Emergency, Terrorism, and Disaster Nursing
Must be able to recognize life-threatening illness or injury
Triage – most impt assessment skill of ER nurses, five-level triage system, assess for
any threat to life or presence of a high-risk situation, next assess to see number of
anticipated resources needed
Primary Survey – helps to identify life-threatening conditions, once a condition is
identified start interventions immediately before proceeding to the next step of the
survey
 Airway with cervical spine stabilization and/or immobilization – look for
dyspnea, inability to speak, foreign body in the airway, trauma to face or
neck; jaw-thrust maneuver, suction, insert airway or endotracheal intubation
using rapid-sequence intubation; immobilize the cervical spine with a rigid
cervical collar and then secure forehead to backboard (don’t use sandbags)
 Breathing – just because you have an airway does not mean you have good
ventilation, watch for dyspnea, asymmetric chest wall movement, decreased
or absent breath sounds, wounds to chest wall, cyanosis, tachycardia,
hypotension; everyone should be given supplemental oxygen (100% via nonrebreather mask)
 Circulation – look for hemorrhage, always check carotid pulse since
peripheral pulses might be absent due to vasoconstriction, check capillary
refill and temperature, insert IV lines (2 large bore) and give NS or LR, apply
direct pressure to bleeding sites, obtain blood typing
 Disability – do a brief neuro exam including LOC, Glasgow Coma Scale (GCS)
and pupil responses; for LOC use AVPU – A (alert), V (responsive to voice), P
(responsive to pain), U (unresponsive)
 Exposure/Environmental Control – remove all clothing from trauma patients
but be sure to provide privacy and limit heat loss
Secondary Survey – begins after addressing every step of the primary survey and
beginning any lifesaving interventions; secondary survey serves to identify all
injuries
 Full set of vital signs/Focused adjuncts/Facilitate family presence
o Vital signs – get BP in both arms if chest trauma or BP is abnormally
high or low
o Focused adjuncts – ECG, O2 sat monitor, portable chest xray, insert
urinary catheter, insert NG tube, begin lab/diagnostic studies,
determine need for tetanus prophylaxis
o Faciliate family presence – assign a member of the health care team to
explain care delivered and answer questions
 Give comfort measures – treat pain, also give verbal reassurance, listen,
reduce stimuli, establish a trusting relationship with pt/family
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History and Head-to-toe assessment – need details such as mechanism of
injury, also chief complaint, subjective complaints, pain, behavior since onset,
health history AMPLE (A-allergies, M-medications, P-past health hx, L-last
meal, E-events/environment leading to the illness or injury)
o Head, neck, face – review pg 1771
o Chest – review pg 1771, always get 12 lead ECG esp. with known or
suspected heart disease
o Abdomen/Flanks – review pg 1771, need to frequently reevaluate, get
a bedside ultrasound if blood in the abdomen is suspected
o Pelvis/Perineum – review pg 1771, do not rock the pelvis, dr may do a
DRE to check for blood
o Extremities – review pg 1771, check pulses before and after splinting,
if an extremity is pulseless this is an emergency!, elevate injured
extremities, apply ice packs, give prophylactic antibiotics for open
fractures, assess for compartment syndrome esp. with crush injuries,
fractures, severe edema (ie. Burns), hemorrhage
Inspect the posterior surfaces – don’t forget to logroll and look at the back
Death in the ER – pt may be a candidate for organ donation, this can help the
families in the grieving process
Environmental Emergencies
Heat-Related
Heat rash – occurs when sweat ducts are blocked; fine, red, popular rash on torso,
neck, skinfolds
Heat syncope – elderly are at greater risk
Heat edema – swelling of hands, feet, ankles; resolves in days with rest, elevation,
and support hose; don’t give diuretics
Heat cramps – brief, intense cramps in large muscle groups fatigued by heavy work;
may also have n/v, tachycardia, pallor, weakness, profuse sweating; happens b/c of
inadequate fluid intake; tx – rest, oral or parenteral replacement of sodium and
water; need to avoid strenuous activity for at least 12 hours, salt replacement or
sports drinks during strenuous exercise in hot, humid weather
Heat exhaustion – occurs from prolonged exposure to heat over hours or days;
fatigue, n/v, extreme thirst, feelings of anxiety, hypotension, tachycardia, elevated
temp, dilated pupils, confusion, profuse sweating; tx – cool area, remove constricting
clothing, monitor for dysrhythmias from electrolyte imbalances, begin oral
fluid/electrolyte replacement if not nauseated, give IV NS, moist sheet to decrease
core temp
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Heatstroke – caused by failure of the hypothalamic thermoregulatory processes,
medical emergency!!, once sweating stops the core temp rises rapidly; core temp >
104, altered mentation, no sweating, circulatory collapse; tx – rapidly reduce the
core temp with clothing removal, wet sheets, immerse in cool water bath, lavage
with cool fluids, give 100% oxygen, do not allow shivering (can give IV thorazine),
stop cooling when core temp is 102; antipyretics are not effective, monitor for
rhabdomyolysis (breakdown of skeletal muscle) which can lead to renal failure,
watch for DIC
Cold-Related
Increased risk with age, medications that suppress shivering (opioids,
psychotropics, antiemetics), alcohol use (causes vasodilation and increased
sensation of warmth), smoking (vasoconstrictive)
Frostbite – local tissue freezing that causes formation of ice crystals in tissues and
cells after peripheral vasoconstriction; s/s – waxy pale yellow to blue mottled skin,
crunchy/frozen skin, tingling, numbness, burning; tx – handle carefully, do not
squeeze, massage, or scrub injured tissue, remove clothing and jewelry, immerse
affected area in warm bath; rewarming is extremely painful and blisters may form in
a couple of hours; after rewarming elevate the extremity to decrease edema; give IV
analgesia and tetanus prophylaxis; may need amputation
Hypothermia – core temp < 95, occurs when body can’t compensate for heat lost to
the environment, lose most heat from head, thorax and lungs; s/s – if mild
(shivering, lethargy, confusion, strange behavior, minor HR changes), if moderate
(rigidity, bradycardia, slow RR, low BP, metabolic/resp acidosis, hypovolemia,
decreased shivering, dysrhythmias, dehydration, thick blood so risk for MI, stroke,
PE, kidney failure), if severe (appear dead); always warm to 86 before pronouncing
them dead; tx – passive external rewarming – remove damp clothing, warm
blankets, gentle handling; active external rewarming – body to body contact, fluid or
air-filled warming blankets, radiant heat lamps; active core rewarming – heated
humidified oxygen, warmed IV fluids, peritoneal lavage with warmed fluids, cardiac
bypass; can cause afterdrop (further drop in core temp when cold peripheral blood
returns to the central circulation) so warm the core before the extremities, stop
rewarming when temp is 90-93
Submersion Injuries
Drowning – death from suffocation after submersion
Near-drowning – survival from potential drowning
Immersion syndrome – happens with immersion in cold water, stimulates the vagus
nerve and causes potentially fatal dysrhythmias
Dry drowning – no aspiration of water but get life-threatening bronchospasm and
airway obstruction; if they aspirate water, will get pulmonary edema and ARDS
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Tx – mechanical ventilation, oxygen, mannitol or Lasix to decrease free water and
treat cerebral edema; watch for decrease in neuro status or for head and neck
injuries
Secondary drowning – delayed death from drowning due to pulmonary
complications; this is why we observe all near drownings for 24 hours
Stings and Bites
Death occurs due to blood loss, allergic reaction, or lethal toxins
Hymenopteran stings (bees, yellow jackets, hornets, wasps, fire ants) – s/s may be
immediate or delayed up to 48 hours; many sting repeatedly, remove the stinger
using a scraping motion, no tweezers as it can cause more venom to be released,
remove rings/watches to prevent dangerous edema; s/s – stinging, burning,
swelling, itching, headache, fever, fainting, n/v, wheezing, hypotension; tx – if mild
(elevate, cool compress, lotions, oral antihistamines), if severe (IM or IV
antihistamines, SC epinephrine, corticosteroids)
Tick bites – ticks release neurotoxin venom as long as the tick head is attached,
remove the tick with tweezers close to the point of attachment and then clean the
skin with soap and water, don’t use hot match, petroleum jelly, or nail polish
Lyme disease – flu-like symptoms, bull’s eye rash, days to weeks later can
develop arthritis, meningitis, neuropathies
Rocky Mountain spotted fever – pink, macular rash on palms, wrists, soles,
feet, ankles; fever, chills, malaise, myalgias, headache
Treat both with doxycycline
Tick paralysis – flaccid ascending paralysis developing over 1-2 days, must
remove tick to prevent death
Animal and human bites – infection rates are very high, tx – clean with irrigation,
debridement, tetanus prophylaxis, leave puncture wounds open, rabies
postexposure prophylaxis
Poisonings
Tx – activated charcoal, skin cleansing, eye irrigation, gastric lavage; before lavage
patients who are unconscious must be intubated, gastric lavage must be done within
1 hour of ingestion to be effective; most common treatment is activated charcoal but
it doesn’t work for all toxins (ie. Must give Mucomyst for Tylenol ingestion); if it is a
dry chemical brush it off first before using water, decontamination is most
important priority except for basic life support; may also be given cathartics, bowel
irrigation, hemodialysis
Violence
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Very important and required that you screen for violence by asking “Do you feel safe
at home?”, “Is anyone hurting you?”
Terrorism
Anthrax, plague, tularemia – treated by antibiotics
Smallpox – can be given vaccine even if already exposed
Botulism – treat with antitoxin
Hemorrhagic fever – no treatment
Nerve agents – atropine, pralidoxime chloride
Mass Casualty Incidents (MCI)
Man-made or natural event or disaster that overwhelms a community’s ability to
respond with existing resources
Triage system (must happen in 15 seconds, victims should be decontaminated at the
scene, then treated and stabilized, then transported)
Green – minor injuries
Yellow – urgent, but non-life-threatening injuries (ie. Open fractures)
Red – life threatening injury that needs immediate tx (ie. Shock)
Blue – expected to die (ie. Massive head trauma)
Black - dead
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