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EMERGENCY AND DISASTER NURSING – Allow family to stay with patient, if possible, to alleviate anxiety

– Provide explanations and information

 Red tags - (immediate) are used to label those who – Provide additional interventions depending upon the stage of
cannot survive without immediate treatment but who have crisis
a chance of survival.

 Yellow tags - (observation) for those who require PRINCIPLES OF TRIAGE

observation (and possible later re-triage). Their condition What is TRIAGE?
is stable for the moment and, they are not in immediate
- it is sorting
danger of death. These victims will still need hospital care
and would be treated immediately under normal - from the French word “trier” meaning to choose, referred to a
circumstances. battlefield
- the rapid focused assessment
 Green tags - (wait) are reserved for the "walking What is the purpose of TRIAGE?
wounded" who will need medical care at some point, after - is to sort or classify all incoming ED patients
more critical injuries have been treated. - the goal is to get the
Right Patient to the
 White tags - (dismiss) are given to those with minor Right Place at the
injuries for whom a doctor's care is not required. Right Time for the
Right Reason to receive
 Black tags - (expectant) are used for the deceased and Right Treatment
for those whose injuries are so extensive that they will not
be able to survive given the care that is available.

How long should the TRIAGE take?

- the common goal is to assess the patient within 2-5 minutes for
Scope and Practice of Emergency Nursing adults
• Emergency management traditionally refers to urgent and (but this time according to ENA caters up to 22% only of patients
critical care needs; per hundred in 8 hours)
• however, the ED has increasingly been used for non-urgent - for pediatrics, 7 minutes
problems, and emergency management has broadened to
include the concept that an emergency is whatever the patient or Who should perform the ED TRIAGE function?
family considers it to be - the Joint Commission on Accreditation of Healthcare
Organization (JCAHO) doesn’t entails what are the specifics of the
The emergency nurse has: triage nurse
• Special training, education, experience, and expertise in - Emergency Nurses Association (ENA) 1999 established he
assessing and identifying health care problems in crisis situations standards of Emergency Nursing Practice, states that safe,
• Nursing interventions are accomplished interdependently in effective triage can only be performed by a registered
consultation with or under the direction of a physician or nurse professional nurse, educated in the principles of triage and has
practitioner minimum experience of 6 months in emergency nursing
• The emergency room staff works as a team - The triage nurse should classify patient 24/7

Four Basic Emergency Action Principles What are the Essential Components of Comprehensive TRIAGE?
• Survey the scene 1. An initial across-the- room look or visualization. This includes
– If any kind of danger is threatening, do not approach the ABCD. For pediatric clients, this may include critical look, general
casualty, call EMS immediately for professional help. appearance, work of breathing and circulation
• Check the casualty for any for unresponsiveness 2. A rapid triage (60secs) of an appropriately elicited chief
• If the person does not respond, Call EMS complaint, key questions, assessment such as feeling of the pulse
• Check the casualty’s airway, breathing and circulation (ABC’s) : and fracture in the extremities
try to the airway without moving the patient 3. Completion of a focused triage history and physical
assessment. This include vital signs, pulse oximetry reading,
Priority Emergency Measures for diagnostics and institution’s protocol
All Patients 4. The triage decision, in which the triage acuity or level is
assigned. This determines the urgency of the condition, includes
• Make safety the first priority the MSE and additional assessment.
• Preplan to ensure security and a safe environment
• Closely observe patient and family members in the event that What should the triage history include?
they respond to stress with physical violence Medications
• Assess the patient and family for psychological function Exposure to infection
Allergies Pregnancy
• Patient and family-focused interventions Immunization
– Relieve anxiety and provide a sense of security LMP
Past medical history - Remember that he patient’s diagnosis is not necessarily the
Family history correct diagnosis
- Exhibit concern for a higher acuity in the presence of other risks
factors, or co-morbidities/ chronic illness
- Remember hat alcoholics can be sick and intoxicated at the
same time
What are the some examples of Adult Mnemonics? - Ask the patient at the end of he triage encounter if here is
PQRST anything else the patient wants to say
Pain assessment
P precipitating factors What are the prioritization principles?
Q quality - Airway
R radiation - Breathing
S severity - Circulation
T time - Disability
T treatment - Systemic before local; life before limb
- Acute before chronic; short term before long
PHOSPHATE - Central before peripheral
For the history of the chief compliant - Actual over Potential
- Trending (worsening trend could consist of minor symptoms
Problem that tend to reoccur repeatedly, increase in severity, or indicate a
Onset steady progressive decline)
Associated Symptoms - Potential for worsening (ex. Drug overdose and chest tightness)
Previous History
Precipitating Factors
Alleviating/ Aggravating Factors TOXICOLOGY
Timing (Poisoning and Drug Overdose)
A. General Guidelines
CIAMEDS (from Emergency Nursing Pediatric Course) - maintain adequate airway, breathing and cardiac output
Chief Compliant - Patients who ingested large amounts of TCA may require
Immunization intubation immediately even if mental status has not yet
Allergies occurred.
Medications - Perform gastric lavage
Past Medical History - Induce emesis for patients with alkali ingestion
Events Surrounding - Contact local poison control center at UP College of Medicine
Diets/ Diapers 524-1078, 524-5651 loc 2311
Symptoms Associated with injury or illness - East Ave Med Ctr 928-0611
- Consider possibility of suicide
SAVE A CHILD (From ENA Hawaii- SAVE Are observations before - All female with chemical ingestion should undergo pregnancy
touching the child, A CHILD are key history and examination test
components) -
Skin B. Principles of Decontamination
Activity External Decontamination
Ventilation - Wash skin with soap and water
Eye Contact - Remove cloths
Abuse - Keep warm, use blankets
Heat Gastric Lavage
Immunization - contraindications includes strong ingestion of strong acids,
Level of Consciousness alkalis, petroleum and distillates.
Dehydration - Airway must be protected with endotracheal tube unless awake,
alert and has a gag reflex
What are some tips for better TRIAGE - Position head on one side of he bed to prevent aspiration
- Look at the patient, listen and do not write while the patient is - If the patient has severe DOB stat intubation
talking to you - Perform gastric lavage unless overdose with acid
- Never appear shocked by what the patient tells you - Lavage is useful within two hours of ingestion
- Do not discount the patient’s concern on triage Activated Charcoal
- Watch people’s faces - Always consider giving charcoal after emesis or lavage until
- Ask specifically about drugs recently started specifically contraindicated
- Do not assume patients are taking their medications - Multiple doses of charcoal in (+) metamphetamine,
- Use the language of symptoms, feelings, and thoughts phenothiazines, digoxin, theophylline, phenobarb, and
organophosphates - Instill activated charcoal, followed by repeated doses of 20-25
- Activated charcoal is not effective for alkalis, cyanide, mineral gm via NGT
acid and ferrous sulfate - Secure RBS, ABG, ECG and CXR
- Watched out for hypotension, CNS and respiratory depression
Cathartics and withdrawal syndrome such as agitation, seizure, restlessness
- contraindicated with infants (risk for dehydration), intestinal and insomnia.
obstruction, electrolyte imbalance
- sodium sulfate is contraindicated in HPN and heart failure Digitalis Overdose
- considered NGT insertion and gastric lavage
Forced Diuresis - secure digitalis assay, CBC, Ca, K, Mg, CXR and ECG/ cardiac
- forced neutral diuresis may be helpful for isoniazid, bromide monitor
and ethanol intoxification - the treatment goal would be to correct hypokalemia.
- make sure to monitor electrolytes Hypomagnesemia or hypocalecemia.
- forced alkaline diuresis may be useful for Phenobarbital, - The doctor may prescribe charcoal and cathartics
salicylates and lithium using sodium bicarbonate. - Watch out for hypotension; fluid challenge my be instituted
- For arrythmias, lidocaine may be given
C. Guidelines for Nurses
- when antidotes are ordered, it is meant to be given immediately Ethanol Toxicity
or at least reasonably within the hour in some cases. They are - maintain adequate airway, ventilation, circulation and
not given when it is the convenient dosing period for the nurses. administer oxygen
- Thiamine is useful to protect/ prevent liver damage
- Phynetoin my be given in cases of seizure, but make sure to give
it SIVP and hook the patient to the cardiac monitor
Specific Substance Ingestion
Acid Ingestion Narcotic Overdose
- provide airway control, ventilation, circulatory support, and fluid - maintain airway, ventilation and circulation
resuscitation - may start on Naloxone 2mg every 5 minutes , max 10mg IV, IM
- wash the oral cavity (controversial) SQ
- emesis, lavage and charcoal are contraindicated - Activated charcoal if (+) for bowel sounds and cathartics
- secure serial CBC and cros-matching - Watch out for signs of pneumonia, infections and
- maintain NPO rhabdomyolysis
- Watch out for complications such as seizure, pulmonary edema
Alkali Ingestion and hypotension
- immediately rinse oral cavity
- administer oxygen and IVF Hydrocarbon/ Kerosene Ingestion
- secure serial CBC, CXR, and monitor electrolytes - Respiratory support
- esophagoscopy and gastroscopy should be performed - Treatment is not required in the absence of symptoms
immediately if there is drooling, stridor and painful swallowing - Promote gastric emptying
- Remove contaminated clothing and wash affected skin with
Amphetamine/ Metamphetamine Toxicity soap and water.
- start charcoal and cathartics - Provide supplemental oxygen
- emesis has no role - secure CBC, ABG abd CXR
- WOF for seizure, psychosis, agitation, hypertensive crisis, Isoniazid Overdose
arrhythmias - place an NGT and do gastric lavage is clean
- Secure ABG, CBC with PC, PT, PTT, RBS, BUN, Crea, Na, K, UA - watch out for seizure, lactic acidosis may give sodium
- Diazepam and Phenytoin for seizure bicarbonate
- Beta-blockers, Lidocaine for dysrythmias - consider mannitol administration for forced diuresis
- secure CBC, RBS, K, ABG
Anticoagulant Overdose
- Secure lab results such as CBC with PC, PT, PTT and Creatinine Narcotic Overdose
- maintain airway, ventilation and circulation
- For Heparin: Give protamine sulfate at 1mg iv for every 50-100 - may give naloxone 2.0mg q 5 minutes initially max of 10mg IV,
units of heparin infused in the preceeding 2 hours, dilute in 25- IM SQ
50ml fluid over 10 minutes - start activated charcoal if (+) with BM and cathartics
- For Warfarin: perform gastric lavage and give activated charcoal - watched out for complications, PNA, hypotension, and seizures
if recently ingested; give vitamin k 5-10 mg every 8-12 hours; give is (+) norpethidine
FFP 2-6units for severe bleeding
Insecticides/ Pesticides
Diazepam Overdose Therapeutics
- Place NGT and do gastric lavage 1. Decontamination
- Protect airway - make he patient rinse with alkaline or baking soda (10gm in
100cc) - Pulmo Edema: treat with high concentration of oxygen,
- change cloths and wash the patient with gloves furosemide and PEEP
- insert NGT and do gastric lavage wih activate charcoal - Cerebral Edema: treat with hyperventilation and osmotic
2. Activated charcoal diuresis with Mannitol
3. Antidote
4. In cases of seizure; consider Phenytoin SHOCK (Multisystem Stressor)
5. wof for hypoglycemia
6. Give mannitol if with good urine output Pathophysiology
- secure CBC, RBS, ABG, SGOT and SGPT - Shock is a multisystem stressor that involves inadequate tissue
perfusion and altered metabolism.
- Inadequate tissue perfusion can lbe a result of nay condition
Paracetamol Overdose that alters heat function (cardiogenic), blood
- Insert NGT volume(hypovolemic), blood pressure (neurogenic) and
- Activate charcoal about 30-100mg and then remove via NGT distribution of blood volume (septic/ anaphylactic)
suction prior to acetylcysteine - Shock is a very complex clinical syndrome in which tissue
- Sodium Sulfate to induce vomiting perfusion is inadequate to meet the demands for oxygen
- Antidote: N-acetylcysteine (NAC) . the initial administration - It alters cellular functions and eventually impairs body organ
would be 150mg/kg body weight infused in 200ml 5% dextrose functions
over 15 minutes followed by IV infusion of 50mg/kg in 500ml of - Multi Organ Dysfunction Syndrome (MODS) is a term used to
5% dextrose water describe several impairment of the human functions
- NAC is very effective in preventing paracetamol-induced
hepatotoxicity when administered; when administered with in 8 Sepsis and Septic Shock
hours from the time of ingestion, the better. But beyond 8 hours, - Sepsis is an acute systemic clinical syndrome caused by bacteria,
the protective effect diminishes progressively as the treatment viruses or fungi in the blood, most commonly gram (-) bacilli
interval increases - At an early phase, generalized inflammatory response is
triggered, causing widespread vasodilation
Salicylate Poisoning - The progression to septic shock is due to the toxins released
from the organism involved
Diagnostics: - Bacterial endotoxins activates the complement, coagulation and
- CBC, K, RBS, ABG and UA fibrinolytic system; inceases vascular permeability and trigger the
- PT, PTT, SGOT, SGPT and alk Posh with 48 hours post ingestion vasoactive kinins causing vasodilation and increased capillary
permeability thereby decreasing the vascular resistance and
Therapeutics: facilitating fluid shifting from intravascular to interstitial
- Stabilize respiratory and cardiac functions - Another response would be due to the histamine release
- Avoid diluting the gastric contents since this may incease gastric causing increase in vascular permeability
absorption - This changes are further stimulated by the catecholamine and
- Consider NGT insertion prostaglandins that are released from ischemic tissues
- Give activated charcoal 1gm/ kg body weight every 6 hours - “COLD SHOCK” is he term used during the stage in which tissue
- Sodium sulfate 15-30 gm in 100cc H20 orally if tolerated or with perfusion becomes severely compromised and ischemic cellular
NGT with every other doses of activated charcoal to prevent damage occurs.
charcoal constipation or fecal impaction - In addition the, fever is present due to the pyrogens released by
- To increase urine ph, consider sodium bicarbonate the organism
- Glucose and KCl should be infused with other fluids
Anaphylactic Shock
Treatment Plan - systemic anaphylactic shick is potentially life threatening
- if with dehydration and hypokalemia, manage with vigorous and situation
with electrolyte replacement - it is he result of an exaggerated hypersensitivity response to an
- Cerebral edema can be best avoided using hypertonic antigen
rehydration solution - the classic form of anaphylaxis occurs in a sensitized person
- Alkaline diuresis to maintain urinary ph at approx 8 usually 1-20 minutes ater the exposure to the antigenic
- Monitor urine output substance
- Assess hydration status - the most common substance that can cause reactions would be,
- Watch closely for signs of fluid overload drugs, antibiotics, foods, anesthetics, antisera and blood
- Hemodialysis is indicated for initial salicylate level of >160ml/dl products
or with profound acidosis of below 7; or when there is renal - hypersensitivity reaction occurs over the surface of he mast cells
failure, severe CNS dysfunction, pulmonary edema or which are located primarily in he lungs, small blood vessels and
deterioration despite supportive therapy connective tissues
- it also attacks basophils circulating in the blood
Other Treatments - the antigenic substance triggers the release of kinins,
- Acidemia: NaHCO3 histamines, prostaglandins, eosinophils, neutrophils
- Seizure: Diazepam - “sow reacting substance of anaphylaxis” (SRSA) such as
prostaglandins and leukotrienes produces deleterious results - Angi-histamine
icluding profound shock - Bronchodilator
- Histamine is he primary mediator of anaphylactic attack. - Steroids
Leukotrienes produces vasoconstriction that is even worst than - Mast cell stabilizer
histamine - Glucagon
- The prostaglandins exaggerate the bronchoconstriction; kinins - ECG monitoring
increases the vascular permeability
- The combined effects of the substance causes respiratory Nursing Diagnosis and Intervention (SEPSIS)
distress and obstruction 1. Fluid volume deficit related to active loss from vascular
compartment secondary to increased capillary permeability and
shifting of intravascular volume into interstitial spaces
Toxic Shock
- it is another syndrome of shock believed caused by bacterial Desired Outcome
toxins Within 4 hours of initiation of therapy, the patient is
- e.g. Staph A enters he blood steam from the site of infection, normovolemic as eveidenced by good peripheral pulses, stable
commonly the vagina, diffusing across the mucus membranes. body weight, good urine output and decreased adventitious
Hey are then circulated throughout the body breath sounds
- thise toxins causes massive vasodilatation and eventually to a
shock state Intervention
- Monitor hemodynamic pressures
For Septic Shock Assessment - Administer crystalloid and fluid replacement as prescribed
- history and risk factors includes, malnutrition, - VS hourly
immunosuppresion, liver and renal diseases, recent traumayic - Maintain proper inotropic administration
injuries, surgical or invasive procedure - Weigh patient daily
- commonly caused by E Coli, Klebsiella, Enterobacter, Staph A. as - Monitor specific gravity
well as fungi and viruses - Assess for interstitial edema
- Proper positioning
For Anaphylactic Assessment
- recent exposure to pharmacological agents, blood transfusion 2. Decreased Cardiac Output related to negative inotropic
and insect bites or stings changes at the myocardium secondary to effects of tissue O2
- clinical presentation is dependent on several factors and varies deprivation
with the portal of antigen entry, the amount absorbed, rate of
absorption, and the degree of hypersensitivity Desired Outcome
- Ingestion: cramping, nausea, vomiting and may precede Within 8 hours of initiation of therapy, patient has a n adequate
systemic shock syndrome cardiac output as evidenced by good BP, urine output and god
- Inhalation: hoarseness, dyspnea and whezing peripheral pulses
- Allergic: urticaria or itching at the site of the sting, or drug
injection Intervention
- Assess patient for signs of deceasing CO
Diagnostic Test/ Procedure - Administer inotropics as prescribed
-WBC, serum glucose, GS-CS, ABG, BUN, CT, BT, Liver studies - Position patient on supine to increase/ optimize preload and
enhance stroke volume
Collaborative Management (Septic) - Monitor cardiac rhythm
- antibiotic therapy specific to he organism - Minimize cardiac oxygen demand by assisting patient with ADL
- Hemodynamic monitoring
- Fluid resuscitation 3. Altered Cerebral, renal, gastrointestinal tissue perfusion
- Inotropic Agents related to decreased to circulating blood volume secondary to
- Ventilatory Support massive vasodilatation and interruption of arterio-venous blood
- Alkaline Support flow associated to vasoconstriction and clot formation
- Nutritional Support
- Steroids Desired outcome
- Antipyretic Agent Within 24 hours after initiating therapy, the patient has an
- Naloxone adequate tissue perfusion as evidenced by orientation to time,
- GI solution place and person, good bowel sounds and good urine output

Collaborative Management (Anaphylaxis) Intervention

- Airway maintenance - Assess LOC hourly
- Epinephrine - Assess signs of decreasing renal perfusion
- Supplemental Oxygen - Assess/ monitor peripheral vascular resistance
- Fluid Resuscitation - Assess peripheral pulses
- Vasopressors - O2 saturation monitoring
- Assess evidence of decreasing visceral circulation including and associated vasodilation and increased capillary
bowel sounds permeability
Desired Outcome:
* Other examples of nursing problems… After 4 hours of continuous nursing intervention, the patient has
4. Impaired Gas exchange, related to alveolar- capillary an adequate cardiac output as evidenced by a near normal BP of
membrane changes secondary to interstitial edema, alveolar morethan 90/60, good urine output and normal sinus rhythm
destruction and endotoxin release with activation of histamine
and kinins
5. Ineffective breathing pattern related to decreased lung - Assess for physical and hemodynamic parameters indicating a
function secondary to central respiratory depression occurring in decreased cardiac ouput
the lat shock Check for apical pulse
Palpate peripheral for amplitude
6. Ineffective thermoregulation related to successful entry Assess BP
bacterial endotoxins, increasing the hypothalamic termperature Calculate MAP
regulating center Measure CVP
- Monitor ECG changes
7. Altered Nutrition less than body requirements related to - WOF signs of edema
increased need secondary to increased metabolic rate - Admisister fluid replacement therapy as prescribed
- Administer vasopessors as prescribed

Multiple Injury
Nursing Diagnosis and Interventions (Anaphylaxis) This includes:
1. Ineffective airway clearance realated to tracheobronchial 1. Major Trauma
obstruction secondary to bronchoconstriction and increased 2. Craniocerebral Trauma
secretions associated with histamine response and the presence 3. Chest Trauma
of leukotrienes and prostaglandins 4. Abdominal Trauma
Desired Outcome: 5. Renal and Lower Tract Trauma
Within 2 hours of intervention, the patient has an adequate Mechanisms of Injury:
airway clearance as evidenced by by a state of eupnea and the - Objects Producing Injury (ex. MVA, handgun, glass, wood,
presence of breath sounds in all lung fields metal)
- Type of Energy (ex. Kinetic, thermal, chemical, radiation)
Interventions: - Force of Energy (ex. Velocity, tension force, shearing force)
- Assess patency of airway on a continuing basis. Auscultate all - Use of Protective devices (ex. Helmet, airbags, seat belt)
lung fields
- Stand by Adrenergic agent in case of cardio-pulmonary arrest Types of Injury:
- Maintain intubation set at all times Blunt Injury – occurs without interruption on the skin integrity
- If laryngeal edema pevents intubation, prepare tracheostomy Penetrating – are produced from the motion of the objects that
set penetrate the tissue causing direct damage.
- Monitor ABG results
Oxygen Delivery and Consumption
2. Impaired gas exchange related to alveolo-capillary membrane - an oxygen debt is created by a profound imbalance between
changes secondary to increased vascular permeability oxygen supply and demand brought about by hypovolemia and
associated with histamine response inadequate tissue perfusion
Desired Outcome: - after initial restoration of circulating blood volume, he body
Within 2hours of initiation of intervention, he patient has develops a “hyperdynamic circulatory state”, which is associated
adequate gas exchange as evidenced by eupnea and O2 sat of with improved survival and fewer complications
more than 90% - the hyperdynamic state usually peaks within 48-72 hours and
diminishes in 7 -10 days
Intervention: - inability to achieve this state increases the mortality
- Monitor patient for the presence of SOB
- Secure ABG results as necessary Neuroendocrine Stress Response
- Monitor pulse oximetry reading regularly - shortly after the trauma, the CNS triggers a series of reactions
- Administer steroids as prescribed that promotes cmpentation including brain, blood, and bone
- Position patient in a sitting position to enhance lung expansion marrow
- Remain with the patient, encourage slow, deep breathing if - cathecolamines are released
possible. Help patient alleviate anxiety by responding calmly and - these hormones mobilizes glycogen stores, increases glucose
explaining all procedures before performing to them availablty, suppresses pancreatic insulin, resulting in an increase
net of glucose
3. Decreased cardiac output related to decreased preload and - centrally mediated release of ADH promotes water absorption,
afterload secondary to release of vasoactive chemical mediators increasing intravascular volume and diminishes urine output
Systemic Inflammatory Response Syndrome
- the release of cathecolamine triggers massive amount of WBC Management of Patients With Hypothermia
at the site of injury • Use ABCs, remove wet clothing, and rewarm
- SIRS is used without he presence of infection; SEPSIS is termed • Rewarming
in the presence of a widespread inflammation and infection – Active core rewarming
Cardiopulmonary bypass, warm fluid administration, warm
Multi Organ Dysfunction Syndrome humidified oxygen, and warm peritoneal lavage
Coagulopathy – Passive external rewarming
Hypothermia Warm blankets and over-the-bed heaters
Psychologic Response • Cold blood returning from the extremities has high levels of
lactic acid and can cause potential cardiac dysrhythmias and
electrolyte disturbances
Environmental Emergencies—Heat
Stroke Management Patients With
• A failure of heat regulating mechanisms Carbon Monoxide Poisoning
• Types
– Exertional: occurs in healthy individuals during exertion in • Inhaled carbon monoxide binds to hemoglobin as
extreme heat and humidity carboxyhemoglobin, which does not transport oxygen
– Hyperthermia: the result of inadequate heat loss • Manifestations: CNS symptoms predominate
• Elderly, very young, ill, or debilitated—and persons on some – Skin color is not a reliable sign and pulse oximetry is not valid
medications—are at high risk • Treatment
• Can cause death – Get to fresh air immediately
• Manifestations: CNS dysfunction, elevated temperature, hot dry – Perform CPR as necessary
skin, anhydrosis, tachypnea, hypotension, and tachycardia – Administer oxygen: 100% or oxygen under hyperbaric pressure
• Monitor patient continuously
Management of Patients With Heat Stroke
Management of Patients With
• Use ABCs and reduce temperature to 39° C as quickly as Chemical Burns
possible • Severity of the injury depends upon the mechanism of action of
• Cooling methods the substance, the penetrating strength and concentration, and
– Cool sheets, towels, or sponging with cool water the amount of skin exposed to the agent
– Apply ice to neck, groin, chest, and axillae • Immediately flush the skin with running water from a shower,
– Cooling blankets hose, or faucet
– Iced lavage of the stomach or colon – Lye or white phosphorus must be brushed off the skin dry
– Immersion in cold water bath • Protect health care personnel from the substance
• Monitor temperature, VS, ECG, CVP, LOC, urine output • Determine the substance
• Use IVs to replace fluid losses • Some substances may require prolonged flushing/irrigation
– Hyperthermia may recur in 3 to 4 hours; avoid hypothermia • Follow-up care includes reexamination of the area at 24 hours,
72 hours, and 7 days
Environmental Emergencies—Frostbite
• Trauma from freezing temperature and actual freezing of fluid Management of Patients With
in the intracellular and intercellular spaces Substance Abuse
• Manifestations: hard, cold, and insensitive to touch; may
appear white or mottled; and may turn red and painful as • Acute alcohol intoxication: a multisystem toxin
rewarmed – Alcohol poisoning may result in death
• The extent of injury is not always initially known – Maintain airway and observe for CNS depression and
• Controlled but rapid rewarming; 37° to 40° C circulating bath hypotension
for 30- to 40-minute intervals – Rule out other potential causes of the behaviors before it is
• Administer analgesics for pain assumed the patient is intoxicated
• Do not massage or handle; if feet are involved, do not allow – Use a nonjudgmental, calm manner
patient to walk – Patient may need sedation if noisy or belligerent
– Examine for withdrawal delirium, injuries, and evidence of
Environmental Emergencies—Hypothermia other disorders
• Internal core temperate is 35° C or less
• Elderly, infants, persons with concurrent illness, the homeless,
and trauma victims are at risk Crisis Intervention—Rape Victims
• Alcohol ingestion increases susceptibility
• Hypothermia may be seen with frostbite; treatment of • How the patient is received and treated in the ED is important
hypothermia takes precedence to his or her psychological well-being
• Physiologic changes in all organ systems • Crisis intervention begins as soon as the patient enters the
• Monitor continuously facility; the patient should be seen immediately
• Goals are to provide support, reduce emotional trauma, and • Critical incident stress management (CISM)
gather evidence for possible legal proceedings • Programs that include education, field support, defusing,
• Patient reaction; rape trauma syndrome debriefing, demobilization, and follow-up components
• History taking and documentation • Persons with ongoing stress reactions should be referred to
• Physical examination and collection of forensic evidence mental health specialists
• Role of the sexual assault nurse examiner (SANE)

Psychiatric Emergencies
Personal Protective Equipment (PPE)
• Overactive, underactive, violent, and depressed or suicidal • Purpose: to shield the health care provider from chemical,
patients physical, biological, and radiologic hazards that may exist when
• Management caring for contaminated patients
– Maintain the safety of all persons and gain control of the • Categories of protective equipment:
situation – Level A: self-contained breathing apparatus (SCBA) and vapor-
– Determine if the patient is at risk for injuring himself or others tight chemical-resistant suit, gloves, and boots
– Maintain the person’s self-esteem while providing care – Level B: high level of respiratory protection (SCBA) but lesser
– Determine if the person has a psychiatric history or is currently skin and eye protection; chemical-resistant suit
under care to contact the therapist – Level C: air-purified respirator, coverall with splash hood, and
• Crisis intervention chemical-resistant gloves and boots
• Interventions specific to each of the conditions – Level D: typical work uniform

Isolation Precautions for

Biological Terrorism Agents
Roles and Function of the Nurse in Emergency and Disaster • Biological agents may be delivered or spread in a number of
Nursing ways
• Educator • Due to modern travel, spread of infection may occur in areas
• Counselor thousands of miles apart
• Team member • Health care providers need to be aware of potential signs of
• Facilitator (include triaging) biological weapon dissemination; signs and symptoms are similar
• Advocate to those of common disease process
• Researcher • Isolation practices depend upon the infecting agent
• Always use Standard Precautions
Terrorism, Mass Casualty, and Disaster Nursing • Some agents require Transmission-Based Precautions
• Terminal disinfection and disposal of wastes depends on the
Emergency Operations Plan (EOP) infecting agent
• Health care facilities are required by the Joint Commission on
Accreditation of Healthcare Organizations to create a plan for Chemical Weapons
emergency preparedness and to practice this plan twice a year • Chemical substances that quickly cause injury and/or death and
• Essential components of the plan: cause panic and social disruption
– An activation response • Agents
– An internal/external communication plan – Nerve agents
– A plan for coordinated patient care – Blood agents
– Security plans – Vesicants
– Identification of external resources – Pulmonary agents
– A plan for people management and traffic flow • Agents vary in volatility, persistence, toxicity, and period of
• Essential components of the plan: latency
– A data management strategy • Limitation of exposure is essential with evacuation and
– Deactivation response decontamination as soon possible and as close to the scene of
– Post-incident response the incident as possible
– A plan for practice drills Nerve Agents
– Anticipated resources • Sarin and soman organophosphates
– Mass casualty incident planning • Inhibit cholinesterase-causing cholinergic symptoms
– An education for all of the above progressing to loss of consciousness, seizures, copious secretions,
apnea, and death
Managing Short- and Long-Term Psychological Effects After a • Treatment: supportive care, atropine, benzodiazepine, and
Disaster pralidoxime
• Provide active listening and emotional support • Decontaminate with copious amounts of soap and water or
• Provide information as appropriate saline for at least 20 minutes
• Refer to therapist or other resources • Blot; do not wipe off
• Discourage repeated exposure to media regarding the event • Plastic equipment will absorb sarin gas
• Encourage return to normal activities and social roles Vesicants
• Lewisite, sulfur mustard, nitrogen mustard, and phosgene
• Cause blistering and burning
• Respiratory effects can be serious and cause death
• Decontaminate with soap and water; do not scrub or use
hypochlorite solutions
• Eye exposure requires copious irrigation
• Treatment for lewisite exposure: dimercaprol IV or topically

Radiation Exposure
• Radiation exposure may occur due to nuclear weapons, nuclear
reactor incidents, or exposure to radioactive samples
• Exposure to radiation is affected by time, distance, and
• Types of radiation exposure:
– External radiation: all or part of the body is exposed to
radiation; as decontamination is not necessary, it is not a medical
– Contamination: exposure to radioactive gases liquids or solids;
requires immediate medical management to prevent
– Incorporation: uptake of the radioactive material into the body

Radiation Decontamination
• Triage outside the hospital
• Cover floor and use strict isolation precautions to prevent the
tracking of contaminants
• Seal air ducts and vents
• Waste is double bagged and put in a container labeled radiation
• Staff protection
– Water-resistant gowns, 2 pairs of gloves, caps, goggles, masks,
and booties
– Dosimetry devices
• Patients are surveyed for radiation and directed to the
decontamination area
• Each patient is decontaminated with a shower outside the ED
• Water, tarps, towels, soap, gowns, all the patient’s belongings,
etc., must be collected and contained
• Patients are surveyed and showered again as necessary
• Showering should be performed so as not to contaminate clean
areas with runoff from the showering
• Biologic samples: nasal and throat swabs; blood
• Internal contamination requires additional treatment: catharsis
and gastric lavage with chelating agents

Radiation Injuries
• Acute radiation syndrome (ARS): dose of radiation determines if
ARS will develop
• All body systems are affected by ARS
• Presenting signs and symptoms determine predicted survival
• Probable survivors have no initial symptoms or only minimal
• Possible survivors present with nausea and vomiting that
persists for 24 to 48 hours
• Improbable survivors are acutely ill with nausea, vomiting,
diarrhea, and shock; neurologic symptoms suggest lethal dose;
and survival time is variable