Module #15B: Nursing Care of the Individual Requiring Emergency Care
Emergency and Disaster Care Notes Module # 15B
Most clients with life-threatening or potentially life-threatening problems are
transported to the emergency department (ED). The sequence by which clients
are cared for is based on a prioritization process know as triage. Triage is
normally performed by nurses as clients enter the emergency department. It is
also performed by emergency medical personnel or first responders outside of
the hospital when there are multiple casualties.
In the hospital setting, triage is a vital assessment skill needed by the emergency
nurse which facilitates rapid determination of a client’s acuity level. This
facilitates treatment of clients who have a threat to life, vision, or limb before
treating other clients. The Emergency Severity Index (ESI) is a 5-level triage
system that provides a standardized approach to triage and guides initiation of
appropriate interventions by prioritizing clients based on urgent needs or threat
to life. See table 69-2 page 1822.
PRIMARY SURVEY
Assessment of a client in the emergency room begins with a primary survey focusing
on airway, breathing, circulation, and disability. It identifies life-threatening
conditions and facilitates immediate intervention as each step is performed.
The following summarize risk factors, key assessment findings that the nurse looks
for, and immediate response required. See Table 6-3 page 1824.
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. See page 1823
Cervical spine must be stabilized with rigid cervical collar or other means of
immobilization in clients with face, head, or neck trauma and/or significant
upper torso injuries. Page 1823.
Breathing alterations:
Risk factors - fractured 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.
Interventions: open & clear airway, administer high-flow oxygen (100%) via a nonrebreather 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 heart or blood vessels, shock, or
decreased 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
Draw blood for type and cross match as well as CBC, coagulation, toxicology,
chemistry studies when IV is inserted.
Insert two large-bore IV catheters – 18, 16, or 14 gauge or size that can be
successfully inserted,
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
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 and reassess neuro status, quick reduction of fractures using
traction splints like the Kendrick to immobilize limbs, restore circulation and
help prevent trauma to large blood vessels. Pain relief is important but may be
deferred until blood pressure is adequate or during secondary survey.
SECONDARY SURVEY
The secondary survey is a brief, systematic process that is aimed at identifying all
injuries. See pages 1824 to 1827 and Table 69-5 page 1826.
Assessment: Exposure/environmental control.
All trauma patients should have their clothes removed for a thorough physical
assessment (cut along seams if a crime situation. Save all clothes and bandages in
separate paper bags with patient’s ID on each).
Interventions:
Full set of vital signs/five interventions/facilitate family presence:
Obtain vital signs, including bilateral blood pressure, heart rate, respiratory rate,
and temperature,
Five interventions are initiated: 1) ECG monitoring; 2) pulse oximetry; 3) Foley
catheter insertion unless contraindicated See page 1825; 4) orogastric or
nasogastric tube inserted; 5) blood for laboratory studies is collected if not
drawn during IV insertion.
Family presence: family members wishing to be present during invasive procedures
and resuscitation should be supported.
Pain management strategies should include a combination of pharmacologic and
nonpharmacologic measures.
History and head-to-toe assessment:
A thorough history of the event, illness, injury is obtained from the patient, family,
and emergency personnel. See pages 1825-6.
AMPLE – allergies, medications taken/prescribed, past health history, last meal,
events preceding the illness or injury.
A thorough 60 second head-to-toe assessment is necessary.
Look for anything that could kill the client.
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.
Gently palpate chest for flail chest etc.
Listen to abdomen before palpating – absence of bowel sounds or rigid abdomen –
will go to surgery
The pelvis is gently palpated. Avoid pelvic rocking to check for pelvic fractures –
may sever large blood vessels.
Gently assess the perineum for bleeding and visible injuries.
Gently palpate limbs and reduce fractures
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 assessment apply warm blankets, over head warmers, and use warmed IV
fluids to prevent hypothermia
Draw blood for labs if not already done.
Any remaining 5 interventions are completed
All clients should be evaluated to determine their need for tetanus prophylaxis.
Ongoing client monitoring and evaluation of interventions are critical and the nurse
is responsible for providing appropriate interventions and assessing the patient’s
response.
Depending on the patient’s injuries and/or illness, the 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.
DEATH IN THE EMERGENCY DEPARTMENT
The emergency nurse follows hospital protocol in supporting and preparing the
bereaved to grieve, collecting the deceased’s belongings, arranging for an
autopsy, preparing for viewing the body, and making mortuary arrangements.
The nurse may also contact a pastor or social services and assist with contact of
other family members.
Many clients who die in the ED are 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. The nurse is responsible
for contacting the local organ procurement organization. Representatives of that
organization then determine if donation is appropriate and approach the family
or next of kin to determine wishes related to organ donation.
GERONTOLOGIC CONSIDERATIONS IN EMERGENCY CARE
Elderly people are at high risk for injury primarily from falls.
Risk factors – decreased visual acuity, limited neck mobility, slower gait, and
reduced reaction time
The three most common causes of falls in the elderly are generalized weakness,
environmental hazards, and orthostatic hypotension due to dehydration and side
effects of medications.
When assessing a patient who has experienced a fall, it is important to determine
whether the physical findings may have actually caused the fall or may be due to
the fall itself.
Check for confusion/loss of consciousness due to MI, TIA, CVA or head injury due
to the fall.
EMERGENCY MANAGEMENT OF DISORDERS PREVIOUSLY STUDIED
See Table 69-1 for information on the etiology, assessment findings, and
interventions for treatment of common conditions managed in the emergency
room.
Utilize this chart as a reference/review in preparing for your clinical rotation to the
emergency room.
ENVIRONMENT RELATED EMERGENCIES
HEAT-RELATED EMERGENCIES
Pathophysiology – prolonged exposure to moderately high temperatures or brief
exposure to extremely high temperatures made 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 such as sweating, vasodilation, and increased respirations leading to
heat related emergencies. See Table 69-7 for more examples of risk factors and
Table 69-8 for emergency management.
COLD RELATED EMERGENCIES
Frostbite Pathophysiology – prolonged exposure or exposure to intense cold causes
vasoconstriction, decreased circulation, and vascular stasis. Ice crystals form in
intracellular spaces, intracellular sodium and chloride increase, cells rupture
and organelles are damaged followed by formation of edema in 3 hours, blisters
in 6 hours to days, and tissue necrosis with gangrene which may necessitate
amputation
Hypothermia pathophysiology – heat produced by the body cannot compensate for
heat loss to the 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 increase a
client’s risk. The elderly 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
SUBMERSION INJURY
Submersion injury pathophysiology - Drowning is death from hypoxia caused by
aspiration and swallowing liquid leading to pulmonary edema after submersion
in water or other liquid. Intense bronchospasm with airway obstruction is
referred to as dry downing. See Figure 69-5 and Table 69-10 on page 1833. All
victims of near-drowning should be observed in a hospital for a minimum of 4 to
6 hours. Delayed pulmonary edema (also known as secondary drowning) can
occur and is defined as delayed death from drowning due to pulmonary
complications.
BITES AND STINGS
Bites cause injury and possible death due to tissue laceration, crushing, or chewing
which may be accompanied by release of toxins and may result in bleeding, allergic
reactions, or infection. Insect stings may cause mild discomfort or serious allergic
reactions/anaphylaxis. See Chapter 14 for more information on anaphylaxis.
Black Widow Spider venom is neurotoxic and often leads to increasing pain,
hypertension, paresthesia, and can cause seizures, muscle spasms, and shock.
Brown Recluse Spider venom is cytotoxic often causing deep necrotic ulceration
encircled with bluish purple discoloration.
Tic bites can result in Rocky Mountain spotted fever, tick paralysis, or Lyme
disease. See Chapter 65 for additional review.
Snakebites: Venom from rattlesnakes, copperheads, and water moccasins is
hemolytic while venom from a coral snake is neurotoxic. Snake bites can result in
necrosis, loss of function at site, GI bleeding, respiratory difficulty, constricted
pupils, seizures, severe hemorrhage, renal failure, and hypovolemic shock.
Animal or human bites are associated infection and mechanical destruction of the
skin, muscle, tendons, blood vessels, and bone.
Consideration of rabies prophylaxis is an essential component in the management of
animal bites. An initial injection of rabies immune globulin is 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
A poison is any chemical that harms the body. Poisoning can be accidental,
occupational, recreational, or intentional. Severity of the poisoning depends on
type, concentration, and route of exposure. Specific management of toxins
involves decreasing absorption, enhancing elimination, and implementation of
toxin-specific interventions per the local poison control center. See Table 69-12
to reference information on common poisons.
Options for decreasing absorption of poisons include gastric lavage, activated
charcoal, dermal cleansing, and eye irrigation.
Patients with an altered level of consciousness or diminished gag reflex must be
intubated before lavage.
Lavage must be performed within 2 hours of ingestion of most poisons and is
contraindicated in patients who ingested caustic agents, co-ingested sharp
objects, or ingested nontoxic substances.
The most effective intervention for management of poisonings is administration of
activated charcoal orally or via a gastric tube within 60 minutes of poison
ingestion.
Contraindications to charcoal administration are diminished bowel sounds, ileus, or
ingestion of a substance poorly absorbed by charcoal.
Charcoal can absorb and neutralize antidotes, and these should not be given
immediately before, with, or shortly after, charcoal.
Skin and ocular decontamination involves removal of toxins from eyes and skin
using copious amounts of water or saline. With the exception of mustard gas,
most toxins can be safely removed with water or saline.
Water mixes with mustard gas and releases chlorine gas.
Decontamination takes priority over all interventions except basic life support
techniques.
Elimination of poisons is increased through administration of cathartics, wholebowel irrigation, hemodialysis, hemoperfusion, urine alkalinization, chelating
agents, and antidotes.
A cathartic such as sorbitol is given with the first dose of activated charcoal to
stimulate intestinal motility and increase elimination.
Hemodialysis and hemoperfusion are reserved for patients who develop severe
acidosis from ingestion of toxic substances.
VIOLENCE
Violence is the acting out of the emotions of fear or anger to cause harm to someone
or something. It may be the result of organic disease, psychosis, or antisocial
behavior and can occur in the home, community, and workplace including the
emergency room.
Domestic violence is a pattern of coercive behavior in a relationship that involves
fear, humiliation, intimidation, neglect, and/or intentional physical, emotional,
financial, or sexual injury. Most victims are women, children, and the elderly
and can be found in all professions, cultures, socioeconomic groups, ages, and in
both genders.
Screening for domestic violence is required for any patient who is found to be a
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 the 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
The pathogens most likely to be used in a bioterrorist attack are anthrax, smallpox,
botulism, plague, tularemia, and hemorrhagic fever.
Anthrax, plague, and tularemia can be treated effectively with commercially
available antibiotics if sufficient supplies are available and the organisms are not
resistant.
Smallpox can be prevented or ameliorated by vaccination even when first given
after exposure.
Botulism can be treated with antitoxin.
There is no established treatment for viruses that cause hemorrhagic fever.
See Table 69-13 pp. 1839-1840.
CHEMICAL AGENTS OF TERRORISM
Chemicals used as agents of terrorism are categorized according to their target
organ or effect.
Sarin is a highly toxic nerve gas that can cause death within minutes of exposure.
Sarin enters the body through the eyes and skin and acts by paralyzing the
respiratory muscles; antidotes for nerve agent poisoning include atropine and
pralidoxime chloride.
Phosgene is a colorless gas normally used in chemical manufacturing. If inhaled at
high concentrations for a long enough period, it causes severe respiratory
distress, pulmonary edema, and death.
Mustard gas is yellow to brown in color and has a garlic-like odor. The gas irritates
the eyes and causes skin burns and blisters.
See Table 69-14 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. Explosion of this type of bomb scatters radioactive dust, smoke, and
other material into the surrounding environment resulting in radioactive
contamination. The main danger from an RRD results from the force of the
explosion, objects projected from it, with only those casualties in close proximity
exposed to significant radiation., Measures to limit contamination and
decontamination should be initiated.
Ionizing radiation (e.g., nuclear bomb, damage to a nuclear reactor) represents a
serious threat to the safety of the casualties and the environment.
Exposure to ionizing radiation may or may not include skin contamination with
radioactive material; if external radioactive contaminants are present,
decontamination procedures must be initiated immediately.
Acute radiation syndrome develops after a substantial exposure to ionizing
radiation and follows a predictable pattern.
Explosive devices used as agents of terrorism result in one or more of the following
types of injuries: blast, crush, or penetrating.
See Table 69-15 for information on acute radiation syndrome.
EXPOSURE TO BLASTS OR EXPLOSIONS
Blast injuries result from the supersonic over-pressurization shock wave that occurs
following the explosion, causing damage to the lungs, middle ear, gastrointestinal
tract, and brain.
Crush injuries often result from explosions that occur in confined spaces and result
from structural collapse.
Some explosive devices contain materials that are projected during the explosion,
leading to penetrating injuries.
EMERGENCY AND MASS CASUALTY INCIDENT PREPAREDNESS
A mass casualty incident (MCI) is a manmade (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.
MCIs usually involve large numbers of casualties, involve physical and emotional
suffering, and result in permanent changes within a community. They always
require assistance from people and resources outside the affected community
(e.g., American Red Cross, Federal Emergency Management Agency [FEMA]).
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, and this training helps citizens to understand their personal
responsibility in preparing for a natural or manmade disaster.
Citizens are taught what to expect following a disaster and how to safely help
themselves, their family, and their neighbors.
Training includes the teaching of life-saving skills, with an emphasis on decisionmaking and rescuer safety.
When a mass casualty incident occurs, first responders (i.e. trained volunteers,
police, and firemen) as well as emergency medical personnel are dispatched to
the scene. If hazardous materials are present first responders are taught to wait
for the proper equipment to avoid adding themselves to the 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.
Triage of casualties in a major emergency or mass casualty incident (MCI) differs
from the usual triage that occurs in the ED and must be conducted in less than
15 seconds/victim. The goal is to do the most good for the most people.
A system of colored ribbons/tags is used to designate both the seriousness of the
injury and the likelihood of survival.
Green tags are tied to those with minor injury or no noticeable injury. These are the
walking wounded. They are identified when first responders arrive at the scene
and call out “ If you can walk come to the sound of my voice.” These people can
often assist you to care for other victims or help to document a description of the
scene, the location of various categories of victims, and the number of each type
of victims. This written information is vital and when reported to EMS and to
hospitals it assists with appropriate distribution of victims and resources.
Next, first responders start where they are standing and quickly triage the
remaining victims in a systematic.
This process, START (Simple Triage and Rapid Transport) continues in this way:
The responder walks up to the victim and asks if he is okay. If no response; a look,
listen, and feel is performed to assess for respirations. If none are noted, a gentle
head tilt with jaw lift is performed and the look, listen, and feel is 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 the head in
position for open airway or the victim is log rolled into the rescue position (a
Sim’s lateral position with the lower arm placed under the 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.
The legs are elevated and a blanket applied if the victim is in shock. There is no
time to perform CPR in this type of situation.
Yellow tags indicate a non-critical or non–life-threatening injury. These people will
need to be seen by a physician but can be delayed. These include simple
fractures, minor burns that can wait 1 to 2 hours to receive medical care.
Red tags indicate a life-threatening injury requiring immediate intervention. These
include victims with airway problems, obvious and dramatic arterial bleeding,
internal bleeding within the abdomen or due to a fractured leg, severe burns,
brain or spinal cord injuries.
Black tags are used to identify those 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.
In mass casualty incidents there are often many more green tag casualties than red
or yellow casualties. The green casualties not remaining at the scene to help are
often the first to arrive at hospitals and most are transported by private cars.
Red tag victims must be cared for first by first responders after all victims are
triaged or by EMS once they have arrived on the scene. The red tag’s are also
the first to be cared for at the hospital ER on arrival.
If there is known or suspected contamination, decontaminated facilities can be set
up at the scene, and 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.
The total number of casualties a hospital can expect is estimated by doubling the
number of casualties that arrive in the first hour.
Generally, 30% of casualties will require admission to the hospital, and 50% of
these will need surgery within 8 hours.
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 are placed to direct movement of victims to the appropriate areas.
Additional staff and physicians are called to the hospital to assist based on the
reports received from the disaster site.
All health care providers should have a role in emergency and MCI preparedness,
knowledge of the hospital’s emergency response plan, and participation in
emergency/MCI preparedness drills are required.
Response to MCIs often requires the aid of a federal agency such as the National
Disaster Medical System (NDMS), which is a division within the U.S.
Department of Homeland Security that is responsible for the coordination of the
federal medical response to MCIs.
One component of the NDMS is to organize and train volunteer disaster medical
assistance teams (DMATs).
DMATs are categorized according to their ability to respond to an MCI. A 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 self-sufficient but are used to replace
a Level-1 team, using and supplementing the equipment left on site.
Many hospitals and DMATs have a critical incident stress management unit that
arranges group discussions to allow participants to verbalize and validate their
feelings and emotions about the experience.
Post traumatic stress syndrome is a common problem that results from MCIs. It
may present immediately or months after the event and is often characterized by
emotions ranging from fear to anger, denial, and shock. Victims often avoid the
location or persons that remind them of the event and often experience flashbacks
and nightmares during which they relive the event. Initially it is important to
promoting a sense of safety and caring. Supportive listening, debriefing, and
referrals are helpful.
THE NURSES ROLE IN THE EMERGENCY ROOM
Characteristics of the emergency nurse’s practice include:
 Use of the nursing process in the 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.
 Responsibility for triage and prioritization.
 Emergency operations preparedness.
 Stabilization and resuscitation.
 Crisis intervention for unique client populations such as sexual assault
survivors and crime victims or perpetrators.
 Provision of care in uncontrolled or unpredictable environments.
 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.