Revised ER Nsg (2)

8/4/2019 Revised ER Nsg (2)

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University of the Assumption NCM 106College of Nursing June 2011

Prepared by: Leah Marie S. Navarro, RN, MAN Page 1

EMERGENCY and DISASTER NURSING

Nurses are always faced with challenges and rewards for the care they provide for otherpeople. Their task is not only confined in the four walls of the hospital but in the outside world aswell. Every nurse must tackle diverse tasks with professionalism, competency, and above allconcern. And in every emergency situation, nurses must focus in rapid assessment andmanagement and must be geared up to provide client care for almost any situation they mayencounter and must always learn by heart that every second counts.

Learning Objectives:

After an interactive lecture/ discussion, students will be able to:

Define the meaning of emergency and emergency nursing

Identify the different emergency situations

Discuss how to assess and manage patients in emergency situations

Make and report quickly accurate assessments of people in emergency situations

Act quickly, safely and appropriately in emergency situations

Perform appropriate nursing intervention in any given situation

LESSON I


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EMERGENCY: A suddenly occurring threat to life or health that calls for immediate attention to

seriously ill or injured victims (Blackwell, 2005) It encompasses an unforeseen combination of circumstances calling for

immediate action for a range of victims from one to many. (LeMone and Burke,

2007) Any natural or man-made situation that results in severe injury, harm, or loss of

humans or property. (Veenema, 2007)

EMERGENCY NURSING: Is the delivery of specialized care to a variety of ill or injured patients (Lippincott

Williams and Wilkins, 2007)

The following are TYPES OF EMERGENCY, their clinical manifestations,assessment, and management: (Smeltzer, et al., 2010)

AIRWAY OBSTRUCTION

Upper airway obstruction is a medical emergency, which maybe partial orcomplete occlusion caused by aspiration of foreign bodies, anaphylaxis, viral orbacterial infection, trauma, and inhalation or chemical burns.

***Partial obstructionof the airway can lead to progressive hypoxia, hypercarbia,and respiratory and cardiac arrest***Complete obstructioncan cause brain injury or death will occur within 3 to 5minutes secondary to hypoxia

Clinical Manifestations of a patient with airway obstruction:

Patient cannot speak, breathe or cough

Clutch the neck between the thumb and fingers

Choking

Apprehension

Refusing to lie flat

Inspiratory and expiratory stridor

Labored breathing

Use of accessory muscles

Flaring nostrils

Increasing anxiety

Restlessness Confusion

Cyanosis and loss of consciousness are late signs

Assessment and Diagnostic Findings:

Ask the person if he or she is choking

If patient is unconscious, inspection of the oropharynx

X-ray, laryngoscopy and bronchoscopy may also be performed


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Management:

Abdominal thrust (Heimlich maneuver)

Adapted from hubpages.com

How to perform abdominal thrust:o Stand behind the person who chokingo Place both arms around the persons waisto Make a fist with one hand with the thumb outside the fisto Place thumb side of the fist against the persons abdomen above

the navel and below the xiphoid processo Grasp fist with one hand

o Quickly and forcefully exert pressure against the personsdiaphragm, pressing upward with quick, firm thrusts

o Apply thrusts 6 to 10 times until the obstruction is clearedo The pressure from the thrusts should lift the diaphragm, force air

into the lungs, and create an artificial cough powerful enough toexpel the aspirated object

Head-tilt-chin- lift maneuver

How to perform the head-tilt-chin- lift maneuver:o Place one hand on the victims forehead, and firm backward

pressure is applied with the palm to tilt the head backo The fingers of the other hand are placed under the bony part of the

lower jaw near the chin and lifted upo The chin and the teeth are brought forward almost to occlusion to

support the jaw

Note: Hands crossed at the neck is the universal sign for choking.


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Adapted from pmrcrc.blogspot.com

Jaw-thrust maneuver

*** This is done by placing one hand on each side of the patients jaw, theangles of the patients lower jaw are grasped and lifted, displacing themandible forward.

***This is a safe approach to opening the airway of a patient withsuspected spinal cord injury because it can be accomplished withoutextending the head.

Adapted from www.tags-search.com

Nursing alert: The head-tilt-chin-lift maneuver, which helps tilt the head back,

should be used only if it is determined that the patients cervical spine is not injured.

(Smeltzer, et. al., 2010)


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Oropharyngeal airway insertion

Adapted from viaaereadificil.com.br

***For a patient who is breathing spontaneously but who is unconscious, asemicircular tube or tubelike plastic device called an oropharyngeal airwayis inserted over the back of the tongue into the lower posterior pharynx.

*** This type of device prevents the tongue from falling back against theposterior pharynx and obstructing the airway. It can also allow health careproviders to suction secretions.

Endotracheal intubation

***To establish and maintain the airway in patients with respiratory

insufficiency or hypoxia is the purpose of endotracheal intubation.

***This is performed by physicians, nurse anesthetist, respiratory therapist,flight nurses, and nurse practitioners, because the procedure requires skill,only these people who have had extensive training can perform theprocedure.

Cricothyroidotomy

Adapted from www.surgeryencyclopedia.com


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***It is the opening of the cricothyroid membrane to establish airway. Thisprocedure is used in emergency situation in which endotracheal intubationis either not possible or contraindicated.

HEMORRHAGE

The following are the management of hemorrhage:

Fluid replacement - it is imperative to maintain circulation. Replacementfluids may include isotonic electrolyte solutions, colloids and bloodcomponents therapy.

The table below will show you the Volume Resuscitation Therapiesaccording to LeMone and Burke, 2007

COMPONENT INDICATIONS ADVANTAGES DIADVANTAGES

Normal Saline Restoration of

circulating volumeVehicle compatiblewith administrationof blood

Good availability

Low costSafe to use

Hyperchloremic

acidosis associatedwith prolonged use ofsodium solutions

Whole Blood Replaces bloodvolume and oxygen-carrying capacity inhemorrhage andshock

Contains RBCs,plasma proteins,clotting factors, andplasma

Contains fewplatelets orgranulocytes;deficient in clottingfactors V and VIIGreatest risks are for

incompatibility orcirculatory overload

Packed RBCs Restoration ofintravascular volumeReplacement ofoxygen-carryingcapacity

One unit of RBCsshould increase thehemoglobin of a 70-kg adult byapproximately 1g/dlin the absence ofvolume overload or

continuing bloodloss

Red cells requirecompatibility testingRisk for transmittingblood bornepathogensShould be warmed toavoid hypothermia

Platelets Continuedhemorrhage

Compatibility testingis not requiredTypical platelettransfusion should

Postexposureprophylaxis with anti

Rh immune globulinshould be considered


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raise the platelets ofa 70-kg adultapproximately30,000-50,000/ULGood availability

following Rh+ platelettransfusion to an Rh-woman

Control of external hemorrhage

Direct Pressure

According to LeMone and Burke, 2007, the following are the majorpressure points used for the control of bleeding:

Temporal to control scalp bleeding

Carotid to control head and neck bleeding

Subclavian to control bleeding in axilla, shoulder, and upperchest

Brachial to control arm bleeding

Radial to control bleeding in hand and wrist

Femoral to control upper leg bleeding

Popliteal to control lower leg bleeding

--

Adapted from wildernessmanuals.com

Adapted from www.wildernessmanuals.com

Nursing Alert: The infusion rate is determined by the severity of the blood loss and

the clinical evidence of hypovolemia. If massive blood replacement is necessary, the

blood must be warmed in a commercial blood warmer, because administration of

large amounts of blood that has been refrigerated has a core effect that may lead to

cardiac arrest and coagulopathy. (Smeltzer, et. al., 2010)


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Application of Tourniquet

Adapted from www.tpub.com

Control of internal hemorrhage***According to LeMone and Burke, 2007, discovering the cause andlocation of injury, as well as the extent of related blood loss, are the mostimportant concerns. Once the source of internal hemorrhage has beenrecognized, interventions are initiated, including operative control of

bleeding and continual assessment of the client.

HYPOVOLEMIC SHOCK

- Shock is a condition in which there is loss of effective circulating bloodvolume. Inadequate organ and tissue perfusion follows, ultimately resulting incellular metabolic derangements. (Smeltzer, et. al., 2010)

- According to LeMone and Burke, hypovolemic shock is caused by a decreasein intravascular volume of 15% or more. In hypovolemic shock, the venousblood returning to the heart decreases, and ventricular filling drops.

The following are the causes of loss of plasma or blood: Hemorrhage(>500 ml blood loss) traumatic injuries, major

surgeries Fluid shifting conditions

- Burns (large partial-thickness or full-thickness burns)- Nephrotic syndrome- Liver cirrhosis- Pancreatitis


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- Bowel obstruction Dehydration

- Excessive sweating (vigorous exercise)- Excessive vomiting or diarrhea- Insensible fluid losses (respiratory tract, hot environment)- Polyuria (DM, diabetes insipidus)- Diuretic medications- Inadequate oral fluid intake- Impaired recognition of thirst (older people)

Manifestations of Hypovolemic Shock: (LeMone and Burke, 2007)

Initial Stage:o Blood pressure : normal to slightly decreasedo Pulse: slightly increased from baselineo Respirations: normal (baseline)o Skin: cool, pale (in periphery), moisto Mental Status: alert and orientedo Urine output: slight decreaseo Others: thirst, decreased capillary refill time

Compensatory and Progressive Stage:o Blood pressure: hypotensiono Pulse: rapid and threado Respirations: increasedo Skin: cool, pale (includes trunk), poor turgor with fluid loss,

edematous with fluid shifto Mental status: restless, anxious, confused, or agitatedo Urine output: oliguria (less than 30 ml/hr)o Others: marked thirst, acidosis, hyperkalemia, decreased capillary

refill time, decreased or absent peripheral pulse

Irreversible Stage:o Blood pressure: severe hypotension (often systolic pressure is below

80mmHg)o Pulse: very rapid, weako Respirations: rapid, shallow, crackles and wheezeso Skin: cool, pale, mottled with cyanosiso Mental status: disoriented, lethargic, comatoseo Urine output: anuriao Others: loss of reflexes, decreased or absent peripheral pulses


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Basic Pathophysiology (Smeltzer, et. al., 2010)

- Venous return is decreased because of the lack of fluid in the vascular space,causing decreased ventricular filling. The ventricles do not have as muchblood as normal to pump out, so the stroke volume is decreased.

- The heart rate will increase to compensate for the diminished stroke volumeand resulting poor cardiac output and blood pressure.

- Eventually, if the fluid or blood loss continues, the heart rate will not be ableto compensate for the decreased stroke volume.

- The end result of hypovolemic shock is inadequate tissue perfusion.

Management of hypovolemic shock:

A. Medical:

Treatment of the underlying cause

Fluid and blood replacement*** Deliver a minimum of 20 ml/kg of crystalloid (or colloid equivalent)

Decreased blood volume

Decreased venous return

Decreased stroke volume

Decreased cardiac output

Decreased tissue perfusion


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Fluids Indications Advantages Disadvantages

Crystalloids

0.9% sodiumchloride (normalsaline solution)

LactatedRingers

Hypertonicsaline (3%)

-Restoration of circulatingvolume-Vehicle compatible with

administration of blood

Restoration of circulatingvolumeReplacement of electrolytedeficit

Widely available,inexpensive, safeto use

Lactate ion helpsbuffer metabolicacidosis, goodavailability, safe touse, low cost

Small volumeneeded to restoreintravascularvolume

Require large volumeof infusion; can causehypernatremia,

pulmonary edema,abdominalcompartmentsyndrome

Requires largevolume of infusion;can cause metabolicacidosis, pulmonaryedema, abdominalcompartmentsyndrome

Danger ofhypernatremia andcardiovascularcompromise fromrapid fluid shifts

Colloids

Albumin (5%,

25%)

Dextran

Hetastarch

Expands blood volume in

shock and trauma

Rapidly expands

plasma volume,good availability

Synthetic plasmaexpander

Synthetic plasmaexpander

Expensive; requires

human donors, limitedsupply; can causeheart failure, notsubstitute for wholeblood, hypersensitivityreaction can occur

Interferes with plateletaggregation; notrecommended forhemorrhagic shock

Prolongs bleedingand clotting time

(Adapted from Smeltzer, et al.,2010 and LeMone and Burke, 2007)


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Redistribution of fluid

Adapted from Smeltzer, et al., 2010

B. Nursing:

Administering blood and fluids safely

Implementing other measures- Oxygen administration

WOUNDS

***According to Langan and James, 2005, wounds are categorized according towhich skin or tissue is broken. The six types of wounds are as follows:

Abrasions occur when the skin is rubbed or scraped off. It can becomeinfected when dirt and germs become embedded.

Incisions are made with sharp cutting instruments. Incisions tend to bleedfreely because the blood vessels are cut cleanly with little surrounding tissuedamage.

Lacerations are torn wounds with torn tissue underneath. They are madewith blunt objects. Bomb fragments can cause lacerations.

Punctures occur when objects penetrate into the tissues, leaving a smallsurface opening. They do not bleed freely, but larger wounds may causeinternal bleeding.

Avulsions are the tearing away of tissue from a body part. Bleeding typicallyis heavy. The torn tissue may be reattached, so place the tissue in a steriledressing in a cool container. Take care not to freeze the tissue or submerge inwater or saline.

Proper positioning (modified Trendelenburg) for the patient who shows signs of

shock. The lower extremities are elevated to an angle of about 20 degrees; the

knees are straight, the trunk is horizontal, and the head is slightly elevated.

Smeltzer et. al. 2010


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Amputations are traumatic or nontraumatic removal of limbs from the body.Shock will develop, and a tourniquet is often necessary.

The following are the management of wounds:

Wound cleansing

Primary closure Delayed primary closure

TRAUMA

***According to LeMone and Burke, 2007, it is an injury to human tissues and organsresulting from the transfer of energy from the environment.

Multiple trauma***is caused by a single catastrophic event that causes life-threatening injuries toat least two distinct organs or organ systems.

Priority management:

Establish airway and ventilation

Control hemorrhage

Prevent and treat hypovolemic shock

Assess for head and neck injuries

Evaluate for other injuries reassess head and neck, chest, assessabdomen, back and extremities

Splint fractures

Perform a more thorough and ongoing examination andassessment

Intra-abdominal injuriesCategories:

Penetrating abdominal trauma results in high incidence of injury tohollow organs, particularly the small bowels. The liver is the mostfrequently injured solid organ.

Blunt trauma to the abdomen results from motor vehicle crushes, falls,

blows and explosions.

Assessment:

Internal bleedingo Front of the body, flanks and back are inspected for bluish discoloration,

asymmetry, abrasion and contusion

The primary goal of treatment is to restore the physical integrity and function of the

injured tissue while minimizing scarring and preventing infection. (Smeltzer, et. al.,

2010


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Intraperitoneal injuryo Abdomen is assessed for tenderness, rebound tenderness, guarding,

rigidity, spasm, increasing distention, and pain

Genito- urinary injuryo Typically includes a rectal and/or vaginal examination, is performed to

determine any injury to the pelvis, bladder, urethra, or intestinal wall.

Laboratory studies that aid in assessment include the following: Urinalysis to detect hematuria (indicative of a urinary tract injury)

Serial hematocrit and hemoglobin levels to evaluate trends reflecting thepresence or absence of bleeding

White blood cell (WBC) count to detect elevation (generally associatedwith trauma)

Serum amylase analysis to detect increasing levels, which suggestpancreatic injury or perforation of the gastrointestinal tract

Management:

Resuscitation procedures (restoration of airway, breathing and circulation)

Immobilization

Know the mechanism of injury

Withheld oral fluids

Tetanus prophylaxis and broad spectrum antibiotics are administered asprescribed

Continuously monitor condition of patient for changes

Crush Injuries*** It occurs when a person is caught between opposing forces.

The patient is observed for the following: Hypovolemic shock resulting from extravasation of blood and plasma into

injured tissues after compression has been released

Paralysis of a body part

Erythema and blistering of skin

Damaged body part (usually an extremity) appearing swollen, tense andhard

Renal dysfunction

Pain in the left shoulder is common in a patient with bleeding from a ruptured

spleen, whereas pain in the right shoulder can result from laceration of the liver.

(Smeltzer, et al., 2010)

Referred pain is a significant finding because it suggests intraperitoneal injury.



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Management:

Observe patient for acute renal insufficiency

Elevate an injured extremity to relieve swelling and pressure

Medications for pain and anxiety as prescribed

Fracture

***According to Ignatavicius and Workman, 2010, it is a break or disruption in thecontinuity of a bone that often affects the human needs for mobility and sensation.

A fracture is classified by the extent of the break: (Ignatavicius and Workman,2010)

Complete fracture the break is across the entire width of the bone insuch a way that the bone is divided into two distinct sections

Incomplete fracture the fracture does not divide the bone onto twoportions because the break is through only part of the bone

A fracture is also described by the extent of associated soft-tissue damageaccording to Ignatavicius and Workman, 2010:

Closed or simple fracture is one that does not extend through the skinand therefore has no visible wound.

Open or compound fracture the skin surface over the broken bone isdisrupted, which causes an external wound.

***These fractures are often graded to define the extent of tissue damage:o Grade I is the least severe injury, and skin damage is minimalo Grade II - an open fracture is accompanied by skin and muscle

contusionso Grade III there is damage to skin, muscle, nerve tissue, and blood

vessels

Specific Types of Fractures:

Comminuted fracture is one that produces several bone fragments.

Avulsion a fracture in which a fragment of bone has been pulled away bya tendon and its attachment

Compression a fracture in which bone has been compressed (seen invertebral fractures)

Depressed a fracture in which fragments are driven inward ( seenfrequently in fractures of skull and facial bones)

Epiphyseal a fracture through the epiphysis

Greenstick a fracture in which one side of the bone is broken and theother side is bent

Impacted a fracture in which a bone fragment is driven into another bonefragment

Oblique a fracture occurring at an angle across the bone (less stablethan a transverse fracture)

Pathologic a fracture that occurs through an area of diseased bone, can

occur without trauma or fall

Spiral a fracture that twist around the shaft of the bone

Stress a fracture that results from repeated loading of bone and muscle

Transverse a fracture that is straight across the bone shaft


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Adapted from nursingcrib.com

Clinical Manifestations of fracture according to Smeltzer,et al., 2010:

Pain

Loss of function Deformity

Shortening

Crepitus

The following are the management for fracture:

Reduction*Fracture Reduction refers to restoration of the fracture fragments to

anatomic alignment and positioning. Closed Reduction is accomplished by bringing the bone

fragments into anatomic alignment through manipulation andmanual traction. The extremity is held in the aligned positionwhile the physician applies a cast, splint, or other device.

Open Reduction through a surgical approach, the fracturefragments are anatomically aligned. Internal fixation devices(metallic pins, wires, screws, plates, nails, and rods) may be usedto hold the bone fragments in position until solid bone healingoccurs.

Immobilization

Maintaining and restoring function Controlling by elevating the injured extremity and applying ice as

prescribed Routine monitoring of neurovascular status Restlessness, anxiety, and discomforts are controlled with

reassurance, position changes and pain relief strategies

Nursing Alert: Testing for crepitus can produce further tissue damage and should

be minimized as much as possible. (Smeltzer, et al., 2010)


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Isometric and muscle-setting exercises are encouraged tominimize atrophy and to promote circulation

Participation in activities of daily living is encouraged to promoteindependent functioning and self-esteem

Factors that enhance fracture healing:

Immobilization of fracture fragments Maximum bone fragment contact

Sufficient blood supply

Proper nutrition

Exercise: weight bearing for long bones

Hormones: growth hormone, thyroid, calcitonin, vitamin D, anabolicsteroids

Electric potential across fracture

Factors that inhibit fracture healing:

Extensive local trauma

Bone loss Weight bearing prior to approval

Malalignment of the fracture fragments

Inadequate immobilization

Space or tissue between bone fragments

Infection

Local malignancy

Metabolic bone disease (eg. Pagets disease of the bone)

Irradiated bone (radiation necrosis)

Avascular necrosis

Intra-articular fracture

Age (elderly persons heal more slowly)

Corticosteroids (inhibit the repair rate)

According to Ignatavicius and Workman, the following are thecomplications of fracture:

Acute compartment syndrome

Crush syndrome

Hypovolemic shock

Fat embolism syndrome

Venous thromboembolism

Infection

Chronic complications, such as ischemic necrosis and delayed union

ENVIRONMENTAL EMERGENCIES

Heat stroke is an acute medical emergency caused by failure of the heat-regulating mechanisms of the body. The most common cause of heat stroke isprolonged exposure to an environmental temperature of greater than 39.2 C(102.5 F).


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Management:

Primary goal reduce the high body temperature as quickly as possible isthe primary goal

IV infusion therapy of normal saline and lactated Ringers solution

Frequent measurement of urine output

Dialysis for renal failure, antiseizure medications to control seizures,potassium for hypokalemia, and sodium bicarbonate to correct metabolicacidosis are additional supportive care

Frostbite is trauma from exposure to freezing temperatures and freezing of theintracellular fluid and fluids in the intercellular spaces. Frostbite can result invenous stasis and thrombosis.

Management:

Restore normal body temperature is the goal of management

Remove constrictive clothing and jewelry that could impair circulation

Wet clothing is removed as rapidly as possible

Controlled yet rapid rewarming is instituted*hemorrhagic blebs which may develop 1 hour to a few days afterrewarming are left intact and not ruptured. Nonhemorrhagic blisters aredebrided to decrease the inflammatory mediators found in the blister fluid.

Hypothermia is a condition in which the core (internal) temperature is 35 C(95 F) or less as a result of exposure to cold or an inability to maintain bodytemperature in the absence of low ambient temperatures.

Management:

Monitoring The ABCs of basic life support are a priority Patients vital signs, CVP, urine output, arterial blood gas

levels, blood chemistry determinations and chest x-rays areevaluated frequently

Continuous ECG monitoring is performed An arterial line is inserted and maintained to record blood

pressure and to facilitate blood sampling

Rewarming Active internal (core) rewarming methods are used for

moderate to severe hypothermia (less than 28 C to 32.2 C)

Most heat-related deaths occur in the elderly because their circulatory systems

are unable to compensate for stress imposed by heat. (Smeltzer, et al., 2010)

Dry heat should never be applied, nor should the frostbitten areas be rubbed or

massaged as part of the warming process. These actions produce furthertissue injury. (Ignatavicius and Workman, 2010)


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and include cardiopulmonary bypass, warm fluidadministration, warm humidified oxygen by ventilator, andwarmed peritoneal lavage.

Passive or active external rewarming is used for mildhypothermia (32.2 C to 35 C). Passive active rewarminguses over-the-bed heaters to the extremities and increases

blood flow to the acidotic, anaerobic extremities. Activeexternal rewarming uses forced air warm blankets. Care mustbe taken to prevent extremity burn from these devices,because the patient may not have effective sensation to feelthe burn.

Supportive careSupportive care during rewarming includes the following as directed:

External cardiac compression Defibrillation of ventricular fibrillation Mechanical ventilation with positive end-expiratory pressure

(PEEP) and heated humidified oxygen to maintain tissueoxygenation

Administration of warmed IV fluids to correct hypotension andto maintain urine output and core rewarming

Administration of sodium bicarbonate to correct metabolicacidosis if necessary

Administration of antiarrhythmic medications Insertion of an indwelling urinary catheter to monitor urinary

output and renal function

Near drowning is defined as survival for at least 24 hours after submersionthat caused respiratory arrest. The most common consequence is hypoxemia.Factors associated with drowning and near drowning include alcohol ingestion,

inability to swim, diving injuries, hypothermia, and exhaustion.

Management:

Therapeutic goals include maintaining cerebral perfusion andadequate oxygenation to prevent further damage to vital organs

Immediate cardiopulmonary resuscitation is the factor with thegreatest influence on survival

Arterial blood gases are monitored to evaluate oxygen, carbondioxide, bicarbonate levels, and pH.

Use of endotreacheal intubation with PEEP improves oxygenation,prevents aspiration, and corrects intrapulmonary shunting andventilation-perfusion abnormalities caused by aspiration of water.

If patient is breathing spontaneously, supplemental oxygen amy beadministered by mask

Prescribed rewarming procedures are started during resuscitation

Intravascular volume expansion and inotropic agents are used to treathypotension and impaired tissue perfusion

ECG monitoring is initiated, because dysrrhythmias frequently occur

An indwelling urinary catheter is inserted to measure urine output


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Nasogastric intubation is used to decompress the stomach and toprevent the patient from aspirating gastric contents

Decompression sickness also called the bends, occurs in patients whohave engaged in diving (lake, as well as ocean, diving), high- altitude flying, or

flying in commercial aircraft within 24 hours after diving. Decompression sicknessresults from formation of nitrogen bubbles that occur with rapid changes inatmospheric pressure. They may occur in joint or muscle spaces, resulting inmusculoskeletal pain, numbness, or hypesthesia.

*Signs and symptoms include joint and extremity pain, numbness, hypesthesia,and loss of range of motion. Neurologic symptoms mimicking those of a stroke orspinal cord injury can indicate an air embolus.

Management:

Patent airway and adequate ventilation are established

100% oxygen is administered throughout treatment and transport

Chest x-ray is obtained to identify aspiration

At least one IV line is started with lactated Ringers or normal salinesolution

If an air embolus is suspected, the head of the bed should be lowered

Patients wet clothing is removed, and the patient is kept warm

If air transport is necessary, low-altitude flight (below 1000 feet) is required

Anaphylactic reaction is an acute systemic hypersensitivity reaction thatoccurs within seconds or minutes after exposure to certain foreign substances,such as medications and other agents, or foods.

*Be alert for the following signs and symptoms: Respiratory Signs:

o Nasal congestiono Itchingo Sneezing and coughingo Possible respiratory distress that progresses rapidlyo Chest tightnesso Other respiratory difficulties, such as wheezing, dyspnea, and

cyanosis

Skin Manifestations:o Flushing with a sense of warmth and diffuse erythemao Generalized itching over the entire bodyo Urticaria (hives)o Massive facial angioedema possible with accompanying upper

respiratory edema

Nitrogen bubbles can become air emboli in the bloodstream and thereby produce

stroke, paralysis or death. (Smeltzer, et al., 2010)


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Cardiovascular Manifestations:o Tachycardia or bradycardiao Peripheral vascular collapse as indicated by:

Pallor Imperceptible pulse Decreasing blood pressure

Circulatory failure, leading to coma and death Gastrointestinal Problems:

o Nauseao Vomitingo Colicky abdominal painso Diarrhea

Management:

If patient is in cardiac arrest, cardiopulmonary resuscitation isinstituted

Oxygen is provided in high concentrations during cardiopulmonary

resuscitation or if the patient is cyanotic, dyspneic, or wheezing Epinephrine, in a 1:1000 dilution, is administered subcutaneously in

the upper extremity or thigh and may be followed by a continuous IVinfusion

Antihistamines and corticosteroids may also be administered toprevent recurrence of the reaction and to treat urticaria andangioedema

IV fluids, volume expanders, and vasopressor agents areadministered to maintain blood pressure and normal hemodynamicstatus

In patients with episodes of bronchospasm or a history of bronchialasthma or chronic obstructive pulmonary disease, aminophylline andcorticosteroids may also be administered to improve airway patencyand function

If hypotension is unresponsive to vasopressors, glucagon may beadministered intravenously for its acute inotropic and chronotropiceffects

POISONING***Poison is any substance that, when ingested, inhaled, absorbed, applied to the

skin, or produced within the body in relatively small amounts, injures the body byits chemical action.

Ingested (Swallowed) Poisons swallowed poisons may be corrosive.

Corrosive poisons include alkaline and acid agents that can cause tissuedestruction after coming in contact with mucous membranes.

Management:

Control of the airway, ventilation, and oxygenation are essential

ECG, vital signs, and neurologic status are monitored closely forchanges

An indwelling urinary catheter is inserted to monitor renal function


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Blood specimens are obtained to determine the concentration of drugor poison

Efforts are made to determine what substance was ingested; theamount; the time since ingestion; signs and symptoms; age andweight of the patient

The patient who has ingested a corrosive poison, which can be a

strong acid or alkaline substance, is given water or milk to drink fordilution

The following gastric emptying procedures may be used asprescribed:

o Syrup of ipecac to induce vomiting in the alert patient (never

use with corrosive poisons)o Gastric lavage for the obtunded patient; gastric aspirate is

saved and sent to the laboratory for testingo Activated charcoal administration if the poison is one that is

absorbed by charcoalo Cathartic, when appropriate

If there is a specific chemical or physiologic antagonist (antidote), it is

administered as early as possible to reverse or diminish the effects ofthe toxin

Carbon monoxide poisoning*** Carbon monoxide poisoning may occur as a result of industrial or householdincidents or attempted suicide.

Clinical Manifestations:

Person may appear intoxicated

Headache

Muscular weakness

Palpitation

Dizziness

Confusion, which can progress rapidly to comaManagement:

Carry the patient to fresh air immediately; open all doors and windows

Loosen all tight clothing

Initiate cardiopulmonary resuscitation if required; administer 100%oxygen

Dilution is not attempted if the patient has acute airway edema or obstruction or

if there is clinical evidence of esophageal, gastric, or intestinal burn or

perforation. (Smeltzer, et al., 2010)

Vomiting is never induced after ingestion of caustic substances (acid or

alkaline) or petroleum distillates. (Smeltzer, et al., 2010)


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Prevent chilling; wrap the patient in blankets

Keep the patient as quiet as possible

Do not give alcohol in any form or permit the patient to smoke

Carboxyhemoglobin levels are analyzed on arrival at the emergencydepartment and before treatment with oxygen if possible

Skin Contamination Poisoning (Chemical Burns)

The skin should be drenched immediately with running water from ashower, hose, or faucet, except in the case of lye and whitephosphorus, which should be brushed off the skin dry.

Food Poisoning***Food poisoning is a sudden illness that occurs after ingestion of contaminatedfood or drink.

Management:

The key treatment is determining the source and type of foodpoisoning

Patients respirations, blood pressure, level ofconsciousness, centralvenous pressure, and muscular activity are monitored closely

Fluid and electrolyte status should be assessed

Patient is assessed for signs and symptoms of fluid and electrolyteimbalances

Weight and serum electrolyte levels are obtained for futurecomparisons

Measures to control nausea are also important to prevent vomiting

For mild nausea, the patient is encouraged to take sips of weak tea,

carbonated drinks, or tap water After nausea and vomiting subside, clear liquids are usually

prescribed for 12-24 hours, and the diet is gradually progressed to alow-residue, bland diet

SUBSTANCE ABUSE***It is the misuse of specific substances, such as drugs or alcohol, to alter mood orbehavior.

Acute Alcohol Intoxication**Alcohol is a psychotropic drug that affects mood, judgment, behavior,concentration, and consciousness. Also known as ethanol, alcohol is a multi

system toxin and CNS depressant.

Management:

Assessed patient for head injury, hypoglycemia (mimics intoxication),and other health problems

Nurse should approach the patient in a non judgmental manner, usinga firm, consistent, accepting, and reasonable attitude

If drowsy, the patient should be allowed to sleep off the state ofalcoholic intoxication


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Patient should be undressed and kept warm with blankets

If patient is noisy and belligerent, sedation may be necessary

Alcohol Withdrawal Syndrome / Delirium Tremens**It is an acute toxic state that occurs as a result of sudden cessation of alcoholintake after a bout of heavy drinking or, more typically, after prolonged intake of

alcohol.

Signs of patient with Delirium Tremens:

Anxiety

Uncontrollable fear

Tremor

Irritability

Agitation

Insomnia

Incontinence

Talkative and preoccupied

Experience visual, tactile, olfactory and auditory hallucinations thatare often terrifying

Tachycardia

Dilated pupils

Profuse perspiration

Elevated vital signs in toxic state

Management:

adequate sedation and support to allow the patient to rest and recover

without danger of injury or peripheral vascular collapse physical examination is performed to identify preexisting or

contributing illnesses or injuries

drug history is obtained to elicit information

baseline blood pressure is determined

patient is sedated as directed with sufficient dosage ofbenzodiazepines

patient is placed in a non stressful environment nad observed closely

room remains lighted to minimize the potential for illusions andhallucinations

closet and bathroom doors are closed to eliminate shadows

someone is designated to stay with the patient

PSYCHIATRIC EMERGENCIES*** Psychiatric emergency is an urgent, serious disturbance of behavior , affect, orthought that makes the patient unable to cope with life situations and interpersonalrelationships.

Delirium tremens is a life threatening condition and carries a high mortality rate.



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Overactive Patients***Patients who display disturbed, uncooperative, and paranoid behavior andthose who feel anxious and panicky may be prone to assaultive and destructiveimpulses and abnormal social behavior

Management:

To gain control of the situation is the immediate goal

Approach the patient with a calm, confident, and firm manner

Helpful interventions include the following:o Introduce yourself by nameo Tell the patient, I am here to help you.o Repeat the patients name from time to timeo Speak in one thought sentences and be consistento Give the patient space and time to slow downo Show interest in, listen to, and encourage the patient to talk

about personal thoughts and feelingso Offer appropriate and honest explanations

A psychotropic agent may be prescribed for emergency managementof functional psychosis

Violent behavior

***Violent and aggressive behavior, usually episodic, is a means of expressingfeelings of anger, fear, or hopelessness about a situation.

Management:

Goal of treatment is to bring the violence under control

A specially designated room with at least two exits should be used forthe interview

No objects that could be used as weapons should be in sight, in theroom, or carried in with health care personnel

Patient should not be left alone

Sudden movements should be avoided

Patient is allowed the opportunity to express anger verbally

Medication may be prescribed to reduce tension, anxiety, andhyperactivity

Posttraumatic Stress Disorder***It is the development of characteristic symptoms after a psychologicallystressful event that is considered outside the range of normal human experience.

Psychotropic agents should not be used if the patients behavior results from the use

of hallucinogens. (Smeltzer, et al.,2010)

Restraints are used as last resort and only as prescribed. (Smeltzer, et al., 2010)


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Symptoms:

Intrusive thoughts and dreams

Phobic avoidance reaction

Heightened vigilance

Exaggerated startle reaction

Generalized anxiety

Societal withdrawal

Management:

Establish a trusting relationship

Address and work through the trauma experience

Teach the coping skills needed for recovery and self-care

Underactive or Depressed Patients***Depression is a common response to health problems and is anunderdiagnosed problem, particularly in hospitalized patients.

A person experiences at least five out of nine characteristics, with one of thefirst two symptoms present most of the time:1. Depressed mood2. Loss of pleasure or interest3. Weight gain or loss4. Sleeping difficulties5. Psychomotor agitation or retardation6. Fatigue7. Feeling worthless8. Inability to concentrate9. Thoughts of suicide or death

Management:

Talk with the patient about his or her fears, frustrations, anger,and despair

Help the patient learn to cope effectively with conflict,interpersonal problems and grief

Encourage the patient to discuss actual and potential losses

Help the patient identify and decrease negative self-talk andunrealistic expectations

Monitor the patient for the onset of new problems

Psychoeducational programs, establishment of support systems,and counseling can reduce anxiety- and depression-relateddistress

Suicidal Patients***Attempted suicide is an act that stems from depression and can be viewed ascry fro help and intervention. Males are at greater risk than females.

Risk Factors for suicide:

Age younger than 20 or older than 45 years, especially older than 65years

Gender women make more attempts, men are more successful


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Dysfunctional family

Family history of suicide

Severe depression

Severe, intractable pain

Chronic, debilitating medical problems

Substance abuse

Severe anxiety

Overwhelming problems

Severe alteration in self-esteem or body image

Lethal suicide plan

Emergency management focuses on treating the consequences of thesuicide attempt and preventing further self-injury. (Smeltzer, et al., 2010)


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REFERENCES:

BOOKS:

1. Ignatavicius and Workman (2010). Medical Surgical Nursing (6th edition).

2. Smeltzer, Suzanne, et al., (2010). Textbook of Medical Surgical Nursing (21th edition)

3. LeMone, Priscilla and Burke, Karen (2007). Principles of Medical Surgical Nursing (4thedition)

4. Lippincott Williams and Wilkins (2007). Emergency Nursing made Incredibly Easy

5. Veenema, Tener Goodwin (2007). Disaster Nursing and Emergency Preparedness

6. Langan, Joanne and James, Dotti (2005). Preparing Nurses for Disaster Management

URL:

1. http//nursingcrib.com

2. http//www.hubpages.com

3. http//pmrcrc.blogspot.com

4. http//viaaereadificil.com.br

5. http//www.surgeryencyclopedia.com

6. http//www.wildernessmanuals.com

7. http//www.tpub.com

8. http.www.tags-search.com
http://www.hubpages.com/http://www.wildernessmanuals.com/http://www.wildernessmanuals.com/http://www.tpub.com/http://www.tpub.com/http://www.wildernessmanuals.com/http://www.hubpages.com/


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UNIVERSITY OF THE ASSUMPTIONCollege of Nursing

City of San Fernando (P) Tel. No. 045-9611482 loc.125

SCIENTIA VIRTUS COMMUNITAS

Emergency Nursing Lesson 1Pre-test

Name: ________________________________________ Date: ____________Section: _______________ Score: ___________

You learn more quickly under the guidance of experienced teachers. You waste a lot of time

going down blind alleys if you have no one to lead you. -W. Somerset Maugham, 1874-1965Direction: Choose the correct answer from the given choices in the box. Write the letter of the

correct answer on the space provided for. Use capital letters only. Any form of erasure or

superimposition will be considered wrong.

_____ 1. It encompasses an unforeseen combination of circumstances calling for immediateaction for a range of victims from one to many.

_____ 2. It is the delivery of specialized care to a variety of ill or injured patients._____ 3. It is caused by a decrease in intravascular volume of 15% or more.

_____ 4. The lower extremities are elevated to an angle of about 20 degrees; the kneesare straight, the trunk is horizontal, and the head is slightly elevated.

_____ 5. These are torn wounds with torn tissue underneath._____ 6. It occurs when the skin is rubbed or scraped off._____ 7. It is caused by a single catastrophic event that causes life-threatening injuries to at

least two distinct organs or organ systems._____ 8. It occurs when a person is caught between opposing forces._____ 9. A type of fracture that does not extend through the skin and therefore has no visible

wound._____ 10. A fracture in which a bone fragment is driven into another bone fragment.

A. Lacerations G. Emergency NursingB. Emergency H. Modified Trendelenburg

C. Impacted fracture I. Simple Fracture

D. Hypovolemic shock J. Crush injury

E. Hemorrhage K. Abrasion

F. Avulsion L. Multiple Trauma


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Answer Key: (Lesson 1 Pretest)

1. Emergency

2. Emergency nursing3. Hypovolemic shock

4. Modified trendelenburg

5. Lacerations

6. Abrasion

7. Multiple trauma

8. Crush injury

9. Simple fracture

10. Impacted fracture


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UNIVERSITY OF THE ASSUMPTIONCollege of Nursing

City of San Fernando (P) Tel. No. 045-9611482 loc.125SCIENTIA VIRTUS COMMUNITAS

Emergency Nursing Lesson 1Post Test

Name: ________________________________________ Date: ____________Section: _______________ Score: ___________

Most of the important things in the world have been accomplished by peoplewho have kept on trying when there seemed to be no hope at all.

-Dale CarnegieIdentification: Read carefully the sentences below, then identify and write the correct answeron the space provided for. Any form of erasure or superimposition will be considered wrong.

______________________ 1. This maneuver should be used only if it is determined thatthe patients cervical spine is not injured.

______________________ 2. Any natural or man-made situation that results in severe injury,harm, or loss of humans or property.

______________________ 3. It restores the circulating volume and is compatible withadministration of blood.

______________________ 4. It is the tearing away of tissue from a body part and bleedingtypically is heavy.

______________________ 5. This intra abdominal trauma results in high incidence of injury tohollow organs, particularly the small bowels.

______________________ 6. It is a break or disruption in the continuity of a bone that oftenaffects the human needs for mobility and sensation.

______________________ 7. Testing this can produce further tissue damage and should beminimized as much as possible.

______________________ 8. This is accomplished by bringing the bone fragments into

anatomic alignment through manipulation and manual traction.

______________________ 9. It is a condition in which the core (internal) temperature is (95 F)or less as a result of exposure to cold or an inability to maintainbody temperature in the absence of low ambient temperatures.

______________________ 10. This is never induced after ingestion of caustic substances (acidor alkaline) or petroleum distillates.


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Matching Type: Match column A with Column B. Write the correct answer on the spaceprovided for. Use capital letters only. Any form of erasure or superimpositionwill be considered wrong.

A B

____ 1. Last resort for over active patients A. ER nursing

____ 2. delivery of specialized care to a variety B. frostbite

of ill or injured patients. C. crush injury

____ 3. occurs when the skin is rubbed or scraped off. D. brachial

____ 4. a common response to health problems and is E. avulsion

an under diagnosed problem F. laceration

____ 5. torn wounds with torn tissue underneath. G. restraints

____ 6. occurs when a person is caught between H. complete fracture

opposing forces I. psychotropic agents

____ 7. A pressure point to control arm bleeding J. depression

____ 8. should not be used if the patients behavior K. abrasion

results from the use of hallucinogens. L. comminuted fracture

____ 9. one that produces several bone fragments

____ 10. trauma from exposure to freezing temperatures


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ANSWER KEY: LESSON I (POST TEST)

Identification:1. Head-tilt-chin-lift maneuver2. Emergency

3. Sodium chloride4. Avulsion5. Penetrating abdominal trauma6. Fracture7. Crepitus8. Closed reduction9. Hypothermia10. Vomiting

Matching Type:1. G

2. A3. K4. J5. F6. C7. D8. I9. L10. B


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TRIAGE NURSING

Disaster is any destructive event that disrupts the normal functioning of a community. (Veenema, 2007) What is happening in our world today is an eye opener not only to people inthe medical field, but to ordinary people in the community as well. Destruction in the communityand the economy, flooding all over the world, tornados, tsunamis, terrorists attacks, are clearsigns of global warming and works of inhumanity which needs preparedness by trained peoplefor the good and salvage of not only of the environment but especially of mankind.

Learning Objectives:

After the interactive lecture/discussion, students will be able to:1. Define triage, decontamination, and disaster2. Discuss the different levels of triage3. Identify the typical elements gathered at the point of triage4. Differentiate the different command system5. Identify the different PPE and their levels of protection6. Discuss the different hazardous materials and biological agents, their clinical

manifestations and their management7. List the different natural disasters and their risk for morbidity and mortality8. Discuss the different stages/phases of disaster9. Discuss PTSD, stress management, and debriefing

10. Identify the different roles of nurses in disasters

LESSON 2


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TRIAGE- comes from the French word tiermeaning to sort. It is the continuous

process in which priorities are reassigned as needed treatments, time, andcondition of the victims change. (Langan and James, 2005)

- it is a method of prioritizing patient care according to the type of illness or injury andthe urgency of the patients condition. It is used to ensure that each patient receives

care appropriate to his need and in a timely manner. (Lippincott, 2007)- is the sorting of patients to determine the priority of their health care needs and the

proper site for treatment. (Smeltzer, et al., 2010)- is the sorting or classifying of patients into priority levels depending on illness or

injury severity. (Ignatavicius and Workman, 2010)

START ( Simple Triage and Rapid Treatment)***refers to a specific triage method to evaluate patient respiratory, circulatory,and neurological function and categorize each of them into one of four carecategories. (Langan and James, 2005)

*** According to Veenema, 2007, START was developed by the Newport Beach,California, Fire and Marine Department and Hoag Hospital. It is easy to learn andsimple to use. It is based on the persons ability to respond verbally and ambulate andtheir respirations, perfusion, and mental status (RPM). The system works as follows:

(1) All patients who can walk (walking wounded) are categorized as Delayed(GREEN) and are asked to move away from the incident area to a specificlocation.

(2) The next group of patients is assessed quickly (30-60 seconds per patient) byevaluating RPM:

o Respiration (position upper airway or determine respiratory rate)o Perfusion/blood circulation (check capillary refill time)o Mental status (determine patients ability to obey commands)

The table below shows the color-coding for Simple Triage and Rapid Transport (START)System (Adapted from LeMone and Burke, 2007)

COLOR DESCRIPTOR AND ORDER OF TRANSPORT

Red (Immediate) Critically injured, with problems that will require immediateintervention to correct. (Clients with a respiratory rate ofabove 30 are tagged red. If their respirations are below 30,assess their circulatory status. If capillary refill takes morethan 2 seconds, tag them red. If it is below 2 seconds,

assess mental status.

Yellow (Delayed) Injured, and will require some medical attention, but they willnot die if care is delayed while you care for other clients; notambulatory and will require a stretcher for transportation.( Clients who can follow simple commands such as handgrips are tagged as yellow. Clients who cannot follow simplecommands are tagged as red.


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Green (Ambulatory) Not critically injured, and can walk and care for themselves.(Have them walk to a safe place, but do not lose track ofthem; every client triaged at an incident is tracked to the bestof the responders ability).

Black (Expectant) Deceased, or have such catastrophic injuries that they are

not expected to survive to be transported. (If the client is notbreathing, open the airway manually. If they remain apneic,tag them black; if they begin breathing, they are taggedred)

According to Lippincott Williams and Wilkins, 2007, the Emergency NursesAssociation (ENA) has established guidelines for triage based on a five-tier system:

LEVEL I: RESUSCITATION

This level includes patients who need immediate nursing and medicalattention.

Case examples include:o Cardiopulmonary arresto major trauma with hypotensiono severe respiratory distress and seizures

LEVEL II: EMERGENT

These patients need immediate nursing assessment and rapid treatment.

Case examples include:o Head injurieso Chest paino Strokeo Asthmao Sexual assault injuries

LEVEL III: URGENT

These patients need quick attention, but can wait as long as 30 minutes forassessment and treatment.

Case examples include:o Signs of infectiono Mild respiratory distresso Moderate pain

LEVEL IV: LESS URGENT

Patients in this triage category can wait up to 1 hour for assessment andtreatment.

Case examples include:o Earacheo Chronic back paino Upper respiratory symptomso Mild headache


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LEVEL V: NONURGENT

These patients can wait up to 2 hours (possibly longer) for assessment andtreatment.

Case examples include:o Sore throato Menstrual cramps

According to Veenema, 2007, the following are the Typical Information ElementsGathered at the Point of Triage:

Name

Age

Gender

Chief complaint

History of present illness

Mechanism of injury

Past medical and surgical history

Allergies to food and medication Current medications

Date of last tetanus immunization

Last menstrual period (for women between ages 11-60y/o)

Vital signs: temperature, pulse, blood pressure and respiratory rate

Skin vital sings: temperature, color and moisture

Level of consciousness

Visual inspection for deformities, lacerations, bruising, rashes, etc.

Height and weight

Mode of arrival

Private medical provider

Military Triage:***It is based on medical need, medical utility, and an additional category, social utility.

***Social utility is the notion of allocating resources to those who may be the mostuseful or most valued in a society.

***In the military, there is a social utility to treating those with minor injuries quicklybecause to do so serves a larger social purpose of returning soldiers to thebattlefield to help win the battle.

Common Problems Experienced in Triage Nursing

1. Failure to determine and attend to a patient who complaints of severe pain2. Failure to recognize or acknowledge high-risk chief complaints3. Failure to take adequate vital signs4. Failure to adequately document the triage5. Failure to re-triage


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Key Triage Points to Remember, according to LeMone and Burke, 2007:

Use a triage system that is easy to learn, easy to implement in stressful conditions, anddoes not require advanced diagnostic skills yet allows for basic client interventions.

Use the incident Management System on every incident and wear personnelidentification vests.

Get accurate preliminary and final client counts and relay this information to the incident

commander. Use some type of visual color-coded identification system to indicate client priority.

Do not fall into trap of using your time providing one-to-one client care.

Retriage clients frequently, at the incident, on arrival at the treatment area, andperiodically thereafter.

Make certain the walking-wounded are gathered and treated.

Preplan for potential incidents that may occur.

Be aware that emergency responders may be potential targets.

Practice, practice, practice

HOSPITAL EMERGENCY INCIDENT COMMAND SYSTEM (HEICS) (Langan andJames, 2005)***A hospital-based incident command system used as a framework for reporting andcommunication, which entails assignment of specific roles to individuals in an effort to createa distinct chain of command that is temporarily enacted in response to a disaster situation.

***Under HEICS, there is an incident commander with four chiefs reporting: logistics,operations, planning, and finance. These chiefs can contact their counterpart in otheragencies and communicate effectively due to the common language.

***HEICS provides an organizational chart with positions that have specific missions toaddress during the emergency situation. Each position has a job action sheet describing

responsibilities assigned to the person holding the position.

***HEICS continues to change its systems and positions in response to new information orwhen gaps are identified during exercises.

INCIDENT COMMAND SYSTEM***A framework for reporting and communication, which entails assignment specific roles toindividuals in an effort to create a distinct chain of command that is temporarily enacted inresponse to a disaster situation. It is also the model for command, control, and coordinationof the response. (Langan and James, 2005)

***It is a federally mandated command structure that coordinates personnel, facilities,equipment, and communication in any emergency situation.

***It is the center of operations for organization, planning, and transport of patients in theevent of a specific local mass casualty incident (MCI).

***It ensures that any hazardous substances used during MCI are identified promptly andthat appropriate personal protective equipment is distributed.


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***The priorities of ICS are life safety, incident stability, and property conservation.

***The incident commander is the first responder on the scene, although once a higher-ranking responder arrives, this person will likely assume command of the situation.

***According to Langan and James, 2005 , the responsibilities of the incident

commander include: Assume command

Assess situation or event

Implement emergency management plan

Determine response strategies

Activate resources

Order an evacuation

Averse activities

Determine the end of the incident

HOSPITAL OPERATIONS PLAN (Smeltzer, et al., 2010)***These plans are developed by the facilitys safety committee and are overseen by anadministrative liaison. The emergency preparedness planning committee must have arealistic understanding of its resources.

Components of the Emergency Operation Plan:

An activation response: The EOP activation response of a health care facility defineswhere, how, and when the response is initiated.

An internal/external communication plan: Communication is critical for all partiesinvolved, including communication to and from the prehospital arena.

A plan for coordinated patient care: A response is planned for coordinated patientcare into and out of the facility, including transfers to other facilities. The site of thedisaster can determine where the greater number of patients may self-refer.

Security plans: A coordinated security plan involving facility and community agenciesis key to the control of an otherwise chaotic situation.

Identification of external resources: External resources are identified, including local,state, and federal resources and information about how to activate these resources.

A plan for people management and traffic flow: People management includes

strategies to manage the patients, the public, the media, and personnel. Specificareas are assigned, and a designated person is delegated to manage each of thesegroups.

A data management strategy: A data management plan for every aspect of thedisaster will save time at every step. A back up system for charting, tracking, andstaffing is developed if the facility has a computer system.


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Demobilization response: Deactivation of the response is as important as activation;resources should not be unnecessarily exhausted. The person who decides whenthe facility resumes daily activities is clearly identified. Any possible residual effectsof a disaster must be considered before this decision is made.

An after-action report or corrective plan: Facilities often see increased volumes of

patients 3 months or more after an incident. Post incident response must include acritique and a debriefing for all parties involved, immediately and again at a laterdate.

A plan for practice drills: Practice drills that include community participation allow fortroubleshooting any issues before a real-life incident occurs.

Anticipated resources: Food and water must be available for staff, families, andothers who may be at the facility for an extended period.

MCI planning: MCI planning includes such issues as planning for mass fatalities andmorgue readiness.

An education plan for all of the above: A strong education plan for all personnelregarding each step of the plan allows for improved readiness and additional inputfor fine-tuning of the EOP.

Initiating the Emergency Operations Plan:

Identifying patients and documenting patient information***Patient tracking is a critical component of casualty management. Disaster tags,which are numbered and include tag priority are used to communicate patientinformation.

Triage***It is the sorting of patients to determine the priority of their health care needs andthe proper site for treatment. In nondisaster situations, health care workers assign ahigh priority and allocate the most resources to those who are the most critically ill.

Managing internal problems***Each facility must determine its supply lists based on its own needs assessment.

Communicating with the media and family***Communication is key component of disaster management. Communication withinthe vast team of disaster responders is paramount; however, effective, informativecommunication with the media and worried family members is also crucial.

PERSONAL PROTECTIVE EQUIPMENT (Smeltzer, et al., 2010)***The purpose of PPE is to shield health care workers from the chemical, physical, biologic,and radiologic hazards that may exist when caring for contaminated patients.

Personal Protective Equipment: (LeMone and Burke, 2007) Gas mask: Used in broad range of military, industrial, and emergency situations

to protect the user from hazardous dust, gas, or other aerosols.


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Hood, helmet or headgear: Generally worn to protect the skin, eyes, airways,and respiratory system.

Protective clothing: Made to guard against mild irritants and even serious lethalmaterials.

Gloves Goggles

Footwear

***The U.S. Environmental Protection Agency (EPA) has divided protective clothing andrespiratory protection into the following four categories:

Level A protection is worn when the highest level of respiratory, skin, eye, andmucous membrane protection is required. This include self-contained breathingapparatus (SCBA) and a fully encapsulating, vapor-tight, chemical-resistant suit withchemical-resistant gloves and boots.

Level B protection requires the highest level of respiratory protection but a lesserlevel of skin and eye protection than with level A situation. This level of protectionincludes the SCBA and a chemical-resistant suit, but the suit is not vapor tight.

Level C protectionrequires the air-purified respirator, which uses filters or absorbentmaterials to remove harmful substances from the air. A chemical-resistant coverallwith splash hood, chemical-resistant gloves, and boots are included in level Cprotection.

Level D protectionis the typical work uniform

Adapted from www.princeton.edu.com

No single PPE is capable of protecting against all hazards. (Smeltzer, et. al., 2010)

Some protective suits are disposable, intended for one use only. Others are durable,

multilayered fabrics that are completely impermeable and are reusable.


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DECONTAMINATION***It is the process of removing accumulated contaminants, is critical to the health andsafety of health care providers by preventing secondary contamination. (Smeltzer, et. al.,2010)

***It is the physical process of removing harmful substances from personnel, equipment,

and supplies whenever there is a risk of secondary exposure from the hazardous substance.(Langan and James, 2005)

***It is primarily for chemical warfare. It is not needed for covert bioterrorism events. Theonly possible exception is an overt anthrax attack in which the toxins may mimic chemicalexposures and warrant decontamination until the agent is known.

Decontamination Triage Procedure:

***According to Langan and James, 2005, events involving massive numbers of victimsrequire changing triage priorities to ensure the survival of the maximum number ofpatients. The command center will change triage modes based on the following:

Number of victims Available decontamination equipment

Number of decontamination technicians

Availability of medications

***The command center will contact the decontamination area and direct them to changetriage priorities to what is called a support mode. (Langan and James, 2005)

First prioritywill be victims exposed but not symptomatic

Second prioritywill be victims exposed but minimal medical care required

Third prioritywill be victims exposed requiring maximum medical care

Final prioritywill be the deceased

***According to Smeltzer,et al., 2010, although many principles and theories surrounddecontamination of a patient, authorities agree that, to be effective, decontaminationmust include a minimum of two steps.

The first step is removal of the patients clothing and jewelry and then rinsing thepatient with water.

The second step consists of a thorough soap-and-water wash and rinse.

The support mode of triage requires establishing a temporary care area outside the

hospital. Those awaiting decontamination will wait in the support area. (Langan and

James, 2005)


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DISASTER: (Veenema, 2007)*** An ecologic disruption, or emergency of a severity and magnitude that result

in deaths, injuries, illness, and property damage that cannot be effectively managedusing routine procedures or resources and that require outside assistance.

Classifications: Natural those caused by natural or environmental forces- result of an ecological disruption or threat that exceeds the

adjustment capacity of the affected community (WHO) Man-made human generated, in which the principal direct causes are

identifiable human actions, deliberate or otherwise.

Three categories of man-made disasters:

1. Complex Emergencies***Involve situations where populations suffer significant

casualties as a result of war, civil strife, or other political conflict.

2. Technological disasters***Large numbers of people, property, community infrastructure,and economic welfare are directly and adversely affected bymajor industrial accidents, unplanned release of nuclear energy; and fires or explosions from hazardous substances such asfuel, chemicals, or nuclear materials.

3. Disasters that are not caused by natural hazards but occur inhuman settlements

Stages and Phases of a Disaster: Nondisaster Stage (Interdisaster Phase)

***Is the time for planning and preparation as the threat of a disaster is still in thefuture. It is a time for prevention, preparedness, and mitigation activites.

Predisaster Stage (Preimpact Phase)***Occurs when there is knowledge about an impending disaster that has not yetoccurred. Activities during this stage include warning, preimpact mobilization, andevacuation if appropriate.

Impact Stage (Impact Phase)***Is a time when the disaster event has occurred and the communityexperiences the immediate effect.

Emergency Stage (Postimpact Phase)***Involves the immediate response to the effects of the disaster. The communityrelies on local assistance or aid because outside sources of aid have not yetarrived.


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Reconstruction Stage (Recovery Phase)***Restoration, reconstruction, and mitigation take place. This stage involvesrebuilding and returning to some semblance of normalcy but also includesmitigation activities or planning to prevent subsequent disasters or to minimizethe effects of future disasters.

HAZARDOUS MATERIALS (Veenema, 2007)*** It is any substance that is potentially toxic to the environment or to living cells.

Classifications of hazardous materials:

Nerve agents are among the most potent and deadly of the chemical weapons.They are rapidly lethal, and hazardous by any route of exposure. They are also liquidat room temperatures with the capability of producing a vapor that may be well

absorbed through the skin as well as the lungs and GI tracts.

Clinical presentation of exposed patients:o Gaspingo Miosiso Copious secretionso Sweatingo Generalized twitching

Clinical Diagnostic Test:o Red blood cell and serum cholinesterase

Management:o Thorough decontaminationo Immediate endotracheal intubation for patients with respiratory failure and

compromised airwayso Suctioning for bronchial secretionso Prophylactic anticonvulsants to prevent seizureso Oximes to reactivate the inhibited acetylcholinesterase and reverse paralysiso Antocholinergics to antagonize the muscarinic effects

Vesicating/Blister Agents are chemicals the severely blister the eyes, respiratorytract, and skin on contact. Possible substances included in this class are mustard

agents, Lewisites/chloroarsine agents, and phosgene oxime.

Clinical Presentations:o Redness and blurring of the eyes with lacrimationo Blepharospasmo Lid edemao Nasal irritation and dischargeo Sinus burningo Nose bleeds

The key to effective disaster management is predisaster planning and preparation.


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o Sore throato Cougho Laryngitiso Dyspneao Chemical [neumonitiso Pulmonary edemao ARDS, respiratory failure

Treatment:o Washing of exposed skin with water and soapo Flushing the eyes with copious amount of watero Typical burn therapy is accomplished with antibiotic ointment, sterile

dressing, and other supportive therapyo Intubation and airway management may be required for patients with airway

damageo Prevention of infection with careful cleaning and topical antibiotics and pain

relief for symptomatic and supportive care

Clinical Diagnostic Tests:o CBCo Glucoseo Serum electrolyteso Renal function (BUN and creatinine)o Chest X-rayo Pulse oximetry or ABG measurements

Blood/ Tissue Agents are chemicals that affect the body by being absorbed intoand distributed by the blood to the tissues. Substances include arsine, carbon

monoxide, cyanide agents, and sodium monofluoroacetate.

Clinical Presentations: Cyanide poisoning -10-15 minutes of gasping, tachypnea, tachycardia, flushing,

sweating, headache, giddiness, dizziness, followed by nausea, agitation, andconfusion. For higher concentration : bradycardia, apnea, seizures, shock, coma,and death

Arsine/ Phosphine poisoning burning sensation in the chest followed by chestpain upon inhalation. Initial symptoms include nausea, vomiting, headache,malaise, weakness, dizziness, abdominal pain, dyspnea, and occasionally redstained conjunctiva. Symptoms progresses to hematuria, jaundice, and possibly

renal failure.

Clinical Diagnostic Tests:o CBCo Blood glucoseo Electrolyte determinationso Urine for hemoglobinuria


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Management:o Closely monitor serum electrolytes, calcium, BUN, creatinine, hemoglobin,

and hematocrito For victims of arsine poisoning, avoid high levels of fluid replacement to

avoid the onset of congestive heart failure symptoms.

Pulmonary/ Choking Agents are chemicals that causes severe irritation or swellingof the respiratory tract causing pulmonary damage and untimely impairing oxygendelivery. Substances include ammonia, bromine, chlorine, hydrogen chloride, methylbromide, phosgene, phosphorus and sulfuryl fluoride.

Clinical Presentations:o Eye paino Rednesso Lacrimationo Sore throato Runny noseo Coughingo Headacheo Nauseao Hemoptysiso Chokingo Dyspneao Raleso Hemoconcentrationo Hypotension

o Possible cyanosis

Treatment:o Evaluation of respiratory function and oxygenation is criticalo Pulse oximetry should be performedo Endotracheal intubation for patients with ventilator failure and severe

hypoxemia

Riot Control Agents are chemical compounds that temporarily inhibit a personsability to function by causing irritation to the eyes, mouth, throat, lungs, and skin.Three major agents are considered to be control agents: chloroacetophenone (CN),also known as mace, chlorobenzylidenemalononitrile (CS)n and

diphenyllaminearsine (DM).

Clinical Presentations:o Temporary blindness due to lacrimation and blepharospasmo Conjunctival rednesso Cougho Chest tightnesso Sneezingo Mouth, nose, and throat irritation

There is no antidote for arsine or phosphine poisoning. Do not administer arsenicchelating drugs. Patient may need blood transfusion. (Veeneman, 2007)


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BIOLOGICAL WARFARE AND BIOLOGICAL AGENTS (Smeltzer, et. al., 2010)*** Biologic Warfareis a covert method of effecting terrorist objectives.

Types of Biologic Agents:

Anthrax is recognized as the most likely weaponized biologic agent availableand has been recognized as a highly debilitating agent for centuries. Bacillusanthracis is a naturally occurring gram-positive, encapsulated rod that lives in thesoil in the spore state throughout the world.

Clinical manifestations:o Hemorrhage, edema and necrosiso Fever, nausea and vomitingo Cough, headache, chills, weaknesso Mild chest discomfort, dyspnea, syncope

Treatment:o Recommended treatment includes penicillin, erythromycin, gentamicin,

doxycyclineo In a mass casualty situation, treatment with ciprofloxacin or doxycycline is

recommended.***Treatment is continued for 60 days.

Small Pox (variola) is classified as a DNA virus. It has an incubation period ofapproximately 12 days, extremely contagious, and is spread by direct contact.

Clinical Manifestations:o High fever, malaise, headache, backache, prostrationo Maculopapular rash beginning on the face, mouth, pharynx and forearmso Progresses to the trunk and also become vesicular to pustular

Treatment:o Supportive care with antibiotico Isolation with the use of transmission precautionso Standard decontamination of the roomo Household or face-to-face contact with the patient after the fever begins

should be vaccinated within 4 days to prevent infection and deatho Cremation is preferred for all deaths because the virus can survive in

scabs for up to 13 years

BLAST INJURIES (Langan and James, 2005)*** Injuries from blasts are grouped under four types based on the mechanism of the blast.

Primary blast mechanisms occur only with high-order explosives. Gas filledstructures within the body are affected most frequently, such as the lungs, GItract, and middle ear.

No specific treatment is required. Situation improves within 30 minutes after exposure

ends. (Veenema, 2007)


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Secondary category, injuries result from flying debris and bomb fragments. Anypart of the body can be affected, and injuries range from penetrating callistic(fragmentation) to blunt injuries.

Tertiary injuriesresult from individuals being thrown by the blast wind. Fractures,traumatic amputations, and open and closed brain injuries can occur.

Quaternary category, all injuries not fitting into the previous three categories is

grouped. It may include exacerbation or complications of existing conditionsaffecting any part of the body. Injury types include burns, crash injuries, asthma,COPD, respiratory problems, angina, hyperglycemia, and hypertension.

*** Some of the visible indicators internal soft tissue injury are:

Hematemesis: vomiting bright red blood

Hemoptysis: coughing up bright red blood

Melena: excretion of tarry black stools

Hematochezia: excretion of bright red blood from the rectum

Nonmenstrual vaginal bleeding

Hematuria: passing of blood in the urine

Epixtaxis: nosebleed Pooling of blood near the skin surface

*** Frequently, there are no visible signs of injury and more subtle clues will have to beused, such as:

Pale, clammy skin

Lowered body temperature

Rapid, thready pulse

Decreasing blood pressure

Dilated pupils that are slow to react

Ringing in the ears or tinnitus

Syncope Thirst

Yawning, air hunger

Anxiety, restlessness with feelings of impending doom

NATURAL DISASTERS***According to Veeneman, 2007, these are natural causes often result in significant losses,physical destruction of dwellings, social and economic disruption, human pain and suffering,injury, and loss of life.

Earthquake generally considered to be the most destructive and frightening of all

forces of nature, is a sudden, rapid shaking of the Earth caused by the breaking andshifting of rock beneath the Earths surface. It can result in a secondary disaster,catastrophic tsunami.

Risk of Morbidity and Mortality:

Deaths and injuries vary according to the type of housing available, time ofday of occurrence, and population density


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Common injuries include cuts, broken bones, crush injuries, and dehydrationfrom being trapped in rubble

Stress reactions are also common

Prevention/Mitigation:

Incorporate principles of seismic safety into public and private decisions

regarding the setting, design, and construction of structures

Epidemics outbreak or occurrence of one specific disease from a single source in agroup, population, community, or geographic area, in excess of the usual orexpected level.

***Quick response is essential because epidemics, resulting in human and economiclosses and political difficulties, develop rapidly.

Flood

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