Module 15: Nursing Care of Individual Experiencing Shock/Trauma/Disaster: Critical Care
Concepts-
Emergency and Disaster Care Notes
Most clients with life-threatening or potentially life-threatening problems - transported to (ED).

Sequence for care based on prioritization process known as triage

Triage normally performed by nurses as clients enter emergency department; also performed by
emergency medical personnel or first responders outside of hospital when multiple casualties.

In the hospital setting, triage- critical assessment skill needed by emergency nurse to facilitates
rapid determination of client’s acuity level> facilitate trt of clients who have threat to life, vision, or
limb before treating other clients

Categorizes - most critical treated first

Emergency Severity Index: (Fig 69-1)-Five-level triage system that incorporates
illness severity and resource utilization ;Emergency Severity Index 5-level
triage system- provides standardized approach to triage/guides initiation of
appropriate interventions by prioritizing clients based on urgent needs or threat
to life. See table 69-2 page 1766.
PRIMARY SURVEY -Assessment of client in emergency room; begins with primary survey focusing on
airway, breathing, circulation, and disability; identifies life-threatening conditions/ facilitates immediate
intervention as each step performed.
Important-summary of risk factors, key assessment findings that nurse looks for/ immediate response
required. See Table 6-3 page 1768; *Recognize causes of life threatening injury Tab 69-4 p.1769
Airway- with cervical spine stabilization and/or immobilization:

Risk factors – facial trauma, vomiting, tongue in airway, seizures, near-drowning, anaphylaxis,
foreign body obstruction, cardiopulmonary arrest

Assessment findings: dyspnea, inability to vocalize, visible foreign body in the mouth or airway, and
trauma to the face or neck.

Airway interventions progress rapidly from the least to the most invasive and may progress from
opening the airway by *jaw-thrust maneuver, suctioning and/or removal of foreign body, *rapid –
sequence intubation/insertion of a nasopharyngeal or oropharyngeal airway, to endotracheal
intubation or cricothyroidotomy as needed.

Cervical spine must be stabilized - rigid cervical collar or other means of immobilization in clients
with face, head, or neck trauma and/or significant upper torso injuries.
Breathing alterations:

Risk factors - fx ribs, pneumothorax, penetrating injury, allergic reactions, pulmonary emboli,
asthma, tension pneumothorax, and flail chest

Assessment findings: Look listen & feel, estimate respiratory rate - dyspnea,
rapid/slow/shallow/deep/irregular respirations, absence of nasal/oral air flow, use of accessory or
abdominal muscles, paradoxical or asymmetric chest wall movement, visible chest wall wound,
cyanosis of nail beds, mucus membranes or skin, tracheal deviation and neck vein distention.
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
Interventions: open & clear airway, administer high-flow oxygen (100%) via a non-rebreather mask,
bag-valve-mask ventilation with 100% oxygen, assist with intubation, and/or thoracostomy/chest
tube insertion as needed.
Circulation:

Risk factors – myocardial infarction, injury to hear/ blood vessels, shock, or dec circulating volume

Assessment findings: absence/thready/rapid/slow carotid or femoral pulse (peripheral pulses often
absent due to direct injury or vasoconstriction) Pale/cyanotic/cool/clammy skin, capillary refill < 3
seconds, altered mental status, presence of external bleeding, rigid abdomen

Interventions: CPR, advanced life support, direct pressure to wound, elevate legs if appropriate
o Draw blood for type and cross match as well as CBC, coagulation, toxicology, chemistry
studies when IV inserted.
o **Insert two large-bore IV catheters – 18, 16, or 14 gauge or size that can be
successfully inserted (*Critical- IV access, fluids with trauma!) Priority!
o **Begin aggressive fluid resuscitation using normal saline or lactated Ringer’s
solution, plasma expanders, or packed red blood cells (O negative if needed), auto
transfusion when there are clean chest injuries, client supine with legs elevated if in
shock, in rare cases pneumatic antishock garment for bleeding pelvic fractures (consider
risk when deflating)
Disability:

Risk factors – head injury, stroke, shock, metabolic problem as diabetic coma, overdose, fractured
limbs, etc.

Assessment findings: altered level of consciousness based on AVPU: A = alert, V = responsive to
voice, P = responsive to pain, and U = unresponsive, Glasgow Coma Scale (Chapter 57) and
altered pupils size, shape, response to light, and equality.

Deformities and inability to move extremities and pain status

Interventions: report/reassess neuro status, quick reduction of fractures using traction splints like
Kendrick to immobilize limbs, restore circulation, help prevent trauma to large blood vessels. Pain
relief important - may deferred until blood pressure adequate or during secondary survey; **
need adequate neuro evaluation

*Some tools include an “E” for “Exposure/Environmental-removal all patients garments to identify
any/all injuries.
E = Exposure/Environmental Control

Remove trauma patients’ clothing-perform thorough physical assessment; once exposed, limit
heat loss, pvt hypothermia, maintain privacy, use warming blankets, overhead warmers, warmed IV
fluids/save clothing, label.
SECONDARY SURVEY –**brief, systematic process – identify all injuries. p. 1769; Tab. 69-5 p. 1776.

F- Full set of vital signs/five interventions/facilitate family presence: focused adjuncts (obtain vital
signs, including) bilateral blood pressure, heart rate, respiratory rate, and temperature, comfort
measures
o interventions: 1) ECG monitoring; 2) pulse oximetry; 3)portable chest x-ray to confirm
placement tubes 4) Foley catheter insertion *unless contraindicated; 5)orogastric or
nasogastric tube inserted; 6) blood for laboratory studies is collected if not drawn during IV
insertion; 7) tetanus prophylaxis
o Family presence: family members wishing to be present during invasive procedures and
resuscitation should be supported.
o Pain management strategies should include a combination of pharmacologic and
nonpharmacologic measures.

G-Give comfort measures

H- History and head-to-toe assessment: A thorough history of event, illness, injury from patient,
family, and emergency personnel.
o AMPLE – allergies, medications taken/prescribed, past health history, last meal, events
preceding the illness or injury.
o Thorough 60 second head-to-toe assessment; Look for anything that could kill the client.
o Gently palpate skull with palms of hands checking the back of skull by pushing down on bed
not by lifting head, look for Battle’s sign and raccoon eyes, if no stabilization devise in place
gently run hand behind cervical spine feeling for step offs and asking client about numbness or
tingling, apply stabilization device and ask again if numbness or tingling are now present –
skull injuries may indicate fractures, increased ICP, intracranial bleeding, cerebral spinal fluid
leaks or spinal injury. Combative clients may have brain trauma.
o Gently palpate chest for flail chest etc.
o Listen to abdomen before palpating – absence of bowel sounds/ rigid abdomen – *to surgery
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Pelvis gently palpated-avoid pelvic rocking to check for pelvic fractures – may severe large
blood vessels.
o Gently assess perineum for bleeding and visible injuries.
o Gently palpate limbs and reduce fractures
o Assess back: Log roll (maintaining cervical spine immobilization) for examination of back for
ecchymoses, abrasions, puncture wounds, cuts, deformities, spine for misalignment, deformity
or pain, and quick rectal exam for tone and stool for blood testing.
After assessmento Record all findings/ongoing monitoring
o Apply warm blankets, over head warmers, and use warmed IV fluids to prevent hypothermia
o Draw blood for labs if not already done.
o Any remaining 5 interventions are completed
o All clients-evaluated to determine need for tetanus prophylaxis (*tab 69-6)
o Ongoing client monitoring/evaluation of interventions-critical-nurse responsible for providing
appropriate interventions and assessing the patient’s response.
Depending on patient’s injuries and/or illness-patient may: (1) be transported for diagnostic studies
such as x-ray, CT scan, or exploratory/diagnostic surgery; (2) require focused abdominal sonography or
peritoneal lavage; (3) be admitted to a general unit, telemetry, or intensive care unit; or (4) be
transferred to another facility.
o
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DEATH IN THE EMERGENCY DEPARTMENT-emergency nurse follows hospital protocol in
supporting/preparing the bereaved to grieve, collecting deceased’s belongings, arranging for autopsy,
preparing for viewing the body, and making mortuary arrangements; may also contact a pastor or social
services and assist with contact of other family members.
o Many clients who die in ED-potential candidates for *non–heart beating donation; certain
tissues and organs such as corneas, heart valves, skin, bone, and kidneys can be harvested from
clients after death
o Nurse responsible for contacting the local organ procurement organization; representatives of that
organization then determine if donation appropriate and approach family or next of kin to
determine wishes related to organ donation.
GERONTOLOGIC CONSIDERATIONS IN EMERGENCY CARE- Elderly at high risk for injury primarily
from falls.
o Risk factors – dec visual acuity, limited neck mobility, slower gait, and reduced reaction time
o Three most common causes of falls in elderly: generalized weakness, environmental hazards, and
orthostatic hypotension due to dehydration and side effects of medications.
o When assessing a patient who has experienced a fall-important to determine if * physical findings
may have actually caused fall or may be due to the fall itself.
o Check for confusion/loss of consciousness due to MI, TIA, CVA or head injury due to fall.
EMERGENCY MANAGEMENT OF DISORDERS PREVIOUSLY STUDIED- See Table 69-1 for information
citing on etiology, assessment findings, and interventions for trt of common conditions managed in
emergency room.
ENVIRONMENT RELATED EMERGENCIES
HEAT-RELATED EMERGENCIESo Pathophysiology – prolonged exposure to moderately high temperatures or brief exposure to
extremely high temperatures- worse by high humidity, physical activity, restrictive clothing, illness
such as heart disease or febrile illness, or medications such as diuretics can over tax hypothalamic
thermoregulatory mechanisms as sweating, vasodilation, and inc respirations leading to heat
related emergencies. **See Table 69-7 for more examples of risk factors and Table 69-8 for
emergency management.
o *Heat Exhaustion-Clinical syndrome characterized by fatigue, lightheadedness, nausea/vomiting,
diarrhea, feeling of impending doom, tachypnea, tachycardia, dilated pupils, mild confusion, ashen
color, profuse diaphoresis and hypotension, mild to severe temperature elevation (99.6º to 104º F
[37.5º to 40º C]) due to dehydration
o Place patient in cool area, remove constrictive clothing
o Place moist sheet over patient to dec core temperature
o Provide oral fluid
o Replace electrolytes
o Initiate normal saline IV solution if oral solutions are not tolerated
o Adm to hospital if not improved within 3-4 hrs
o *Heat Stroke-Failure of hypothalamic thermoregulatory processes; vasodilation, inc sweating,
respiratory rate deplete fluids and electrolytes, specifically sodium; sweat glands stop functioning
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and core temperature inc (>104º F [40º C]); Alt mentation, absence of perspiration, and circulatory
collapse can follow; Cerebral edema and hemorrhage dt direct thermal injury to the brain
Stabilize patient’s ABC, rapidly reduce temperature
Cooling methods: remove clothing, cover with wet sheets
Place patient in front of large fan; immerse in ice water bath
Administer cool fluids or lavage with cool fluids
Shivering: Inc core temperature, complicates cooling efforts, treated with IV
chlorpromazine
o Aggressive temperature reduction until core temperature reaches 102º F
(38.9º C) *NOTE antipyretics NOT effectivef
o Monitor for signs of rhabdomyolysis, myoglobinuria, and DIC
COLD RELATED EMERGENCIES
o Frostbite Pathophysiology – prolonged exposure or exposure to intense cold > vasoconstriction,
dec circulation, vascular stasis. Ice crystals form in intracellular spaces, intracellular sodium and
chloride inc >cells rupture and organelles damaged > formation of edema in 3 hours, blisters in 6
hours to days >tissue necrosis with gangrene > necessitate amputation
Frost bite 24 hrs after injury-text Fig 69-3, Fig 69-4 p. 1775
o
o
o
o
o
Frostbite to toes-
Gangrenous necrosis 6 weeks after injury
o Hypothermia pathophysiology – heat produced by body cannot compensate for heat loss to
environment. Greatest heat loss is from the head, thorax, and lungs with each breath. Exposure to
freezing temperatures with inadequate clothing, moisture, wind, near-drowning and water
immersion inc. Ederly are more prone to hypothermia, and rapid infusion of cold IV fluids, certain
drugs, alcohol, and diabetes are considered risk factors for hypothermia. See Table 69-9
o Mild hypothermia (93.2º to 96.8º F9; 34º to 36º C);
o Shivering
o Lethargy, confusion, r ational to irrational behavior
o Minor heart rate changes
o Moderate hypothermia (86º to 93.2º F;30º to 34º C)
o Rigidity, bradycardia, bradypnea
o Blood pressure by Doppler
o Metabolic and respiratory acidosis, hypovolemia
o Shivering disappears at temperature- <92º F (33.3º C)
o Coma when core temperature-<82.4º F (28º C); death usually when core temp <78º F (25.6º C)
o Profound hypothermia (<86º F [30º C]) makes person appear dead
o Bradycardia, asystole
o Ventricular fibrillation
o Management Hypothermia
o Warm to at least 90º F (32.2º C) before pronouncing dead
o Cause of death—refractory ventricular fibrillation
o Manage/maintain ABCs; Rewarm patient; Correct dehydration/acidosis; Treat cardiac
dysrhythmias
o Mild hypothermia: Passive or active external re-warming
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
Passive external re-warming: Move patient to warm, dry place; remove damp
clothing; place warm blankets on patient

Active external re-warming: body-to-body contact, fluid- or air-filled warming
blankets, radiant heat lamps
o Moderate to profound hypothermia: Active core re-warming

Use heated, humidified oxygen; warmed IV fluids; peritoneal, gastric, or colonic
lavage with warmed fluids
o Risks of rewarming
o “Afterdrop”, a further drop in core temperature > Hypotension & Dysrhythmias
o Re-warming should be discontinued once core temperature - 95º F (35º C)
SUBMERSION INJURY
o Submersion injury pathophysiology - Drowning -death from hypoxia dt aspiration and swallowing
liquid >pulmonary edema after submersion in water or other liquid. Intense bronchospasm with airway
obstruction -referred to as “dry downing”. See Fig 69-6and Tab 69-10 1777. All victims near-drowning
should be observed in hospital for minimum of 4 to 6 hours. Delayed pulmonary edema (also known
as secondary drowning) can occur= delayed death from drowning dt pulmonary complications.
o
o
Submersion Injury-Aggressive resuscitation efforts and mammalian diving reflex improve survival of
near-drowning victims
Treatment of submersion injuries
o Correct hypoxia and acid-base and fluid imbalances
o Support basic physiologic functions; rewarm if hypothermia present
o Initial evaluation: ABCD; mechanical ventilation with PEEP or CPAP to improve gas exchange
when pulmonary edema is present
o Deterioration in neurologic status: Cerebral edema, worsening hypoxia, profound acidosis
BITES AND STINGS- Bites cause injury-possible death dt tissue laceration, crushing, or chewing which may
be accompanied by release of toxins >bleeding, allergic reactions, or infection. Insect stings> mild
discomfort or serious allergic reactions/anaphylaxis. See Chr 14 for more information on anaphylaxis.
Black Widow Spider-Brown Recluse Slide Show
o
o
o
Black Widow Spider venom neurotoxic >often leads to inc pain, HTN, paresthesia >seizures,
muscle spasms, shock.
Brown Recluse Spider venom cytotoxic> often cause deep necrotic ulceration encircled with bluish
purple discoloration.
Tic bites >Rocky Mountain spotted fever, tick paralysis, or Lyme disease- See Chapter 65 for
additional review. *Know how to remove tick…don’t squeeze-use forceps or tweezers to grasp at
point of attachments and pull upwards (p. 1778)
Copperhead
coral snake
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o
o
Snakebites: *At risk for hypovolemic shock/hemolysis- need IV access first (not in ch 69)
Venom from rattlesnakes, copperheads, water moccasins is *hemolytic while venom from
coral snake is *neurotoxic. Snake bites> necrosis, loss of function at site, GI bleeding, respiratory
difficulty, constricted pupils, seizures, severe hemorrhage, renal failure, and hypovolemic shock.
Animal or human bites-assoc infection and mechanical destruction of skin, muscle, tendons, blood
vessels, and bone.
o Consideration of rabies prophylaxis-essential component in management of animal bites. Initial
injection of rabies immune globulin given, followed by a series of five injections of human diploid
cell vaccine on days 0, 3, 7, 14, and 28 to provide active immunity.
POISONINGS- any chemical that harms body; can be accidental, occupational, recreational, or intentional;
severity of poisoning depends on type, concentration, and route of exposure.
o Specific management of toxins involves dec absorption, enhancing elimination, and implementation
of toxin-specific interventions per local poison control center. **See p. 1780 Table 69-11
o Options for dec absorption of poisons include gastric lavage, activated charcoal, dermal
cleansing, and eye irrigation.
o
Patients with alt level of consciousness or diminished gag reflex- must intubate before
lavage; lavage must be performed within 2 hours of ingestion of most poisons;
**contraindicated in patients who ingested caustic agents, co-ingested sharp objects, or
ingested nontoxic substances.
o
Most effective intervention for mgt of poisonings-adm activated charcoal orally or via a gastric
tube within 60 minutes of poison ingestion.
o Contraindications to charcoal adm are diminished bowel sounds, ileus, or ingestion of a
substance poorly absorbed by charcoal- Charcoal can absorb/neutralize antidotes; should not
be given immediately before, with, or shortly after, charcoal.
o Skin and ocular decontamination involves removal of toxins from eyes and skin using copious
amounts of water or saline- with *** exception of mustard gas, most toxins can be safely removed
with water or saline (water mixes with mustard gas >chlorine gas.)
o *Decontamination takes priority over all interventions except basic life support techniques.
o Elimination of poisons-inc through adm of cathartics, whole-bowel irrigation, hemodialysis,
hemoperfusion, urine alkalinization, chelating agents, and antidotes.
o Cathartic as sorbitol given with first dose of activated charcoal to stimulate intestinal
motility and inc elimination.
6  RNSG 2432
o
Hemodialysis and hemoperfusion-reserved for patients who develop severe acidosis
from ingestion of toxic substances.
VIOLENCE- acting out of emotions of fear or anger to cause harm to someone or something; may be result
of organic disease, psychosis, or antisocial behavior; can occur in home, community, and workplace inc ED
o Domestic violence- pattern of coercive behavior in relationship that involves fear, humiliation,
intimidation, neglect, and/or intentional physical, emotional, financial, or sexual injury-most victims
women, children, and elderly, can be found in all professions, cultures, socioeconomic groups,
ages, and in both genders
o Screening for domestic violence required for any patient who is found to be victim of abuse;
appropriate interventions should be initiated, including making referrals, providing emotional
support, and informing victims about their options.
AGENTS OF TERRORISM- Terrorism involves overt actions such as dispensing of disease pathogens
(bioterrorism) or other agents (e.g., chemical, radiologic/nuclear, explosive devices) as weapons for the
expressed purpose of causing harm.
****BIOTERRORISM *view PPT video
o Pathogens most likely to be used in a bioterrorist attack are anthrax, smallpox, botulism, plague,
tularemia, and hemorrhagic fever.
o Anthrax, plague, and tularemia can be treated effectively with commercially available
antibiotics if sufficient supplies available and organisms not resistant.
o Smallpox can prevent ameliorated by vaccination even when first given after exposure.
o Botulism can be treated with antitoxin.
o No established treatment for viruses that cause hemorrhagic fever.
**See Table 69-12.
****CHEMICAL AGENTS OF TERRORISM- categorized according to target organ or effect.
o Sarin-highly toxic nerve gas >cause death within minutes of exposure- enters body through eyes
and skin; acts by paralyzing respiratory muscles; antidotes for nerve agent poisoning inc atropine
and pralidoxime chloride
o Phosgene -colorless gas normally used in chemical manufacturing; if inhaled at high
concentrations for long enough period > severe respiratory distress, pulmonary edema, and death.
o Mustard gas- yellow to brown in color, garlic-like odor; irritates eyes > skin burns and blisters.
*See Table 69-13 p. 1783 for organs impacted by various chemical agents.
RADIATION EXPOSURE- Radiologic/nuclear agents can be delivered by Radiologic dispersal devices,
(RRD) also known as “dirty bombs,” consisting of a mix of explosives and radioactive material.
o
Explosion of this type of bomb scatters radioactive dust, smoke, and other material into
surrounding environment > radioactive contamination
o Main danger from RRD from force of explosion, objects projected from it, with only those
casualties in close proximity exposed to significant radiation.
o Measures to limit contamination and decontamination required.
Ionizing radiation (e.g., nuclear bomb (click for YouTube video), damage to nuclear reactor) represents
a serious threat to safety of casualties and environment. See Table 69-14 p. 1784 for information on acute
radiation syndrome.
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o
o
o
Exposure to ionizing radiation may/may not inc skin contamination with radioactive material; if
external radioactive contaminants present, decontamination procedures >initiate immediately.
Acute radiation syndrome develops after substantial exposure to ionizing radiation-follows a
predictable pattern.
Explosive devices used as agents of terrorism result in one or more of following types of injuries:
blast, crush, or penetrating.
EXPOSURE TO BLASTS OR EXPLOSIONS-Blast injuries result from supersonic over-pressurization shock
wave that occurs following explosion> damage to lungs, middle ear, GI tract, and brain. Crush injuries often
from explosions that occur in confined spaces and result from structural collapse. Some explosive devices
contain materials that are projected during explosion, leading to penetrating injuries.
EMERGENCY AND MASS CASUALTY INCIDENT PREPAREDNESS- mass casualty incident (MCI)-man
made (e.g., an act of warfare or terrorism) or natural (e.g., severe weather event) disaster that overwhelms a
community’s ability to respond with existing resources.
o MCIs usually involve large numbers of casualties, involve physical and emotional suffering >
permanent changes within a community; require assistance from people and resources outside the
affected community (e.g., American Red Cross, Federal Emergency Management Agency [FEMA]).
o Many communities have initiated programs to develop community emergency response teams
(CERTs) which can assist as first responders. CERTs have been recognized by FEMA as
important partners in emergency preparedness, training helps citizens to understand their personal
responsibility in preparing for a natural or manmade disaster.
o Citizens taught what to expect following a disaster and how to safely help themselves, their family,
and their neighbors-training inc teaching of life-saving skills, with emphasis on decision-making and
rescuer safety.
o When a mass casualty incident occurs, first responders (i.e. trained volunteers, police, and
firemen) as well as emergency medical personne-dispatched to the scene. If *hazardous
materials present first responders taught to wait for proper equipment to avoid adding
themselves to number of casualties. First responders usually carry gloves, masks, goggles, a
helmet for self protection as well as sterile bandages and a blanket in their automobiles.
Preparing to respond in event of a disaster or MCI
o Expected of ALL nurses, regardless of their specialty area or place of practice.
o Preparing to respond important
o impact of disaster increasing
o nurses occupy largest sector of healthcare workers and are positioned to assist
individuals and families during and after a disaster/MCI (nurses key players in
emergency/disaster response)
o nurses highly trusted by public
o when nurses prepared they provide example to others in community to be prepared
o Inc preparedness = inc response effectiveness.
Planning to respond (*Nurse professional responsibility- important) inc
o Develop personal/family emergency plan (provisions for child, family, pet care and transportation
outside of normal work hours)- facilitates nurse reporting for emergency work when needed.
o Personal protective equipment (PPE), including gloves, mask, and eye wear essential in a home
first aid kit.
Triage of casualties in major emergency or mass casualty incident (MCI)
o Differs from usual triage that occurs in ED
o Must be conducted in less than 15 seconds/victim
o Goal-do most good for most people.
o System of colored ribbons/tags to designate both seriousness of injury and likelihood of survival.
8  RNSG 2432
o
Green tags -minor injury or no noticeable injury-walking wounded; identified when first
responders arrive at scene and call out “If you can walk come to sound of my voice.” Can
often assist to care for other victims or help to document a description of scene, location of
various categories of victims, and number of each type of victim. Written information vital
and when reported to EMS and to hospitals-assists with appropriate distribution of victims
and resources.
o Next, first responders start where they are standing and quickly triage remaining victims in
a systematic- process, START (Simple Triage and Rapid Transport) continues in this way:
o Responder walks up to victim and asks if he is okay. If no response; a look, listen, and feel
is performed to assess for respirations. If none noted, a gentle head tilt with jaw lift is
performed and the look, listen, and feel are checked again. In no respirations are present,
the process is repeated one more time. If breathing begins a towel or roll is placed under
victim’s back to keep head in position for open airway or victim is log rolled into the
rescue position (a Sim’s lateral position with lower arm placed under victim’s head to
maintain a slight extension for an open airway) after bleeding (apply pressure and tie
bandage on with a bow for easy release) and circulation are also assessed. Legs are
elevated and a blanket applied if victim is in shock. No time to perform CPR in this type of
situation. *Know Tag system
o Yellow tags indicate non-critical or non–life-threatening injury; will need to be seen by
physician but can be delayed; include simple fractures, minor burns that can wait 1 to 2
hours to receive medical care.
o *Red tags indicate life-threatening injury requiring immediate intervention; include victims
with airway problems, decreased level of consciousness, obvious and dramatic arterial
bleeding, and internal bleeding within the abdomen or due to a fractured leg, severe
burns, brain or spinal cord injuries.
o Black tags identify casualties who are deceased or who are expected to die. On
assessment black tag victims do not respond to 2 attempts to open airway, have no
carotid or femoral pulse, and have no capillary refill after 2 seconds.
o In mass casualty incidents there are often many more green tag casualties than red or yellow
casualties. Green casualties not remaining at scene to help are often first to arrive at hospitals and
most are transported by private cars.
o *Red tag victims must be cared for first by irst responders after all victims are triaged or by
EMS once they have arrived on scene. Red tags are also first to be cared for at hospital ER .
o If there is known or suspected contamination, decontaminated facilities can be set up at the
scene; is performed prior to transport to hospitals. Decontamination areas can also be set up at
hospitals. Usually water, saline, or ordinary soap and water are used for decontamination.
Total number of casualties a hospital can expect is estimated by doubling the number of casualties that
arrive in the first hour.
o Generally, 30% of casualties require admission to hospital; 50% will need surgery within 8 hours.
o Hospitals have plans in place to manage casualties. Often various areas of the hospital are set
aside to deal with specific types of victims and personnel wearing color coded vests labeled to
designate their role/profession are assigned specific tasks. Signs placed to direct movement of
victims to appropriate areas. Additional staff and physicians are called to the hospital to assist
based on the reports received from the disaster site.
o
All health care providers should have role in emergency and MCI preparedness, knowledge of
hospital’s emergency response plan, participation in emergency/MCI preparedness drills required.
o To optimize effectiveness in disaster/MCI response, nurses must prepare as a team with other
healthcare professionals; hospital-wide disaster training/drills are imperative to ensure each team
member follows clear lines of communication and performs according to clearly assigned roles. City
and county-wide drills needed to coordinate resources and services between first and secondary
responders.
Organized volunteer groups such as the American Red Cross, Voluntary Organizations Active in Disasters
(VOAD), disaster medical assistance teams (DMATs), and community emergency response teams (CERTs)
are especially appealing to nurses and other healthcare members that work outside of a hospital setting.
Response to MCIs often requires aid of a federal agency such as the National Disaster Medical System
(NDMS), which is a division within U.S. Department of Homeland Security that is responsible for
coordination of federal medical response to MCIs.
o Component of NDMS is to organize/train volunteer disaster medical assistance teams (DMATs).
o DMATs categorized according to ability to respond to MCI. Level-1 DMAT can be deployed within
8 hours of notification and remain self-sufficient for 72 hours with enough food, water, shelter, and
medical supplies to treat about 250 patients per day. Level-2 DMATs lack enough equipment to be
RNSG 2432  9
self-sufficient but are used to replace a Level-1 team, using and supplementing the equipment left
on site.
o Many hospitals and DMATs have critical incident stress management unit that arranges group
discussions to allow participants to verbalize and validate their feelings and emotions about the
experience.
o Post traumatic stress syndrome common problem from MCIs. May present immediately or
months after event; often characterized by emotions from fear to anger, denial, and shock. Initially
important to promote a sense of safety, caring. Supportive listening, debriefing, and referrals
o Formal mental health services required when following behaviors and symptoms are ongoing:
Disorientation, depression, anxiety, severe mental illness (hallucinations, preoccupation with
thoughts), inability to care for oneself, suicidal or homicidal thoughts or plan, problematic substance
use, and/or domestic violence.
o Nurses need to regularly engage in self-care practices to enable them to care for others. Good
self-care practices include: adequate rest/sleep, eating a well-balanced diet, regular physical
activity, engaging in social activities with family and friends, participating in hobbies, and nourishing
your spiritual health.
THE NURSES ROLE IN THE EMERGENCY ROOMUse of nursing process in care of individuals of varying ages whose care is made more difficult by the
limited assess to past medical history and the episodic nature of their health care needs.
o Responsibility for triage and prioritization.
o Emergency operations preparedness.
o Stabilization and resuscitation.
o Crisis intervention for unique client populations such as sexual assault survivors and crime victims
or perpetrators.
o Provision of care in uncontrolled or unpredictable environments.
o Managing unanticipated situations requiring intervention, allocation of limited resources, need for
immediate care as perceived by the client or others, unpredictable numbers of clients, and
unknown client variables.
Prioritization Questions
A teenager arrives by private car. He is alert and ambulatory, but his shirt and pants are covered with blood. He and his
hysterical friends are yelling and trying to explain that they were goofing around and he got poked in the abdomen with a
stick. Which of the following comments should be given first consideration?
1. “There was a lot of blood, and we used three bandages.”
2. “He pulled the stick out, just now, because it was hurting him.”
3. “The stick was really dirty and covered with mud.”
4. “He’s a diabetic, so he needs attention right away.”
Emergency and ambulatory care nurses are among the first health care workers to encounter victims from a bioterrorist
attack. Prioritize the actions for the ED staff in the event of a biochemical incident.
1. Report to the public health department or CDC per protocol
2. Decontaminate the victims in a separate area
3. Protect the environment for the safety of personnel and non-affected patients
4. Don personal protective equipment
5. Triage according to protocol
At 9pm, you admit a 63 year-old with a diagnosis of acute myocardial infraction to the ED. The physician is considering
the use of fibrinolytic therapy with tissue plasminogen activator (tPA, alteplase (Activase). Which information is most
important to communicate to the physician? The patient was:
1. treated with alteplase about 8 months ago
2. takes famotidine (Pepcid) for esophageal reflux
3. has T wave inversions on the 12-lead ECG
4. has had continuous chest pain since 1pm
The End!
Check your Responses
#1 2
#2 3, 4, 2, 5, 1
#3. 4
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