EMERGENCY AND DISASTER NURSING
– Provide explanations and information
 Red tags - (immediate) are used to label those who
cannot survive without immediate treatment but who have
a chance of survival.
 Yellow tags - (observation) for those who require
observation (and possible later re-triage). Their condition
is stable for the moment and, they are not in immediate
danger of death. These victims will still need hospital care
and would be treated immediately under normal
circumstances.
 Green tags - (wait) are reserved for the "walking
wounded" who will need medical care at some point, after
more critical injuries have been treated.
 White tags - (dismiss) are given to those with minor
injuries for whom a doctor's care is not required.
 Black tags - (expectant) are used for the deceased and
for those whose injuries are so extensive that they will not
be able to survive given the care that is available.
Scope and Practice of Emergency Nursing
• Emergency management traditionally refers to urgent and
critical care needs;
• however, the ED has increasingly been used for non-urgent
problems, and emergency management has broadened to
include the concept that an emergency is whatever the patient or
family considers it to be
The emergency nurse has:
• Special training, education, experience, and expertise in
assessing and identifying health care problems in crisis situations
• Nursing interventions are accomplished interdependently in
consultation with or under the direction of a physician or nurse
practitioner
• The emergency room staff works as a team
Four Basic Emergency Action Principles
• Survey the scene
– If any kind of danger is threatening, do not approach the
casualty, call EMS immediately for professional help.
• Check the casualty for any for unresponsiveness
• If the person does not respond, Call EMS
• Check the casualty’s airway, breathing and circulation (ABC’s) :
try to the airway without moving the patient
Priority Emergency Measures for
All Patients
• Make safety the first priority
• Preplan to ensure security and a safe environment
• Closely observe patient and family members in the event that
they respond to stress with physical violence
• Assess the patient and family for psychological function
• Patient and family-focused interventions
– Relieve anxiety and provide a sense of security
– Allow family to stay with patient, if possible, to alleviate anxiety
– Provide additional interventions depending upon the stage of
crisis
PRINCIPLES OF TRIAGE
What is TRIAGE?
- it is sorting
- from the French word “trier” meaning to choose, referred to a
battlefield
- the rapid focused assessment
What is the purpose of TRIAGE?
- is to sort or classify all incoming ED patients
- the goal is to get the
Right Patient to the
Right Place at the
Right Time for the
Right Reason to receive
Right Treatment
How long should the TRIAGE take?
- the common goal is to assess the patient within 2-5 minutes for
adults
(but this time according to ENA caters up to 22% only of patients
per hundred in 8 hours)
- for pediatrics, 7 minutes
Who should perform the ED TRIAGE function?
- the Joint Commission on Accreditation of Healthcare
Organization (JCAHO) doesn’t entails what are the specifics of the
triage nurse
- Emergency Nurses Association (ENA) 1999 established he
standards of Emergency Nursing Practice, states that safe,
effective triage can only be performed by a registered
professional nurse, educated in the principles of triage and has
minimum experience of 6 months in emergency nursing
- The triage nurse should classify patient 24/7
What are the Essential Components of Comprehensive TRIAGE?
1. An initial across-the- room look or visualization. This includes
ABCD. For pediatric clients, this may include critical look, general
appearance, work of breathing and circulation
2. A rapid triage (60secs) of an appropriately elicited chief
complaint, key questions, assessment such as feeling of the pulse
and fracture in the extremities
3. Completion of a focused triage history and physical
assessment. This include vital signs, pulse oximetry reading,
diagnostics and institution’s protocol
4. The triage decision, in which the triage acuity or level is
assigned. This determines the urgency of the condition, includes
the MSE and additional assessment.
What should the triage history include?
Medications
Exposure to infection
Allergies Pregnancy
Immunization
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)
Etiology
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
Cry
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
- Activated charcoal is not effective for alkalis, cyanide, mineral
acid and ferrous sulfate
Cathartics
- contraindicated with infants (risk for dehydration), intestinal
obstruction, electrolyte imbalance
- sodium sulfate is contraindicated in HPN and heart failure
Forced Diuresis
- forced neutral diuresis may be helpful for isoniazid, bromide
and ethanol intoxification
- make sure to monitor electrolytes
- forced alkaline diuresis may be useful for Phenobarbital,
salicylates and lithium using sodium bicarbonate.
C. Guidelines for Nurses
- when antidotes are ordered, it is meant to be given immediately
or at least reasonably within the hour in some cases. They are
not given when it is the convenient dosing period for the nurses.
Specific Substance Ingestion
Acid Ingestion
- provide airway control, ventilation, circulatory support, and fluid
resuscitation
- wash the oral cavity (controversial)
- emesis, lavage and charcoal are contraindicated
- secure serial CBC and cros-matching
- maintain NPO
Alkali Ingestion
- immediately rinse oral cavity
- administer oxygen and IVF
- secure serial CBC, CXR, and monitor electrolytes
- esophagoscopy and gastroscopy should be performed
immediately if there is drooling, stridor and painful swallowing
Amphetamine/ Metamphetamine Toxicity
- start charcoal and cathartics
- emesis has no role
- WOF for seizure, psychosis, agitation, hypertensive crisis,
arrhythmias
- Secure ABG, CBC with PC, PT, PTT, RBS, BUN, Crea, Na, K, UA
- Diazepam and Phenytoin for seizure
- Beta-blockers, Lidocaine for dysrythmias
Anticoagulant Overdose
- Secure lab results such as CBC with PC, PT, PTT and Creatinine
- For Heparin: Give protamine sulfate at 1mg iv for every 50-100
units of heparin infused in the preceeding 2 hours, dilute in 25-
50ml fluid over 10 minutes
- For Warfarin: perform gastric lavage and give activated charcoal
if recently ingested; give vitamin k 5-10 mg every 8-12 hours; give
FFP 2-6units for severe bleeding
Diazepam Overdose
- Place NGT and do gastric lavage
- Protect airway
- Instill activated charcoal, followed by repeated doses of 20-25
gm via NGT
- Secure RBS, ABG, ECG and CXR
- Watched out for hypotension, CNS and respiratory depression
and withdrawal syndrome such as agitation, seizure, restlessness
and insomnia.
Digitalis Overdose
- considered NGT insertion and gastric lavage
- secure digitalis assay, CBC, Ca, K, Mg, CXR and ECG/ cardiac
monitor
- the treatment goal would be to correct hypokalemia.
Hypomagnesemia or hypocalecemia.
- The doctor may prescribe charcoal and cathartics
- Watch out for hypotension; fluid challenge my be instituted
- For arrythmias, lidocaine may be given
Ethanol Toxicity
- maintain adequate airway, ventilation, circulation and
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
Narcotic Overdose
- maintain airway, ventilation and circulation
- may start on Naloxone 2mg every 5 minutes , max 10mg IV, IM
SQ
- Activated charcoal if (+) for bowel sounds and cathartics
- Watch out for signs of pneumonia, infections and
rhabdomyolysis
- Watch out for complications such as seizure, pulmonary edema
and hypotension
Hydrocarbon/ Kerosene Ingestion
- Respiratory support
- Treatment is not required in the absence of symptoms
- Promote gastric emptying
- Remove contaminated clothing and wash affected skin with
soap and water.
- Provide supplemental oxygen
- secure CBC, ABG abd CXR
Isoniazid Overdose
- place an NGT and do gastric lavage is clean
- watch out for seizure, lactic acidosis may give sodium
bicarbonate
- consider mannitol administration for forced diuresis
- secure CBC, RBS, K, ABG
Narcotic Overdose
- maintain airway, ventilation and circulation
- may give naloxone 2.0mg q 5 minutes initially max of 10mg IV,
IM SQ
- start activated charcoal if (+) with BM and cathartics
- watched out for complications, PNA, hypotension, and seizures
is (+) norpethidine
Insecticides/ Pesticides
Therapeutics
1. Decontamination
- make he patient rinse with alkaline or baking soda (10gm in
100cc)
- change cloths and wash the patient with gloves
- insert NGT and do gastric lavage wih activate charcoal
2. Activated charcoal
3. Antidote
4. In cases of seizure; consider Phenytoin
5. wof for hypoglycemia
6. Give mannitol if with good urine output
- secure CBC, RBS, ABG, SGOT and SGPT
Paracetamol Overdose
- Insert NGT
- Activate charcoal about 30-100mg and then remove via NGT
suction prior to acetylcysteine
- Sodium Sulfate to induce vomiting
- Antidote: N-acetylcysteine (NAC) . the initial administration
would be 150mg/kg body weight infused in 200ml 5% dextrose
over 15 minutes followed by IV infusion of 50mg/kg in 500ml of
5% dextrose water
- NAC is very effective in preventing paracetamol-induced
hepatotoxicity when administered; when administered with in 8
hours from the time of ingestion, the better. But beyond 8 hours,
the protective effect diminishes progressively as the treatment
interval increases
Salicylate Poisoning
Diagnostics:
- CBC, K, RBS, ABG and UA
- PT, PTT, SGOT, SGPT and alk Posh with 48 hours post ingestion
Therapeutics:
- Stabilize respiratory and cardiac functions
- Avoid diluting the gastric contents since this may incease gastric
absorption
- Consider NGT insertion
- Give activated charcoal 1gm/ kg body weight every 6 hours
- Sodium sulfate 15-30 gm in 100cc H20 orally if tolerated or with
NGT with every other doses of activated charcoal to prevent
charcoal constipation or fecal impaction
- To increase urine ph, consider sodium bicarbonate
- Glucose and KCl should be infused with other fluids
Treatment Plan
- if with dehydration and hypokalemia, manage with vigorous and
with electrolyte replacement
- Cerebral edema can be best avoided using hypertonic
rehydration solution
- Alkaline diuresis to maintain urinary ph at approx 8
- Monitor urine output
- Assess hydration status
- Watch closely for signs of fluid overload
- Hemodialysis is indicated for initial salicylate level of >160ml/dl
or with profound acidosis of below 7; or when there is renal
failure, severe CNS dysfunction, pulmonary edema or
deterioration despite supportive therapy
Other Treatments
- Acidemia: NaHCO3
- Seizure: Diazepam
- Pulmo Edema: treat with high concentration of oxygen,
furosemide and PEEP
- Cerebral Edema: treat with hyperventilation and osmotic
diuresis with Mannitol
SHOCK (Multisystem Stressor)
Pathophysiology
- Shock is a multisystem stressor that involves inadequate tissue
perfusion and altered metabolism.
- Inadequate tissue perfusion can lbe a result of nay condition
that alters heat function (cardiogenic), blood
volume(hypovolemic), blood pressure (neurogenic) and
distribution of blood volume (septic/ anaphylactic)
- Shock is a very complex clinical syndrome in which tissue
perfusion is inadequate to meet the demands for oxygen
- It alters cellular functions and eventually impairs body organ
functions
- Multi Organ Dysfunction Syndrome (MODS) is a term used to
describe several impairment of the human functions
Sepsis and Septic Shock
- Sepsis is an acute systemic clinical syndrome caused by bacteria,
viruses or fungi in the blood, most commonly gram (-) bacilli
- At an early phase, generalized inflammatory response is
triggered, causing widespread vasodilation
- The progression to septic shock is due to the toxins released
from the organism involved
- Bacterial endotoxins activates the complement, coagulation and
fibrinolytic system; inceases vascular permeability and trigger the
vasoactive kinins causing vasodilation and increased capillary
permeability thereby decreasing the vascular resistance and
facilitating fluid shifting from intravascular to interstitial
- Another response would be due to the histamine release
causing increase in vascular permeability
- This changes are further stimulated by the catecholamine and
prostaglandins that are released from ischemic tissues
- “COLD SHOCK” is he term used during the stage in which tissue
perfusion becomes severely compromised and ischemic cellular
damage occurs.
- In addition the, fever is present due to the pyrogens released by
the organism
Anaphylactic Shock
- systemic anaphylactic shick is potentially life threatening
situation
- it is he result of an exaggerated hypersensitivity response to an
antigen
- the classic form of anaphylaxis occurs in a sensitized person
usually 1-20 minutes ater the exposure to the antigenic
substance
- the most common substance that can cause reactions would be,
drugs, antibiotics, foods, anesthetics, antisera and blood
products
- hypersensitivity reaction occurs over the surface of he mast cells
which are located primarily in he lungs, small blood vessels and
connective tissues
- it also attacks basophils circulating in the blood
- the antigenic substance triggers the release of kinins,
histamines, prostaglandins, eosinophils, neutrophils
- “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
Intervention:
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

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

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