the ED setting.
vi. Provide community agency referral as

needed.
2. ORGAN AND TISSUE DONATION
Issues related to potential organ or tissue donation
often arise in the ED setting. Once a potential donor
is identified, the surviving family members need to
be approached. A team approach involving a
physician, a nurse, arid possibly an organ
procurement coordinator is optimal. Utmost dignity
and professionalism must be maintained. Whatever
decision the family makes regarding organ or tissue
donation, that decision must be supported by health
Care personnel.
3. CHILD ABONDONMENT
States are beginning to pass child abandonment laws in
response to the number of newborn infants being
abandoned following birth. In general, the law allows
mothers to bring their newborn child to the ED and abandon
the child in the care of the ED personnel. The mother bears
no criminal responsibility. Local Departments of Social
Services are then contacted so the child can be placed in
their custody.

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PRINCIPLES OF EMERGENCY CARE

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A. TRIAGE
Triage, a French word meaning to sort, refers to the process
of rapidly determining patient acuity. It is one of the most
important assessment skills needed by the emergency nurse.1
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. A triage cistern identifies and categorizes
patients so that the most critical are treated first.
After the emergency nurse completes the initial assessment to
determine the presence of actual or potential threats to life,
appropriate interventions are initiated for the patients condition.
A history is obtained simultaneously with the assessment. A
systematic approach to the initial patient assessment
decreases the time required to identify potential threats and
minimizes the risk of overlooking a life-threatening condition.
Two systematic approaches, a primary survey and a secondary
survey, were initially developed for use with the trauma patient,
but these can be easily applied to assessment of any
emergency patient.

B. PRIMARY SURVEY
The primary survey focuses on airway, breathing, circulation,
and disability and serves to identify life-threatening conditions
so that appropriate interventions can be initiated. Lifethreatening conditions related to airway, breathing, circulation,
and disability may be identified at any point during the primary

survey. When this occurs, interventions are started immediately

and before proceeding to the next step of the survey.
A =Airway with Cervical Spine Stabilization and/or
Immobilization.
1. Nearly all immediate trauma deaths occur because of
airway obstruction. Saliva, bloody secretions, vomitus,
laryngeal trauma, dentures, facial trauma, fractures, and the
tongue can obstruct the airway. Patients at risk for airway
compromise include those who have seizures, neardrowning, anaphylaxis, foreign body obstruction, or
cardiopulmonary arrest. If an airway is not maintained,
obstruction of airflow occurs and hypoxia, acidosis, and
death may result.
2. 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.
3. Treatment includes opening the airway using the jaw-thrust
maneuver (avoiding hyperextension of the neck), suctioning
and or removal of foreign body, insertion of a
nasopharyngeal or an oropharyngeal airway (will cause
gagging if patient is conscious), and endotracheal
intubation. if unable to intubate because of airway
obstruction, an emergency cricothyroidotomy or
tracheotomy should be performed. Patients should be
ventilated with 100% oxygen using a bag valve mask (BVM)

device before intubation or cricothyroidotomy.

4. Rapid sequence intubation is the preferred procedure for
securing an unprotected airway in the ED. It involves the
use of sedation (e.g. etomidate) and paralysis (eg..
succinylcholine) to facilitate intubation while minimizing the
risk of aspiration and airway trauma.
5. Any patient with face, head, or neck trauma and or on
significant upper torso injuries should always be suspected
of cervical spine a neutral position) and or immobilized
during assessment of the airway. At the scene of the injury,
the cervical spine is immobilized with a rigid cervical collar
or a cervical immobilization device (CED) (also known as
head blocks). Towel rolls are taped to a backboard on
either side of the head. Finally, the patients forehead is
secured to the backboard. Sandbags should not be used
because the weight of the bags could move the head if the
patient must be log-rolled.
B =Breathing.
1. Adequate airflow through the upper airway does not ensure
adequate ventilation.
2. Breathing alterations are caused by many conditions,
including fractured ribs, pneumothorax, penetrating injury,
allergic reactions, pulmonary emboli, and asthma attacks.
3. Patients with these conditions may experience a variety of
signs and symptoms, including dyspnea (e.g., pulmonary
emboli), paradoxic or asymmetric chest wall movement
(e.g. flail chest), decreased or absent breath sounds on the

affected side (e.g. pneumothorax) visible wound to chest

wall (e.g., penetrating injury), cyanosis (e.g., asthma),
tachycardia, and hypotension.
4. Every critically injured or ill patient has an increased
metabolic and oxygen demand and should have
supplemental oxygen.
5. High flow oxygen (100%) via a non-re-breather mask
should be administered and the patients response
monitored. Life-threatening conditions, such as tension
pneumothorax and flail chest, can severely compromise
ventilation, Interventions in these situations include BVM
ventilation with 100% oxygen, intubation, and treatment of
the underlying cause.

C = Circulation.
1. An effective circulatory system includes the heart, intact
blood vessels, and adequate blood volume.
2. Uncontrolled internal and/or external bleeding places a
person at risk for hemorrhagic shock.
3. A central pulse (e.g., carotid) should be checked because
peripheral pulses may be absent as a result of direct injury
or vasoconstriction.
4. If a pulse is palpated, the quality and rate of the pulse are
assessed.
5. Skin should be assessed for color, temperature, and
moisture.
6. Altered mental status is the most significant signs of shock.
7. Care must be taken when evaluating capillary refill in cold

environments because cold delays refill.

6. Intravenous (IV) lines are inserted into veins in the upper
extremities unless contraindicated, such as in a massive
fracture or an injury that affects limb circulation.
7. Two large-bore (14- to 16-gauge) IV catheters should be
inserted and aggressive fluid resuscitation initiated using
normal saline or Ringers lactate solution.
8. Direct pressure with a sterile dressing should be applied to
obvious bleeding sites. Blood samples are obtained for
typing to determine ABO and Rh group.
9. Type specific packed red blood cells should be
administered if needed. In an emergency (life-threatening)
situation, uncrossmatched blood may be given if immediate
transfusion is warranted.
10. The use of the pneumatic antishock garment (PASG) is a
temporary strategy that may be considered for pelvic
fracture bleeding with hypotension.4 The PASG is a threechambered suit that is applied to the patients legs and
abdomen and is inflated with a foot pump. Physiologically,
the PASG increases peripheral vascular resistance in the
patients lower extremities, thus elevating blood sure, and
works to control pelvic fracture bleeding.
11. Care must taken when deflating the garment. Rapid
deflation can result in a severe drop in peripheral vascular
resistance and blood pressurealternative devices to the
PASG include pelvic splints and belts.
D = Disability.
1. A brief neurologic examination completes the primary

survey. The degree of disability is measured by the patients

level of consciousness. Determining the patients response
verbal and/or painful stimuli is one approach to assessing
level consciousness. A simple mnemonic to remember is
AVPU: A = alert, V = responsive to voice, P = responsive to
pain, and U unresponsive.
2. In addition, the Glasgow Coma Scale is used to assess the
arousal aspect of the patents consciousness.
3. Finally, the pupils should be also assessed for size, shape,
response to light, and equality.
C. SECONDARY SURVEY
After each step of the primary survey is addressed and any
lifesaving interventions are initiated, the secondary survey
begins.
The secondary survey is a brief, systematic process that is
aimed at identifying all injuries.
E=Exposure/Environmental Control
All trauma patients should have their clothes removed so
that a thorough physical assessment can be performed.
Once the patient is exposed, it is important to limit heat loss
and prevent hypothermia by using warming blankets,
overhead warmers, and warmed IV fluids.
F=Full Set of Vital Signs/Five Interventions/Facilitate
Family Presence.
1. A complete set of vital signs, including blood pressure, heart
rate, respiratory rate, and temperature, should be obtained
after the patient is exposed.

2. Blood pressure should be obtained in both arms if the

patient has sustained or is suspected of having sustained
chest trauma, or if the blond pressure is abnormally high or
low.
3. At this point, it must be determined whether to proceed with
the secondary survey or to perform additional interventions.
The availability of other team members often influences this
decision. For patients who have sustained significant
trauma and/or have required lifesaving interventions during
the primary survey, the following five interventions should
be performed at this time:
a. The patient should he monitored h
electrocardiogram (ECG) for heart rate and rhythm.
b. The pulse oxymetry should ho initiated and oxygen
saturation (Sp02) monitored.
c. An indwelling catheter should be inserted to monitor
urine output and to check for hematuria, An
indwelling catheter should not be inserted if a
urethral tear is suspected. Patients with pelvic
injuries, with blood at the meatus, or who are unable
to void, and men with a high-riding prostate gland on
digital rectal examination, are at risk for a urethral
tear or transection. A retrograde urethrogram should
be obtained before a catheter is inserted.
d. An Orogastric or a nasogastric tube should be
inserted to provide gastric decompression and
emptying to reduce the risk of aspiration and to test
the contents for blood. A nasogastric tube should not

be placed in the nares of a patient suspected of

having facial fractures or a basilar skull fracture
because the tube could enter the brain through the
cribriform plate; rather, it should be placed orally.
e. Laboratory studies for typing and crossmatching,
hematocrit, hemoglobin, blood urea nitrogen,
creatinine, blood alcohol, toxicology screening,
arterial blood gas (ABGs), electrolytes, coagulation
profile, liver enzymes, cardiac enzymes, and
pregnancy should be facilitated.
Facilitating family presence (FP) completes this
step of the secondary survey. Research supports the
benefits of FP during resuscitation and invasive
procedures to patients, families, and staff. Patients
reported that having family members present comforted
them, served as an advocate for them, and helped to
remind the health care team of their personhood.
Family members who wished to be present during
invasive procedures and resuscitation viewed
themselves as active participants in the care process.
They also believed that they provided comfort to the
patient and that it was their right to be with the patient.
Staff nurses reported that family members who
participated in FP functioned as patient helpers (e.g.
providing support) and staff helpers (e.g., acting as a
translator) and reinforced that FP helped to convey the

sense of the patients personhood. Should a family

member request FP during resuscitation or invasive
procedures, it is essential that a member of the team he
designated to explain care delivered and be available to
answer questions.
G = Give Comfort Measures.
1. Provision of comfort measures is of paramount importance
when caring for patients in the ED. It has been reported that
pain is the primary complaint of all patients who come to the
ED.
2. Many EDs have developed nurse-initiated pain
management protocols to treat pain early, beginning at
triage. Pain management strategies should include a
combination of pharmacologic (e.g. nonsteroidal antiinflammatory drugs, IV opioids) and non-pharmacologic
(e.g., imagery, distraction) measures.
3. Emergency nurses play a pivotal role in ongoing pain
management because of their frequent contact with
patients. General comfort measures such as verbal
reassurance, listening, reducing stimuli (e.g., dimming
lights), and developing a trusting relationship with the
patient and family should he provided to all patients in the
ED.

H = History and head-to-toe assessment

1. History should include following questions
a. What is the chief complaint?
b. What caused the patient to seek attention?
c. What are the patient subjective complaints?
d. What is the patients description of pain (e.g..
location, duration. quality, character)?
e. What are witnesses (if any) descriptions of the
f.

patients hehaior since the onset?

What is the patients health history?
The mnemonic AMPLE is a memory aid that
prompts the nurse to ask about the following:
A = Allergies
M = Medication history
P = Past health history (e.g., preexisting medical
and/or psychiatric conditions, previous
hospitalizations/surgeries, smoking history, recent
use of drugs/alcohol, tetanus immunization, last

menstrual period, baseline mental status).

L= Last meal
E= Events/environment preceding illness or injury
2. Head, Neck, and Face
The patient should be assessed for general

appearance, skin color, and temperature.

The eyes should be evaluated for extraocular

movements.
A disconjugate gaze is an indication of neurologic

damage.
Battles sign, or bruising directly behind the ear(s),
may indicate a fracture of the base of the posterior

portion of the skull.

Raccoon eyes, or periorbital ecchymosis, is usually

an indication of a fracture of the base of the frontal

portion of the skull.

The tympanic membranes and external canal are

checked for blood and cerebrospinal fluid.

Clear drainage from the ear or nose should not be

blocked.
The airway is assessed for foreign bodies, bleeding,

edema, and loose or missing teeth.

Assess for difficulty swallowing, movement.
The trachea is palpated and visualized to determine
whether it is midline. A deviated trachea may signal,

a life-threatening tension pneumothorax.

Subcutaneous emphysema may indicate

laryngotracheal disruption
A stiff or painful neck area may signify a fracture of

one or more cervical vertebrae.

The cervical spine must be protected using a rigid
collar and supine positioning. Patients must be
logrolled while maintaining cervical spine
immobilization when movement is necessary.

3. Chest.
The chest is examined for paradoxic chest

movements and large sucking chest wounds.

The sternum, clavicles, and ribs are palpated for

deformity and point tenderness.

The chest is assessed for pain on palpation,
respiratory distress, decreased breath sounds,

distant heart sounds, and distended neck veins

In addition to tension pneumothorax and open

pneumothorax, the patient should be evaluated for

rib fractures, pulmonary contusion, blunt cardiac

injury, and haemothorax.

A 12-lead ECG should be obtained, particularly on a

patient with known or suspected heart disease.

The ECG should be done to detect dysarrhythmias
and evidence of myocardial ischemia or infarction.

4. Abdomen and Flanks.

The abdomen and flanks are more difficult to
assess. Frequent evaluation for subtle changes in
the abdominal examination is essential. Motor
vehicle collisions and assaults can cause blunt
trauma. Penetrating trauma tends to injure specific,

solid organs (e.g., spleen).

Decreased bowel sounds may indicate a temporary

paralytic ileus.
Bowel sounds in the chest may indicate a

diaphragmatic rupture.
The abdomen is percussed for distention e.g.
tympany (excessive air), dullness [excessive fluid])

and palpated for peritoneal irritation.

Intra-abdominal hemorrhage is suspected, a
focused abdominal sonography for trauma (FAST)
to determine the presence of blood in the peritoneal
space (hemoperitoneum) is preferred. This
procedure is noninvasive and can be performed

quickly at the bedside.

An alternative, a diagnostic peritoneal lavage, may

be considered. Before this procedure, a gastric tube

and a bladder catheter must be inserted to
decompress these organs and reduce the possibility
of perforation.
5. Pelvis and Perineum.
The pelvis is gently palpated, not rocked. If pain is

elicited, it may indicate a pelvic fracture.

The genitalia are inspected for bleeding and obvious

injuries.
A rectal examination is performed to check for blood,
a high-riding prostate gland, and loss of sphincter

tone.
Assess for bladder distention, hematuria, dysuria, or
the inability to void.

6. Extremities.
The upper and lower extremities are assessed for

point tenderness, crepitus, and deformities.

Injured extremities are splinted above and below the

injury to decrease further soft tissue injury and pain.

Grossly deformed, pulseless extremities should be

realigned and splinted.

Pulses are checked before and after movement or

splinting of an extremity.
A pulseless extremity is a time-critical vascular or

orthopedic emergency.
Extremities are also assessed for compartment
syndrome. This occurs as pressure and swelling
increase inside a section of an extremity (e.g.,
anterior compartment of lower leg), compromising

the viability of the extremity muscles, nerves, and

arteries.
I = Inspect the posterior surface
Inspect the Posterior Surfaces. The trauma patient should
always be logrolled (while maintaining cervical spine
immobilization) to inspect the patients posterior surfaces. The
back is inspected for ecehymoses, abrasions, puncture
wounds. cuts, and obvious deformities. The entire spine is
palpated for misalignment, pain, deformity.

INTERVENTION AND EVALUATION

Once do secondary survey is complete, all findings are
recorded. All patients should Be evaluated to determine their
need for tetanus prophylaxis. Information about the patients
past vaccination history and the condition of any wounds is
needed in order to make an appropriate decision.
Regardless of the patients chief complaint, ongoing patient
monitoring and evaluation of interventions are critical in an
emergency situation.
The nurse is responsible for providing appropriate interventions
and assessing the patients response. The evaluation of airway
patency and the effectiveness of breathing will always assume
highest priority. The nurse will monitor 02 saturation and ABGs
to help determine the patients progress in these areas. Level of
consciousness, vital signs, quality of peripheral pulses, urine

output, and skin temperature, color, and moisture provide key

information about circulation and perfusion and are also closely
monitored.
Depending on the patients injuries and/or illness, the patient
may be (I) transported for diagnostic tests such as X-ray or CT
scan: (2) admitted to a general unit, telemetry, or an intensive
care unit; or (3) transferred to another facility. The emergency
nurse is responsible for monitoring the critically ill patient during
intrafacility and interfacility transport and notifying the team
should tile patients condition change from baseline. Nurses
accompanying patients on transports must be competent in
advanced life-support measures.

Death in the Emergency Department

Unfortunately, there are a number of emergency
patients who do not benefit from the skill, expertise, and
technology available in the ED. It is important for the
emergency nurse to be able to deal with feelings about sudden
death so that the nurse can help families and significant others
begin the grieving process.
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 tile body, and making mortuary arrangements. The
death must seem real so that the significant others can begin to
grieve and accept tile death. The emergency nurse plays a

significant role in providing comfort to tile surviving loved ones

after a death in the ED.
Many patients who die in tile ED could potentially be a
candidate for nonheart beating donation. Certain tissues and
ure:iiis such as cornea, heart valves, skin, bone, and kidneys
can be harvested from patients after death.
Approaching families about donation after an
unexpected death is distressing to both the staff and the family.
For many families, however, the act of donation may be the first
positive step in the grieving process. Organ are available to
assist in the process of screening potential donors, counseling
donor families, obtaining informed consent, and harvesting
organs from patients who have died in the ED.

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Summary
Till now we have seen about the definition, history, scope,
legal and ethical issues in emergency nursing, principles of
emergency management, emergency conditions and their
nursing management.

Conclusion
A stitch in time saves nine, and it is better to be prepared
rather than unknown. Trauma can be controlled but not all,
controllable can be prevented by appropriate human behavior.
During trauma help should be implanted as soon as possible to
avoid further casualities.
Assignment
solve the 10 multiple choice questions, 10 marks

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BIBLIOGRAPHY:1. Lewis, Heitkemper & Dirksen (2000) Medical Surgical

Nursing Assessment and Management of Clinical Problem
(7th ed) Mosby, pg no. 2552-66.
2. Black J.M. Hawk, J.H. (2005) Medical Surgical Nursing
Clinical Management for Positive Outcomes. (7th ed)
Elsevier, pg no. 2441-54.
3. Brunner S. B., Suddarth D.S. The Lippincott Manual of
Nursing practice J.B.Lippincott. Philadelphia, pg no. 3205159
4. Understanding medical surgical nursing, F A Davis 6th
edition, elsieiver publication pg. no. 210-224.
5. www.ene.org/issues.html

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1. INEFFECTIVE AIRWAY CLEARANCE

A compromised or ineffective airway max he due to
either complete or partial airway obstruction. Common causes
of airway compromise include the presence of a foreign object
in the airway, airway edema, airway infection, facial or airway
injury, and tongue obstruction.
CLINICAL MANIFESTATIONS
Absence of respirations
Drooling
stridor,
intercostal or substernal retractions
cyanosis, a mid agitation
A decreased level of Consciousness may lead to airway
compromise as a result of obstruction of the posterior
pharynx by the relaxed tongue.
Management
Remove Obstruction.
If an obstruction is present, the airway should be opened by a
chin lift or jaw thrust maneuver. If either of these maneuvers
opens the clients airway, patency is maintained via the

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insertion of a nasopharyngeal or oral airway device. If these

maneuvers fail to relieve the obstruction, more aggressive
interventions must he instituted, such as
performing abdominal or chest thrusts if an aspirated
foreign object is the suspected cause
suctioning the oral cavity to remove secretions or visible
foreign objects
Intubating via the nasal or oral route
Using a laryngeal mask airway (LMA),
Assisting with creating a surgical airway via a
cricothyroidotomy.
Intubate
In some cases, oral or nasal intubation may require the use of
rapid-sequence induction (RSI) This procedure is used in
awake clients who require intubation either to maintain the
airway or as a mechanism to provide adequate ventilation. RSI
is most frequently used in clients who have sustained a head
or spinal injury and in clients who are rapidly tiring from the
effort of maintaining respirations. Rb! involves
Establishing venous access
Hyperventilating the client with 100% oxygen,
Administering intravenous (IV) lidocaine I op/kg to blunt
any transient increase in intracranial pressure from the
actual intubation procedure
Administering an IV general barbiturate or anesthetic
medication such as thiopental 3 to 5 mg/kg,
Verify Tube Placement
After the intubation procedure, the ED nurse is
immediately responsible for auscultation of the clients
chest during assisted ventilation to confirm the presence
of equal bilateral breath sounds.
If breath sounds are heard over the epigastric area, the

tracheal tube must be removed, the client

hyperventilated, and the procedure reattempted.
Breath sounds heard more prominently over the upper
right chest indicate that the tracheal tube has advanced
far into the right main bronchus. The tube needso be
pulled-hack and breath sounds reassessed.
Once the presence of equal and bilateral breath sounds
is confirmed, the tube is secured in place and a chest
film is obtained to document correct tube placement.
Securing and maintaining a patent airway constitutes
the first priority in any ED client. Other treatments
directed at the cause of airway compromise are then
instituted. These measures may include administration
of IV medications if infection or local edema of the
airway is present.

Immobilize the Spine

If the client with an actual or potential airway problem
has also sustained a traumatic injury, simultaneous stabilization
of the clients cervical, thoracic, and lumbar spine must be
instituted and maintained to prevent any further possible spinal
injury.
Manually stabilizing the clients head and
cervical spine
Applying a hard cervical collar around the clients
nuchal area
Placing the client on a long, rigid backboard
Securing the client to the backboard
Placing immobilization devices, such as rolled
towels, at the side of the clients head and neck,
and
Placing a strip of adhesive tape across the
clients forehead and immobilization devices and

then onto the backboard.

2. INEFFFECTIVE BREATHING PATTERN
HYPERVENTILATION
CLINICAL MANIFESTATIONS
Fast respiratory rate
Numbness
Tingling sensation
Carpal or pedal spasm
Anxiety
MANAGEMENT
Instruct patient to take slow breath
Instruct him to breath in paper bag and rebreath their
own carbon dioxide
HYPOVENTILATION
Clinical Manifestaions
RESPIRATORY RATE LESS than 12/min
Decreased level of consciousness
Pallor
Cyanosis
Management
Administer high flow oxygen by bag valve mask
3. IMPAIRED GAS EXCHANGE
Abnormal lung sound rhonchi, wheezing
Pneumothorax (diminished or absent breath sound in
affected side)
Asymmetrical hest movements (trauma or flail chest)

4. TRAUMATIC PNEUMOTHORAX
Cause

Trauma to chest

Clinical manifestation
Penetrating injury or Open wound on chest
Pain
Management
Administer oxygen at high flow via face mask
Apply occlusive dressing on open chest wound
Insert 14-16 gauze needle in anterior chest at 2nd
intercostals space in midclavicular line to drain the air.
Place chest tube with collection bag or suction tube
5. FLAlL ClEST
A flail chest involves serious rib fractures. It occurs when two or
more ribs are fractured in two or more places on the same
chest wall side or when the sternum is detached from the ribs.
The fractured segment has no connection with the remaining rib
cage. This segment then moves in a direction opposite that of
the rest of the chest wall during the processes of inhalation and
exhalation so-called paradoxical chest wall movement (Figure
84-9). Respiratory distress is present, as are skin pallor and
cyanosis. Treatment involves nasal or tracheal intubation and
mechanical ventilation with positive end-expiratorv pressure
(PEEP). Pulmonary contusions are commonly present in
conjunction with a flail chest, and within 24 to 48
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