Chapter 69: Emergency and Disaster Nursing
Most patients with life-threatening or potentially life-threatening problems arrive at the hospital through the
emergency department (ED).
Triage refers to the process of rapidly determining the acuity of the patient’s problem, and it represents one of
the most important assessment skills needed by the emergency nurse.
The triage process is based on the premise that patients who have a threat to life, vision, or limb should be
treated before other patients.
o A triage system categorizes patients so that the most critical ones are treated first.
o The Emergency Severity Index (ESI) is a 5-level triage system that incorporates concepts of
illness severity and resource utilization to determine who should be treated first.
After the initial assessment to determine the presence of actual or potential threats to life, appropriate
interventions are initiated for the patient’s condition.
The primary survey focuses on airway, breathing, circulation, and disability and serves to identify life-
threatening conditions so that appropriate interventions can be initiated.
If life-threatening conditions related to airway, breathing, circulation, and disability are identified
at any point during the primary survey, interventions are started immediately and before
proceeding to the next step of the survey.
Airway with cervical spine stabilization and/or immobilization:
Primary signs and symptoms in a patient with a compromised airway include dyspnea,
inability to vocalize, presence of foreign body in the airway, and trauma to the face or
Airway maintenance should progress rapidly from the least to the most invasive method
and includes opening the airway using the jaw-thrust maneuver, suctioning and/or
removal of foreign body, insertion of a nasopharyngeal or oropharyngeal airway, and
The cervical spine must be stabilized and/or immobilized in any patient with face, head,
or neck trauma and/or significant upper torso injuries.
Breathing alterations are caused by many conditions (e.g., fractured ribs, pneumothorax,
allergic reactions, pulmonary emboli, asthma) resulting in dyspnea, paradoxical or
asymmetric chest wall movement, decreased or absent breath sounds, cyanosis,
tachycardia, and hypotension.
High-flow oxygen (100%) via a non-rebreather mask should be administered and the
patient’s response monitored. Life-threatening conditions may require bag-valve-mask
ventilation with 100% oxygen and intubation.
A central pulse is checked because peripheral pulses may be absent as a result of direct
injury or vasoconstriction.
Skin is assessed for color, temperature, and moisture.
Altered mental status and delayed capillary refill are the most significant signs of shock.
Two large-bore IV catheters should be inserted and aggressive fluid resuscitation initiated
using normal saline or lactated Ringer’s solution.
The degree of disability is measured by the patient’s level of consciousness.
A simple mnemonic can be used: AVPU: A = alert, V = responsive to voice, P =
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responsive to pain, and U = unresponsive.
The Glasgow Coma Scale is used to further assess the arousal aspect of the patient’s
Pupils are assessed for size, shape, response to light, and equality.
The secondary survey is a brief, systematic process that is aimed at identifying all injuries.
Exposure/environmental control. All trauma patients should have their clothes removed so that a
thorough physical assessment can be performed.
Full set of vital signs/five interventions/facilitate family presence:
A complete set of vital signs, including blood pressure, heart rate, respiratory rate, and
temperature, is obtained after the patient is exposed.
Five interventions: 1) ECG monitoring is initiated; 2) pulse oximetry is initiated; 3) an
indwelling catheter is inserted; 4) an orogastric or a nasogastric tube is inserted; 5) blood
for laboratory studies is collected.
Family presence: family members who wish to be present during invasive procedures
and resuscitation view themselves as active participants in the care process and their
presence should be supported.
Give comfort measures. Pain management strategies should include a combination of
pharmacologic and nonpharmacologic measures.
History and head-to-toe assessment:
A thorough history of the event, illness, injury is obtained from the patient, family, and
A thorough head-to-toe assessment is necessary.
Inspect the posterior surfaces. The trauma patient should be logrolled (while maintaining cervical
spine immobilization) to inspect the posterior surfaces.
All patients should be evaluated to determine their need for tetanus prophylaxis.
Ongoing patient monitoring and evaluation of interventions are critical and the nurse is responsible for
providing appropriate interventions and assessing the patient’s response.
Depending on the patient’s injuries and/or illness, the patient may be (1) transported for diagnostic tests such as
x-ray or CT scan; (2) admitted to a general unit, telemetry, or intensive care unit; or (3) transferred to
DEATH IN THE EMERGENCY DEPARTMENT
The emergency nurse should recognize the importance of certain hospital rituals in preparing the bereaved to
grieve, such as collecting the belongings, arranging for an autopsy, viewing the body, and making mortuary
Many patients who die in the ED could potentially be a candidate for non–heart beating donation; certain
tissues and organs such as corneas, heart valves, skin, bone, and kidneys can be harvested from patients
GERONTOLOGIC CONSIDERATIONS: EMERGENCY CARE
Elderly people are at high risk for injury primarily from falls.
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The three most common causes of falls in the elderly are generalized weakness, environmental hazards, and
When assessing a patient who has experienced a fall, it is important to determine whether the physical findings
may have actually caused the fall or may be due to the fall itself.
Prolonged exposure to heat over hours or days leads to heat exhaustion, a clinical syndrome characterized
by fatigue, light-headedness, nausea, vomiting, diarrhea, and feelings of impending doom.
Tachypnea, hypotension, tachycardia, elevated body temperature, dilated pupils, mild confusion,
ashen color, and profuse diaphoresis are also present.
Hypotension and mild to severe temperature elevation (99.6º to 104º F [37.5º to 40º C]) are due to
Treatment begins with placement of the patient in a cool area and removal of constrictive clothing.
Oral fluid and electrolyte replacement is initiated unless the patient is nauseated; a 0.9% normal saline IV
solution is initiated when oral solutions are not tolerated.
A moist sheet placed over the patient decreases core temperature.
Heatstroke results from failure of the hypothalamic thermoregulatory processes.
Increased sweating, vasodilation, and increased respiratory rate deplete fluids and electrolytes, specifically
Eventually, sweat glands stop functioning, and core temperature increases (>104º F (40º C).
Altered mentation, absence of perspiration, and circulatory collapse can follow.
Cerebral edema and hemorrhage may occur as a result of direct thermal injury to the brain.
Treatment focuses on stabilizing the patient’s ABCs and rapidly reducing the temperature.
Various cooling methods include removal of clothing, covering with wet sheets, and placing the patient in front
of a large fan; immersion in an ice water bath; and administering cool fluids or lavaging with cool fluids.
Shivering increases core temperature, complicating cooling efforts, and is treated with IV chlorpromazine.
Aggressive temperature reduction should continue until core temperature reaches 102º F (38.9º C).
Patients are monitored for signs of rhabdomyolysis, myoglobinuria, and disseminated intravascular coagulation.
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Hypothermia is defined as a core temperature <95º F (35º C).
The elderly are more prone to hypothermia, and certain drugs, alcohol, and diabetes are considered risk factors
Core temperature below 86º F (30º C) is a severe and potentially life-threatening situation.
Patients with mild hypothermia (93.2º to 96.8º F [34º to 36º C]) have shivering, lethargy,
confusion, rational to irrational behavior, and minor heart rate changes.
Shivering disappears at temperatures below 92º F (33.3º C). Moderate hypothermia (86º to 93.2º F
[30º to 34º C]) causes rigidity, bradycardia, slowed respiratory rate, blood pressure obtainable only
by Doppler, metabolic and respiratory acidosis, and hypovolemia.
Coma results when the core temperature falls below 82.4º F (28º C), and death usually occurs
when the core temperature is below 78º F (25.6º C).
Profound hypothermia (below 86º F [30º C]) makes the person appear dead. Profound
bradycardia, asystole, or ventricular fibrillation may be present.
Every effort is made to warm the patient to at least 90º F (32.2º C) before the person is pronounced dead. The
cause of death is usually refractory ventricular fibrillation.
Treatment of hypothermia focuses on managing and maintaining ABCs, rewarming the patient, correcting
dehydration and acidosis, and treating cardiac dysrhythmias.
Passive or active external rewarming is used for mild hypothermia.
Passive external rewarming involves moving the patient to a warm, dry place,
removing damp clothing, and placing warm blankets on the patient.
Active external rewarming involves body-to-body contact, fluid- or air-filled
warming blankets, or radiant heat lamps.
Active core rewarming is used for moderate to profound hypothermia and refers to the use of
heated, humidified oxygen; warmed IV fluids; and peritoneal, gastric, or colonic lavage with
Rewarming places the patient at risk for afterdrop, a further drop in core temperature, and can result in
hypotension and dysrhythmias.
Rewarming should be discontinued once the core temperature reaches 95º F (35º C).
Submersion injury results when a person becomes hypoxic due to submersion in a substance, usually water.
Drowning is death from suffocation after submersion in water or other fluid medium. Near-drowning is defined
as survival from potential drowning. Immersion syndrome occurs with immersion in cold water, which
leads to stimulation of the vagus nerve and potentially fatal dysrhythmias.
Aggressive resuscitation efforts and the mammalian diving reflex improve survival of near-drowning victims
even after submersion in cold water for long periods of time.
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Treatment of submersion injuries focuses on correcting hypoxia, acid-base imbalances, and fluid imbalances;
supporting basic physiologic functions; and rewarming when hypothermia is present.
Initial evaluation involves assessment of airway, cervical spine, breathing, and circulation.
Mechanical ventilation with positive end-expiratory pressure or continuous positive airway
pressure may be used to improve gas exchange across the alveolar-capillary membrane when
significant pulmonary edema is present.
Deterioration in neurologic status suggests cerebral edema, worsening hypoxia, or profound acidosis.
All victims of near-drowning should be observed in a hospital for a minimum of 4 to 6 hours. Delayed
pulmonary edema (also known as secondary drowning) can occur and is defined as delayed death from
drowning due to pulmonary complications.
Children are at greatest risk for animal bites, and the most significant problems associated with animal bites are
infection and mechanical destruction of the skin, muscle, tendons, blood vessels, and bone.
Animal bites from dogs and cats are the most common, followed by bites from wild or domestic rodents.
Cat bites cause deep puncture wounds that can involve tendons and joint capsules and result in a greater
incidence of infection. Septic arthritis, osteomyelitis, and tenosynovitis are common.
Human bites also cause puncture wounds or lacerations and carry a high risk of infection from oral bacterial
flora and the h