Emergency Nursing

Emergency Room Nursing:

• Consent to examine and treat is part of the ER record. The patient must give consent for
invasive procedures, but if pt is unable due to being unconscious or in critical condition
and is without friends or family, this should be documented.
• Early identification and adherence to standard precautions for patients who are potentially
infectious is crucial. Nurses in the ER are usually fitted with a HEPA mask.
• Waiting and examine rooms are often places of violence when patients and family channel
their anger and frustrations.
o Safety is the first priority. Security personnel are usually on staff to provide safety
for patients, families and staff.
o Gang members and feuding families are kept in separate rooms
• Patients from prison or those under guard need to be handcuffed to the bed and assessed
to ensure the safety of the staff and patients. In addition, the following precautions are
taken
o Never release hand or ankle restraints
o Always have a guard present in the room
o Place the patient face down to avoid head-butting, spitting or biting
o Medication may be necessary to control violent patients

Patients in the ER frequently deal with severe, sudden injury and death. Nurses need to ease
anxiety and use effective communication. Talk to them in a way that promotes a sense of
security. Give honest answers on a level the family can understand. Families are often feeling
guilt and the nurse should encourage them to verbalize their feelings. When dealing with sudden
death, the nurse should
o Take the family to a private room
o Reassure them everything that was possible was done
o Avoid giving sedation to family members
o Encourage the family to view the body if they want.
• If a patient is unconscious, talk to them, touch them and explain each procedure as if they
are awake.

Common age group in ER is 65+. Emergencies in this age group are difficult to treat as they
may be asymptomatic and have multiple underlying issues. Remember older patients have
fewer social and financial support systems and may need referrals.

Principals of Emergency Care:

• Triage means to sort and is used to sort patients based on the severity of the
injuries/illnesses. Three categories emergent, urgent and non-urgent. **Some facilities
have 5 levels; adding resuscitation before emergent and minor behind non-urgent**
 Resuscitation: needs treatment immediately to prevent death
o Emergent: Life threatening and must be seen immediately.
o Urgent: Serious health problems and must been seen within 1 hour.
o Non-urgent Have episodic illnesses that can addressed within 24 hours without
increased morbidity. These patients need basic first aid or primary care and can be
treated in the ER or safely referred to their PHP.
 Minor likely require no resources to provide their evaluation and
management.
• Resources are imaging studies, medications administered by IV or IM,
invasive procedures or insertion of a catheter.

Airway Obstruction: If permanent airway obstruction is present, permanent brain injury can
occur within 3-5 minutes secondary to hypoxia.
 A person with a foreign body obstruction, cannot speak, cough or breathe. The patient
may clutch their neck between the thumb and fingers (universal distress signal)
• If a person has a partial obstruction, they usually can cough spontaneously and breathe. If
the patient demonstrates a weak, ineffective cough, high-pitched noise while inhaling,
increased respiratory difficulty or cyanosis; they should be treated as if they have a
complete airway obstruction.

Establishing an airway:
• Abdominal thrusts (Heimlich maneuver): a sub diaphragmatic abdominal thrust, by
elevating the diaphragm, can force air into the lungs, to create an artificial cough and
expel an obstructing object.
• Head-tilt-Chin-Lift: Patient is placed in a supine position on a firm, flat surface. Place one
hand on the victims forehead, and firm backward pressure is applied with the palm to tilt
the head back. The fingers of the other hand are placed under the bony part of the jaw,
near the chin and lifted up. The chin and teeth are brought forward to support the jaw.
**only use this method if cervical injury is ruled out**
• Jaw-Thrust: One hand is placed on either side of the jaw, grasping the angles of the lower
jaw are lifted, displacing the mandible forward. **This can be used if a neck injury is
suspected because it does not extend the neck.**

Intubation:
• Oropharyngeal Airway Insertion (OAI): A semicircular tube that is inserted over the back
of the tongue into the lower posterior pharynx in a patient who is spontaneously breathing
but is unconscious. This prevents the tongue from falling backwards against the pharynx
and obstructing the airway. It also allows for suction secretions.
• Endotracheal Intubation: To establish and maintain the airway in patients with respiratory
insufficiency or hypoxia. It is indicated for the following reasons:
o For patients who cannot be adequately be ventilated with an OAI
o To bypass an upper airway obstruction
o To prevent aspiration
o To permit connection of the patient to a resuscitation bag or mechanical ventilator
o To facilitate removal of tracheobronchial secretions
• Combitube: This is a tube that rapidly provides pharyngeal ventilation when a patient is
not hospitalized and cannot be intubated in the field.

Cricothyroidectomy (Cricothyroid Membrane Puncture) emergency tracheotomy. A cut is made

into the Cricothyroid membrane to establish an airway. This is only used in emergency situations
when endotracheal intubation is not possible or is contraindicated.

Hemorrhage: Goals are to control bleeding, Maintain circulating blood volume and prevent shock.
• Fluid replacement is imperative.
o Two large bore IV needles are inserted for fluid replacement and blood infusion.
Packed red blood cells are infused in massive blood loss.
• Type O negative for women of child bearing age and children.
• Type O positive for men and post menopausal women.
• When in doubt, Type O negative is safe for everyone.
• Platelets and clotting factors are given when large amounts of blood are needed.
o The infusion rate is determined by the severity of blood loss and when large
amounts of blood are given, it is warmed first.

Controlling external hemorrhage:

• Direct, firm pressure is applied over bleeding area or involved artery at a site proximal to
the wound. Then a firm pressure dressing is applied and the injured part is elevated to
stop bleeding if possible.
 • A tourniquet is applied only as a last resort. It is tied tightly just proximal to the wound to
control blood flow. The pt is tagged with a skin marking or a piece of tape on the forehead
with a “T” stating the location and the time the tourniquet was applied.

Control of Internal Bleeding:

If no signs of external bleeding can be found but the pt shows signs of shock, internal bleeding is
suspected.
• Packed red blood cells are given at a rapid rate
• ABG’s are obtained
• Patient is kept supine
o Pt is taken for more definitive treatment to determine location/cause of bleeding

Hypovolemic shock:
• Obtain and maintain a patent airway
• Infuse IV fluids at a rapid rate until systolic BP is maintained at normal rate
• Insert Foley to monitor accurate hourly urinary output

Wounds:
• Laceration: skin tear with irregular edges and vein bridging
• Avulsion: tearing away of tissues from supporting structures
• Abrasion: denuded skin
• Ecchymosis/contusion: blood trapped under the surface of the skin
• Hematoma: tumor like mass of blood trapped under skin
• Stab: incision of the skin with we defined edges, usually with a sharp instrument; usually
deeper than is long
• Cut: same as stab but longer than is deep
• Patterned: wound representing the outline of an object

Wound Cleansing:
• Clip hair around wound
• Clean with copious amounts normal saline to clean away dirt, etc.; Betadine or peroxide
should not be allowed to get deep into wound
• Apply non-adherent dressing to protect wound
•
Primary Closure: To suture a wound depends on the nature of the wound, the time since injury
was sustained, and degree of contamination and vascularity of the tissues.

Delayed Primary Closure: May be indicated if tissue has been lost or there is a high potential for
infection. A think layer of gauze (to allow drainage) and then an occlusive dressing. Then the
wound is splintered in a functional position to prevent motion and prevent contractures. If there
are no signs of suppuration (formation of pursuant drainage), then sutures may be indicated. A
tetanus prophylaxis will be given if one was not given within 5 years or if pts immunization status
is unknown.

Collection of Forensic Evidence: In emergency, but especially trauma, you need to document a
description of the wounds, how the injury occurred, the time, and collection of the evidence.
• When cutting away clothes, do not cut through any cuts, tears, etc. in the clothing. Each
piece is put in a separate paper bag. Do not give clothing to family members.
• If a patient dies, al lines and tubes remain in place. Hands are covered with paper bags to
protect the evidence on the hands and under the fingernails. In the surviving patient,
swabs of tissue samples from hands and under the fingernails are taken as we as
photographs of wounds, clothing, etc.
• A verbal statement from the patient should be taken and any remarks in the patient’s own
words are put in quotation marks.
Injury Prevention: Three areas of injury prevention:
• Education: Provide information and written materials on preventing violence and maintain
safety in the home and car.
o Do NOT use the word accident because these events are preventable. People at
risk for trauma should be identified and given materials and counseling to
prevent/avoid risky behaviors.
• Legislation: Nurses should be kept up to date on safety legislation, which is meant to
provide universal safety measures, not infringe on rights.
• Automatic protection: Airbags and seat belts are included in this category. These provide
safety without requiring any personal intervention on the part of the patient.

Multiple Traumas: Caused by a single catastrophic event that causes life threatening injuries to
at least two distinct organs or organ systems.
• Patients with multiple traumas should be treated as if they have a spinal cord injury until
this is ruled out or confirmed. An injury which looks the least lethal may be the most
significant. An amputation may look like the bleeding has stopped, but internal, less
visible bleeding may be occurring.
• The goals of treatment are to determine the extent of the injuries and prioritize treatment.
Any injury interfering with a vita physiological function (airway, circulation, etc.) is given
the highest priority.

Intra-Abdominal Injuries: Categorized as internal or blunt trauma.

• Penetrating (stab wounds, gunshot wounds), usually require surgery
• Blunt trauma may result from MVA’s, crashes, falls, blows or explosions and are usually to
the chest, head or extremities. Blunt injuries to the liver, spleen, kidney or blood vessels
can lead to massive blood loss into the peritoneal cavity.
o Absence of bowel sounds may be an early indication of intraperitoneal involvement.
Other signs are guarding, rebound tenderness, progressive abdominal distention
and muscle rigidity. Labs to help confirm are:
 UA to detect hematuria
 Hemoglobin & hematocrit
 WBC counts increased levels are seen in trauma)
 Amylase (increased levels can mean pancreatic injury or a perforation of the
GI tract.)

Internal Bleeding: Hemorrhage frequently accompanies abdominal injury, especially in the liver
or spleen. S/S of internal/external bleeding are:
• Inspect the front/back/flanks of body for: bluish discoloration, asymmetry, abrasion or
contusion.
• Pain in the left shoulder can mean a ruptured spleen
• Pain in the right shoulder can be a lacerated liver

Intra-peritoneal Injury: Referred pain is usually a sign of intraperitoneal injury. Diagnostic tests
include:
• Abdominal CT or US
• Peritoneal lavage: 1 L of warmed LR or NS is instilled into the abdominal cavity. After at
least 400 M has been returned, a specimen is sent to the lab. If a RBC greater than
100,000, WBC more than 500 or the presence of bile, feces or blood is indicative of
intraperitoneal involvement.

• GU injuries: Do NOT put in a Foley until a GU consult has cleared the patient of any
GU/urinary injuries.
 • With blunt trauma, keep patient on a stretcher to keep spine immobilized. Only move
patient with a backboard.

• All wounds must be located, counted and documented.

• Patient is kept NPO in anticipation of surgery and any stomach contents are aspirated with
an NG tube.

Crush injuries: Occur when a patient is caught between two opposing forces. Watch for any of
the following:
• Hypovolemic shock
• Paralysis of a body part
• Erythema or blistering of skin
• Damaged body part which appears to be swollen, tense or hard
• Renal dysfunction
When a patient has a crushing injury, not only are you assessing for ABC’s but also for renal
insufficiency which can be caused by an injury to the back, which can cause kidney damage.
• Splint major tissue injuries to control bleeding and pain.
• Watch serum lactic levels (a level under 2.5 indicates successful resuscitation

Fractures: When examining for a possible fracture, handle the body part gently and as little as
possible and cut off clothing to visualize body part. Assess for Ecchymosis, tenderness and
crepitation.
• If a pulse less extremity is found, reposition extremity for proper alignment. If the fracture
is in the hip or femur, HARE traction (a portable traction device) is used for alignment. If a
pulse cannot be found, a rapid total body assessment is required and then the patient is
quickly transferred to surgery for an arteriograph or arterial repair.
• After the initial inspection, the involved fractured body Part is assessed for CPM and then
splinted before moving. A splint is applied to the joint at a site distal and proximal to
relieve pain, restore circulation, stop further tissue injury and prevent a closed fracture
from becoming an open one.

Heat Stroke: acute medical emergency when the body’s heat regulating mechanism does not
function properly. It usually occurs in extended heat waves, especially from high humidity. Most
heat related deaths are in the elderly. It causes thermal injury at the cellular level, resulting in
damage to the liver, kidneys and heart.
• The primary goal is to reduce the body’s high temperature as soon as possible. Remove
patients clothing. After the body’s core temp is down to 102F, use of cooling blankets, ice
packs on the head, neck, groin, chest and axxilae, iced saline lavages to the stomach and
colon or immersion of the patient in a cold water bath. Use of an electric fan during these
procedures will help dissipate the heat by convection and evaporation. IV infusion of LR or
NS will restore fluid balance and circulation.

Frost Bite: Exposure of freezing temperatures or actual freezing of the intracellular fluids,
resulting in cellular and vascular damage. Sites most common: hands, feet, nose and ears.
• A frozen extremity may appear hard, cod, insensitive to touch and may be white or
mottled blue/white.
• Cut away constrictive clothing or jewelry
• Do not allow a patient to ambulate if lower extremities are involved.
• Must give rapid but controlled re-warming. The extremity is usually placed in a circulating
bath of 98.6-104F for 30-40 minutes. Treatment is repeated until circulation is restored.
• Do not handle body part and do NOT massage.
• Place sterile gauze or cotton between fingers or toes
• Elevate extremity to avoid swelling
 • Blebs (fluid under the skin) are common from 1 hour to a few days after exposure. Do not
rupture
• NSAIDS

Hypothermia: when the body’s core temperature is below 95F. Elderly, infants, alcoholics,
trauma victims are susceptible. Shivering may not occur at below 90F because the body’s
warmer mechanisms are not effective. The heartbeat and blood pressure are usually so low that
peripheral pulses are undetectable.
• Rewarming methods: warm fluid administration, warm humidified O2 by vent, warmed
peritoneal lavage
o Cardiac monitoring and mechanical ventilation should be accessible during
rewarming
o Administer warmed IV fluids
o Admin sodium bicarb if metabolic acidosis has occurred
o Insert Foley

Terrorism, Mass Casualty and Disaster Nursing:

Level I: Local emergency response personnel can contain and manage the disaster and its
aftermath
Level II: Regional help from surrounding communities is needed
Level III: state and federal assistance is needed

• DMAT’s (Disaster Medical Assistance Teams) organizes voluntary medical personnel to set
up a field hospital.
• CDC (Center for Disease Control) federal agency for disease prevention
• Red Cross provides support and shelter as needed
• OEM (Office of Emergency Management) coordinates disaster relief at state and local
levels
• ICS (Incident Command Center) is the local organization that coordinates personnel,
facilities, equipment and communication in an emergency situation.

Health care facilities are required by JCAHO to create a plan for emergency preparedness and to
practice the plan twice a year. Before creating this plan, the facility must:
• Identify the likelihood of which natural and man-made disasters are likely to occur in that
area
• Identify proximity to chemical plants, military bases, and nuclear facilities that could give
occasion to mass casualties
• Identify Federal, state and judicial buildings as well as schools or any other areas where
large groups of people may gather
• Identify the resources available to the facility

Initiating the EOP (Emergency Operations Plan):

Identifying and documenting Patient Information:

• Disaster tags, which are numbered and include triage priority, name, address, age,
location, description of injuries, and medications given. The patients’ name and tag
number are recorded in a disaster log book and kept at the command center to track
patients and relay info to families, etc.

Triage: When faced with a large number of casualties, you must do the greatest good for the
greatest number of people. Therefore, if a large number of patients have conditions that have
high mortality rate, will be given the lowest triage rating. The reason for this is so you don’t
spend a limited number of resources on people with a limited chance for survival. Patients in
triage are immediately assessed, tagged and either transported or given life saving intervention
at the scene.

NATO Triage System is the most widely used in a mass casualty situation. IT is as follows:

Red=Priority 1. Triage category is immediate, meaning life threatening but survival good if
treated immediately.
• Chest wounds, airway obstruction, shock, open fractures of long bones, hemo or
pneumothorax and serious burns
Yellow=Priority 2 – Triage category: Delayed, meaning injuries are significant but can wait hours
for treatment after immediate casualties are treated.
• Stable abdominal wounds, soft tissue injury, facial wounds, GI tract interruptions
Green=Priority 3. Triage category Minimal, meaning injuries are minor and treatment can be
delayed hours to days. These patients should be moved out of main triage area.
• Minor burns, upper extremity fractures, small cuts with significant bleeding
Black=Priority 4-Triage category Expectant, meaning injuries are extensive and chance for
survival is minimal. Patients should be separated from main group but not removed. Comfort
measures should be provided if possible
• Unresponsive patients with penetrating head wounds, spinal cord injuries, Wounds
involving multiple organs and/or sites, major burns in excess of 60% of BSA, profound
shock,

Communication: A designated person should communicate with media and family members.
They should be stationed away from patient care area and give updates on a regular schedule

Caring for families: a team should be on hand for families of casualties: social workers, clergy,
therapists and counselors.

Nurses’ role in disaster response plan: Nurses may be asked to perform duties outside their
normal range of experience. For instance: a critical care nurse may be required to place chest
tubes if a physician is unavailable. It should be made clear the chain of medical command, so all
knows their position and duties expected.

**People with disabilities should have a plan in case of a disaster which should include family or
friends who will check on the disabled person, as well as an escape route and location of special
equipment used by person in the event rescue workers would be rescuing them.

Ethical Care: In the event of a disaster, nurses may find ethical dilemmas. They may find it hard
not to care for those who are dying or that they may be asked to withhold information to prevent
spreading panic and mis-information.

CISM (Critical Incident Stress Management) is a team who will provide care to prevent or treat
emotional trauma that medical personnel may experience in this type situation. Three stages:
Defusing, Debriefing and Demobilization.

Preparedness: Medical personnel should be aware of any of the following:

• An unusual increase in the number of patients seeking care for fever, respiratory or GI
disturbances
• Clusters of patients presenting with the same symptoms at the same time who may be
from a specific geographical location or event (sporting event, entertainment event, etc.)
• Suspicious of a large number of deaths in a period of time which is less than 72 hours in
length
 • An increase in disease process in an otherwise healthy population

PPE: Four levels:

• Level A: HSMAT gear, including full body protection
• Level B: Highest level of respiratory protection but less of skin and eye protection, still
includes chemical resistant suit and gloves
• Level C: Air purified respirator and coverall with gloves and boots
• Level D: Normal work uniform

Decontamination: the process of removing accumulated contaminants, to prevent secondary

contamination. Must include a minimum of two steps:
• Step one: removal of jewelry and clothing and then rinsing the patient with water
• Step two: A thorough soap and water wash and rinse

Biological Terrorism: Can be delivered in food, water, by direct contact or inhaled.

Anthrax: Bacillus anthracis is infective only in spore form and can cause hemorrhage, edema
and necrosis. The incubation period is 1-6 days. Can be delivered by inhalation, skin contact
and GI ingestion.
• Inhalation causes fever, diarrhea, vomiting and abdominal pain. With severe diarrhea,
hypovolemia is a concern. It can incubate for up to 60 days and the first stage of
symptoms are flu-like and care is not sought until the stage 2 symptoms develop, which is
severe respiratory distress. A hallmark sign of inhalation is a hemorrhagic mediastinitis x-
ray. Anthrax is penicillin resistant and if given within 24 hours of exposure, death can be
prevented and treatment should be continued for 60 days. If death occurs, cremation is
needed to prevent the spread of the infected spores to morticians and forensic medical
personnel.

Smallpox: Variola has an incubation period of 12 days, is extremely contagious and is spread by
direct contact, contact with linens or clothing of infected person, or by droplets after the fever
has decreased and the rash phase develops.
• S/S: high fever, malaise, headache and backache and after 1-2 days, a maculopapular rash
appears on face, mouth, forearms, and pharynx. There is a large amount of virus in the
saliva and pusules and smallpox is only contagious after rash appears.
• Treatment: Antibiotics are started and the patient is isolated with transmission
precautions. Laundry and biologic waste is autoclaved before being washed with hot
water and bleach. People who have been in face-to-face or household contact should be
vaccinated within 4 days to prevent infection and death. IF death occurs, cremation is
preferred as virus can live in scabs for up to 13 years.
Chemical Weapons:

Characteristics:
• Volatility: Ability of chemical to become a vapor. Phosgene and cyanide most volatile.
These chemicals sink to the ground, so one should stand up to limit exposure.
• Persistence: Chemical is less likely to vaporize and disperse. These penetrate the skin
and mucous membranes.
• Toxicity: This is the potential for the chemical to cause injury to the body. This chemical
causes death in 50% of those exposed.
• Latency: The time from absorption to the appearance of symptoms. Sulfur mustard and
pulmonary agents have the longest latency.

Types of chemicals:
Vesicants: (lewisite, nitrogen, phosgene and sulfur mustard gas)
 • Cause blistering and result in burning, conjunctivitis, bronchitis, pneumonia,
hematopoietic suppression, and death. Initially looks like a partial thickness burn
and after 24 hours, large blisters form. Respiratory effects occur after blisters form.
o Decontaminate with soap and water. Do not scrub or use hypochlorite
solutions as they cause penetration, and if the chemical penetrates, it cannot
be removed. Eye exposure requires copious irrigation. With respiratory
exposure, intubation and a bronchoscopy to remove necrotic tissue is
needed. If lewite exposure, an IV of dimercaprol is needed.

Nerve Agents: (sarin, soman)

• Most toxic and least expensive and can be inhaled or absorbed percutaneously or
subQ and the effects result in the continuous stimulation of nerve endings. A small
drop can cause sweating and twitching while a larger amount can cause systemic
symptoms. Effects can begin anywhere from 30 mins to 18 hours after exposure.
S/S includes bilateral miosis, visual disturbances, N&V, bronchoconstriction and
incontinence and increased secretions.
o Decontaminate with large amounts of soap and water or saline solution for 8-
20 mins. Water should be blotted, not wiped off the skin. Maintain airway
and suction secretions. Atropine of 2-4mg via IV followed by 2 mg Q3-8 mins.
For up to 24 hrs. Also can give pralidoxine 1-2 grams in 100-150 ml NS over
15-30 mins.

Blood Agents: (cyanide).

• Can be inhaled, ingested or absorbed through skin or mucous membranes. Leads to
respiratory and muscle failure, respiratory and cardiac arrest and death.
o Rapid administration of amyl nitrate, sodium nitrate and sodium thiosulfate is
essential. Patient is immediately intubated and placed on ventilation. Next
amyl nitrate pearls are crushed and put in ventilator reservoir. Next sodium
nitrate and then thiosulfate are given via IV. Also Vitamin B12 can be given
via IV in large doses.
Pulmonary Agents: (phosgene and chlorine)
• Destroy the pulmonary membrane and fills the alveoli with fluid. S/S include
pulmonary edema, SOB, a hacking cough followed by a frothy sputum production.

Nuclear Radiation Exposure: The farther away and the more a person is shielded, the lower the
exposure. Radiation is measured in rads. 100 rads is considered a high dose. When triaging
patients, they should be outside to prevent further contamination. Floors are covered to prevent
tracking contaminants throughout facility. Strict isolation precautions are taken and all air ducts
and vents should be covered. Personnel wear PPE and dosimeter badges. When the patient
arrives at the facility, they are scanned for internal and external radiation exposure and are then
showered and checked for remaining contaminants. Biologic samples are taken from the nose
and throat and a CBC is obtained. Wounds are irrigated and covered in waterproof dressings.
Fecal and urine samples are also taken.

Three types of injury can occur:

• External irradiation: when all or part of the body is exposed to radiation that
penetrates or passes through the body. This person is not radioactive and does not
need to be isolated or decontaminated and does not constitute a medical
emergency.
• Contamination: When the body is exposed to radioactive gases, liquids or solids
either externally or internally. Contamination requires immediate medical
management.
 • Incorporation: Actual uptake of radioactive agents into cells, tissues, and organs
(usually liver, kidney, thyroid and bone).
.

Acute Radiation Syndrome: occurs with very high levels of exposure, with total body exposure of
the penetrating type. Each body system is affected differently, and those with rapid cell
production are most vulnerable.
• The hematopoietic system is the first to be effected and the least amount of rads causes
S/S, which include decreased lymphocyte count, then decreased neutrophils within 1
week, decreased platelets after 2 weeks and decreased RBC within 3 weeks, leading to
bleeding disorders, etc.
• The GI system is affected with 600 rads or higher. Within 2 hours of exposure, N&V are
seen. An ominous sign is bloody diarrhea and a high fever, usually seen on day 10 after
exposure.
• The CNS is affected with 1000 rads or higher. S/S include cerebral edema, N&V, HA and
increased ICP, which is indicative of a poor outcome. CNS injury on this level is
irreversible.

Phases of Acute Radiation Syndrome:

• Prodromal Phase: (presenting symptoms), occurs 48-72 hours after exposure. S/S includes
N&V, loss of appetite, and fatigue. With high dose exposure: Fever, respiratory distress,
and increased excitability.
• Latent Phase: (symptom free period), after resolution of Prodromal phase, and can last up
to 3 weeks. (Shorter with high dose exposure). S/S includes decreased WBC & RBC
production.
• Illness phase: Follows latent phase ends. S/S include: infection, F&E imbalance, bleeding,
diarrhea, shock and altered LOC. Can take weeks to months to recover.
• Recovery phase: After illness phase. S/S are ICP and resulting death if ICP is not resolved.

Skin: Rashes of varying degrees occur after exposure. They range from Erythema after
exposure of 600-1000 rads, with desquamation (radiation dermatitis) with rads over 1000 and
necrosis with exposure to doses over 5000.