Anda di halaman 1dari 9


Right Treatment

Scope and Practice of Emergency Nursing

• Emergency management traditionally refers to
urgent and critical care needs; How long should the TRIAGE take?
• however, the ED has increasingly been used for - the common goal is to assess the patient within 2-
non-urgent problems, and emergency management 5 minutes for adults
has broadened to include the concept that an (but this time according to ENA caters up to 22%
emergency is whatever the patient or family only of patients per hundred in 8 hours)
considers it to be - for pediatrics, 7 minutes

The emergency nurse has: Who should perform the ED TRIAGE function?
• Special training, education, experience, and - the Joint Commission on Accreditation of
expertise in assessing and identifying health care Healthcare Organization (JCAHO) doesn’t entails
problems in crisis situations what are the specifics of the triage nurse
• Nursing interventions are accomplished - Emergency Nurses Association (ENA) 1999
interdependently in consultation with or under the established he standards of Emergency Nursing
direction of a physician or nurse practitioner Practice, states that safe, effective triage can only
• The emergency room staff works as a team be performed by a registered professional nurse,
educated in the principles of triage and has
Four Basic Emergency Action Principles minimum experience of 6 months in emergency
• Survey the scene nursing
– If any kind of danger is threatening, do not - The triage nurse should classify patient 24/7
approach the casualty, call EMS immediately for
professional help. What are the Essential Components of
• Check the casualty for any for unresponsiveness Comprehensive TRIAGE?
• If the person does not respond, Call EMS 1. An initial across-the- room look or visualization.
• Check the casualty’s airway, breathing and This includes ABCD. For pediatric clients, this may
circulation (ABC’s) : try to the airway without moving include critical look, general appearance, work of
the patient breathing and circulation
2. A rapid triage (60secs) of an appropriately elicited
Priority Emergency Measures for chief complaint, key questions, assessment such as
All Patients feeling of the pulse and fracture in the extremities
3. Completion of a focused triage history and
• Make safety the first priority physical assessment. This include vital signs, pulse
• Preplan to ensure security and a safe environment oximetry reading, diagnostics and institution’s
• Closely observe patient and family members in the protocol
event that they respond to stress with physical 4. The triage decision, in which the triage acuity or
violence level is assigned. This determines the urgency of the
• Assess the patient and family for psychological condition, includes the MSE and additional
function assessment.

• Patient and family-focused interventions What should the triage history include?
– Relieve anxiety and provide a sense of security Medications
– Allow family to stay with patient, if possible, to Exposure to infection
alleviate anxiety Allergies Pregnancy
– Provide explanations and information Immunization
– Provide additional interventions depending upon LMP
the stage of crisis Past medical history
Family history

What is TRIAGE?
- it is sorting
- from the French word “trier” meaning to choose, What are the some examples of Adult
referred to a battlefield Mnemonics?
- the rapid focused assessment PQRST
What is the purpose of TRIAGE? Pain assessment
- is to sort or classify all incoming ED patients P precipitating factors
- the goal is to get the Q quality
Right Patient to the R radiation
Right Place at the S severity
Right Time for the T time
T treatment - Breathing
- Circulation
PHOSPHATE - Disability
For the history of the chief compliant - Systemic before local; life before limb
- Acute before chronic; short term before long
Problem - Central before peripheral
Onset - Actual over Potential
Associated Symptoms - Trending (worsening trend could consist of minor
Previous History symptoms that tend to reoccur repeatedly, increase
Precipitating Factors in severity, or indicate a steady progressive decline)
Alleviating/ Aggravating Factors - Potential for worsening (ex. Drug overdose and
Timing chest tightness)

CIAMEDS (from Emergency Nursing Pediatric TOXICOLOGY

Course) (Poisoning and Drug Overdose)
Chief Compliant
Immunization A. General Guidelines
Allergies - maintain adequate airway, breathing and cardiac
Medications output
Past Medical History - Patients who ingested large amounts of TCA may
Events Surrounding require intubation immediately even if mental status
Diets/ Diapers has not yet occurred.
Symptoms Associated with injury or illness - Perform gastric lavage
- Induce emesis for patients with alkali ingestion
SAVE A CHILD (From ENA Hawaii- SAVE Are - Contact local poison control center at UP College of
observations before touching the child, A Medicine 524-1078, 524-5651 loc 2311
CHILD are key history and examination - East Ave Med Ctr 928-0611
components) - Consider possibility of suicide
Skin - All female with chemical ingestion should undergo
Activity pregnancy test
Ventilation -
Eye Contact B. Principles of Decontamination
Abuse External Decontamination
Cry - Wash skin with soap and water
Heat - Remove cloths
Immunization - Keep warm, use blankets
Level of Consciousness
Dehydration Gastric Lavage
- contraindications includes strong ingestion of
What are some tips for better TRIAGE strong acids, alkalis, petroleum and distillates.
- Look at the patient, listen and do not write while - Airway must be protected with endotracheal tube
the patient is talking to you unless awake, alert and has a gag reflex
- Never appear shocked by what the patient tells - Position head on one side of he bed to prevent
you aspiration
- Do not discount the patient’s concern on triage - If the patient has severe DOB stat intubation
- Watch people’s faces - Perform gastric lavage unless overdose with acid
- Ask specifically about drugs recently started - Lavage is useful within two hours of ingestion
- Do not assume patients are taking their Activated Charcoal
medications - Always consider giving charcoal after emesis or
- Use the language of symptoms, feelings, and lavage until specifically contraindicated
thoughts - Multiple doses of charcoal in (+) metamphetamine,
- Remember that he patient’s diagnosis is not phenothiazines, digoxin, theophylline, phenobarb,
necessarily the correct diagnosis and organophosphates
- Exhibit concern for a higher acuity in the presence - Activated charcoal is not effective for alkalis,
of other risks factors, or co-morbidities/ chronic cyanide, mineral acid and ferrous sulfate
- Remember hat alcoholics can be sick and Cathartics
intoxicated at the same time - contraindicated with infants (risk for dehydration),
- Ask the patient at the end of he triage encounter if intestinal obstruction, electrolyte imbalance
here is anything else the patient wants to say - sodium sulfate is contraindicated in HPN and heart
What are the prioritization principles?
- Airway Forced Diuresis
- forced neutral diuresis may be helpful for isoniazid,
bromide and ethanol intoxification Digitalis Overdose
- make sure to monitor electrolytes - considered NGT insertion and gastric lavage
- forced alkaline diuresis may be useful for - secure digitalis assay, CBC, Ca, K, Mg, CXR and
Phenobarbital, salicylates and lithium using sodium ECG/ cardiac monitor
bicarbonate. - the treatment goal would be to correct
hypokalemia. Hypomagnesemia or hypocalecemia.
C. Guidelines for Nurses - The doctor may prescribe charcoal and cathartics
- when antidotes are ordered, it is meant to be given - Watch out for hypotension; fluid challenge my be
immediately or at least reasonably within the hour in instituted
some cases. They are not given when it is the - For arrythmias, lidocaine may be given
convenient dosing period for the nurses.
Ethanol Toxicity
- maintain adequate airway, ventilation, circulation
and administer oxygen
Specific Substance Ingestion - Thiamine is useful to protect/ prevent liver damage
Acid Ingestion - Phynetoin my be given in cases of seizure, but
- provide airway control, ventilation, circulatory make sure to give it SIVP and hook the patient to the
support, and fluid resuscitation cardiac monitor
- wash the oral cavity (controversial)
- emesis, lavage and charcoal are contraindicated Narcotic Overdose
- secure serial CBC and cros-matching - maintain airway, ventilation and circulation
- maintain NPO - may start on Naloxone 2mg every 5 minutes , max
10mg IV, IM SQ
Alkali Ingestion - Activated charcoal if (+) for bowel sounds and
- immediately rinse oral cavity cathartics
- administer oxygen and IVF - Watch out for signs of pneumonia, infections and
- secure serial CBC, CXR, and monitor electrolytes rhabdomyolysis
- esophagoscopy and gastroscopy should be - Watch out for complications such as seizure,
performed immediately if there is drooling, stridor pulmonary edema and hypotension
and painful swallowing
Hydrocarbon/ Kerosene Ingestion
Amphetamine/ Metamphetamine Toxicity - Respiratory support
- start charcoal and cathartics - Treatment is not required in the absence of
- emesis has no role symptoms
- WOF for seizure, psychosis, agitation, hypertensive - Promote gastric emptying
crisis, arrhythmias - Remove contaminated clothing and wash affected
- Secure ABG, CBC with PC, PT, PTT, RBS, BUN, Crea, skin with soap and water.
Na, K, UA - Provide supplemental oxygen
- Diazepam and Phenytoin for seizure - secure CBC, ABG abd CXR
- Beta-blockers, Lidocaine for dysrythmias Isoniazid Overdose
- place an NGT and do gastric lavage is clean
Anticoagulant Overdose - watch out for seizure, lactic acidosis may give
- Secure lab results such as CBC with PC, PT, PTT sodium bicarbonate
and Creatinine - consider mannitol administration for forced diuresis
- secure CBC, RBS, K, ABG
- For Heparin: Give protamine sulfate at 1mg iv for
every 50-100 units of heparin infused in the Narcotic Overdose
preceeding 2 hours, dilute in 25-50ml fluid over 10 - maintain airway, ventilation and circulation
minutes - may give naloxone 2.0mg q 5 minutes initially max
- For Warfarin: perform gastric lavage and give of 10mg IV, IM SQ
activated charcoal if recently ingested; give vitamin - start activated charcoal if (+) with BM and
k 5-10 mg every 8-12 hours; give FFP 2-6units for cathartics
severe bleeding - watched out for complications, PNA, hypotension,
and seizures is (+) norpethidine
Diazepam Overdose
- Place NGT and do gastric lavage Insecticides/ Pesticides
- Protect airway Therapeutics
- Instill activated charcoal, followed by repeated 1. Decontamination
doses of 20-25 gm via NGT - make he patient rinse with alkaline or baking soda
- Secure RBS, ABG, ECG and CXR (10gm in 100cc)
- Watched out for hypotension, CNS and respiratory - change cloths and wash the patient with gloves
depression and withdrawal syndrome such as - insert NGT and do gastric lavage wih activate
agitation, seizure, restlessness and insomnia. charcoal
2. Activated charcoal - Pulmo Edema: treat with high concentration of
3. Antidote oxygen, furosemide and PEEP
4. In cases of seizure; consider Phenytoin - Cerebral Edema: treat with hyperventilation and
5. wof for hypoglycemia osmotic diuresis with Mannitol
6. Give mannitol if with good urine output
- secure CBC, RBS, ABG, SGOT and SGPT SHOCK (Multisystem Stressor)

Paracetamol Overdose - Shock is a multisystem stressor that involves
- Insert NGT inadequate tissue perfusion and altered
- Activate charcoal about 30-100mg and then metabolism.
remove via NGT suction prior to acetylcysteine - Inadequate tissue perfusion can lbe a result of nay
- Sodium Sulfate to induce vomiting condition that alters heat function (cardiogenic),
- Antidote: N-acetylcysteine (NAC) . the initial blood volume(hypovolemic), blood pressure
administration would be 150mg/kg body weight (neurogenic) and distribution of blood volume
infused in 200ml 5% dextrose over 15 minutes (septic/ anaphylactic)
followed by IV infusion of 50mg/kg in 500ml of 5% - Shock is a very complex clinical syndrome in which
dextrose water tissue perfusion is inadequate to meet the demands
- NAC is very effective in preventing paracetamol- for oxygen
induced hepatotoxicity when administered; when - It alters cellular functions and eventually impairs
administered with in 8 hours from the time of body organ functions
ingestion, the better. But beyond 8 hours, the - Multi Organ Dysfunction Syndrome (MODS) is a
protective effect diminishes progressively as the term used to describe several impairment of the
treatment interval increases human functions

Salicylate Poisoning Sepsis and Septic Shock

- Sepsis is an acute systemic clinical syndrome
Diagnostics: caused by bacteria, viruses or fungi in the blood,
- CBC, K, RBS, ABG and UA most commonly gram (-) bacilli
- PT, PTT, SGOT, SGPT and alk Posh with 48 hours - At an early phase, generalized inflammatory
post ingestion response is triggered, causing widespread
Therapeutics: - The progression to septic shock is due to the toxins
- Stabilize respiratory and cardiac functions released from the organism involved
- Avoid diluting the gastric contents since this may - Bacterial endotoxins activates the complement,
incease gastric absorption coagulation and fibrinolytic system; inceases
- Consider NGT insertion vascular permeability and trigger the vasoactive
- Give activated charcoal 1gm/ kg body weight every kinins causing vasodilation and increased capillary
6 hours permeability thereby decreasing the vascular
- Sodium sulfate 15-30 gm in 100cc H20 orally if resistance and facilitating fluid shifting from
tolerated or with NGT with every other doses of intravascular to interstitial
activated charcoal to prevent charcoal constipation - Another response would be due to the histamine
or fecal impaction release causing increase in vascular permeability
- To increase urine ph, consider sodium bicarbonate - This changes are further stimulated by the
- Glucose and KCl should be infused with other fluids catecholamine and prostaglandins that are released
from ischemic tissues
Treatment Plan - “COLD SHOCK” is he term used during the stage in
- if with dehydration and hypokalemia, manage with which tissue perfusion becomes severely
vigorous and with electrolyte replacement compromised and ischemic cellular damage occurs.
- Cerebral edema can be best avoided using - In addition the, fever is present due to the
hypertonic rehydration solution pyrogens released by the organism
- Alkaline diuresis to maintain urinary ph at approx 8
- Monitor urine output Anaphylactic Shock
- Assess hydration status - systemic anaphylactic shick is potentially life
- Watch closely for signs of fluid overload threatening situation
- Hemodialysis is indicated for initial salicylate level - it is he result of an exaggerated hypersensitivity
of >160ml/dl or with profound acidosis of below 7; response to an antigen
or when there is renal failure, severe CNS - the classic form of anaphylaxis occurs in a
dysfunction, pulmonary edema or deterioration sensitized person usually 1-20 minutes ater the
despite supportive therapy exposure to the antigenic substance
- the most common substance that can cause
Other Treatments reactions would be, drugs, antibiotics, foods,
- Acidemia: NaHCO3 anesthetics, antisera and blood products
- Seizure: Diazepam - hypersensitivity reaction occurs over the surface of
he mast cells which are located primarily in he - GI solution
lungs, small blood vessels and connective tissues
- it also attacks basophils circulating in the blood Collaborative Management (Anaphylaxis)
- the antigenic substance triggers the release of - Airway maintenance
kinins, histamines, prostaglandins, eosinophils, - Epinephrine
neutrophils - Supplemental Oxygen
- “sow reacting substance of anaphylaxis” (SRSA) - Fluid Resuscitation
such as prostaglandins and leukotrienes produces - Vasopressors
deleterious results icluding profound shock - Angi-histamine
- Histamine is he primary mediator of anaphylactic - Bronchodilator
attack. Leukotrienes produces vasoconstriction that - Steroids
is even worst than histamine - Mast cell stabilizer
- The prostaglandins exaggerate the - Glucagon
bronchoconstriction; kinins increases the vascular - ECG monitoring
- The combined effects of the substance causes Nursing Diagnosis and Intervention (SEPSIS)
respiratory distress and obstruction 1. Fluid volume deficit related to active loss from
vascular compartment secondary to increased
capillary permeability and shifting of intravascular
Toxic Shock volume into interstitial spaces
- it is another syndrome of shock believed caused by
bacterial toxins Desired Outcome
- e.g. Staph A enters he blood steam from the site of Within 4 hours of initiation of therapy, the patient is
infection, commonly the vagina, diffusing across the normovolemic as eveidenced by good peripheral
mucus membranes. Hey are then circulated pulses, stable body weight, good urine output and
throughout the body decreased adventitious breath sounds
- thise toxins causes massive vasodilatation and
eventually to a shock state Intervention
- Monitor hemodynamic pressures
For Septic Shock Assessment - Administer crystalloid and fluid replacement as
- history and risk factors includes, malnutrition, prescribed
immunosuppresion, liver and renal diseases, recent - VS hourly
traumayic injuries, surgical or invasive procedure - Maintain proper inotropic administration
- commonly caused by E Coli, Klebsiella, - Weigh patient daily
Enterobacter, Staph A. as well as fungi and viruses - Monitor specific gravity
- Assess for interstitial edema
For Anaphylactic Assessment - Proper positioning
- recent exposure to pharmacological agents, blood
transfusion and insect bites or stings 2. Decreased Cardiac Output related to negative
- clinical presentation is dependent on several inotropic changes at the myocardium secondary to
factors and varies with the portal of antigen entry, effects of tissue O2 deprivation
the amount absorbed, rate of absorption, and the
degree of hypersensitivity Desired Outcome
- Ingestion: cramping, nausea, vomiting and may Within 8 hours of initiation of therapy, patient has a
precede systemic shock syndrome n adequate cardiac output as evidenced by good BP,
- Inhalation: hoarseness, dyspnea and whezing urine output and god peripheral pulses
- Allergic: urticaria or itching at the site of the sting,
or drug injection Intervention
- Assess patient for signs of deceasing CO
Diagnostic Test/ Procedure - Administer inotropics as prescribed
-WBC, serum glucose, GS-CS, ABG, BUN, CT, BT, - Position patient on supine to increase/ optimize
Liver studies preload and enhance stroke volume
- Monitor cardiac rhythm
Collaborative Management (Septic) - Minimize cardiac oxygen demand by assisting
- antibiotic therapy specific to he organism patient with ADL
- Hemodynamic monitoring
- Fluid resuscitation 3. Altered Cerebral, renal, gastrointestinal tissue
- Inotropic Agents perfusion related to decreased to circulating blood
- Ventilatory Support volume secondary to massive vasodilatation and
- Alkaline Support interruption of arterio-venous blood flow associated
- Nutritional Support to vasoconstriction and clot formation
- Steroids
- Antipyretic Agent Desired outcome
- Naloxone Within 24 hours after initiating therapy, the patient
has an adequate tissue perfusion as evidenced by
orientation to time, place and person, good bowel Intervention:
sounds and good urine output - Monitor patient for the presence of SOB
- Secure ABG results as necessary
Intervention - Monitor pulse oximetry reading regularly
- Assess LOC hourly - Administer steroids as prescribed
- Assess signs of decreasing renal perfusion - Position patient in a sitting position to enhance
- Assess/ monitor peripheral vascular resistance lung expansion
- Assess peripheral pulses - Remain with the patient, encourage slow, deep
- O2 saturation monitoring breathing if possible. Help patient alleviate anxiety
- Assess evidence of decreasing visceral circulation by responding calmly and explaining all procedures
including bowel sounds before performing to them

* Other examples of nursing problems… 3. Decreased cardiac output related to

4. Impaired Gas exchange, related to alveolar- decreased preload and afterload secondary to
capillary membrane changes secondary to release of vasoactive chemical mediators and
interstitial edema, alveolar destruction and associated vasodilation and increased
endotoxin release with activation of histamine and capillary permeability
kinins Desired Outcome:
After 4 hours of continuous nursing intervention, the
5. Ineffective breathing pattern related to decreased patient has an adequate cardiac output as
lung function secondary to central respiratory evidenced by a near normal BP of morethan 90/60,
depression occurring in the lat shock good urine output and normal sinus rhythm

6. Ineffective thermoregulation related to successful

entry bacterial endotoxins, increasing the Intervention:
hypothalamic termperature regulating center - Assess for physical and hemodynamic parameters
indicating a decreased cardiac ouput
7. Altered Nutrition less than body requirements Check for apical pulse
related to increased need secondary to increased Palpate peripheral for amplitude
metabolic rate Assess BP
Calculate MAP
Measure CVP
- Monitor ECG changes
Nursing Diagnosis and Interventions (Anaphylaxis) - WOF signs of edema
1. Ineffective airway clearance realated to - Admisister fluid replacement therapy as prescribed
tracheobronchial obstruction secondary to - Administer vasopessors as prescribed
bronchoconstriction and increased secretions
associated with histamine response and the Multiple Injury
presence of leukotrienes and prostaglandins This includes:
Desired Outcome: 1. Major Trauma
Within 2 hours of intervention, the patient has an 2. Craniocerebral Trauma
adequate airway clearance as evidenced by by a 3. Chest Trauma
state of eupnea and the presence of breath sounds 4. Abdominal Trauma
in all lung fields 5. Renal and Lower Tract Trauma
Mechanisms of Injury:
Interventions: - Objects Producing Injury (ex. MVA, handgun, glass,
- Assess patency of airway on a continuing basis. wood, metal)
Auscultate all lung fields - Type of Energy (ex. Kinetic, thermal, chemical,
- Stand by Adrenergic agent in case of cardio- radiation)
pulmonary arrest - Force of Energy (ex. Velocity, tension force,
- Maintain intubation set at all times shearing force)
- If laryngeal edema pevents intubation, prepare - Use of Protective devices (ex. Helmet, airbags, seat
tracheostomy set belt)
- Monitor ABG results
Types of Injury:
2. Impaired gas exchange related to alveolo- Blunt Injury – occurs without interruption on the skin
capillary membrane changes secondary to integrity
increased vascular permeability associated Penetrating – are produced from the motion of the
with histamine response objects that penetrate the tissue causing direct
Desired Outcome: damage.
Within 2hours of initiation of intervention, he patient
has adequate gas exchange as evidenced by Oxygen Delivery and Consumption
eupnea and O2 sat of more than 90% - an oxygen debt is created by a profound imbalance
between oxygen supply and demand brought about
by hypovolemia and inadequate tissue perfusion Environmental Emergencies—Frostbite
- after initial restoration of circulating blood volume, • Trauma from freezing temperature and actual
he body develops a “hyperdynamic circulatory freezing of fluid in the intracellular and intercellular
state”, which is associated with improved survival spaces
and fewer complications • Manifestations: hard, cold, and insensitive to
- the hyperdynamic state usually peaks within 48-72 touch; may appear white or mottled; and may turn
hours and diminishes in 7 -10 days red and painful as rewarmed
- inability to achieve this state increases the • The extent of injury is not always initially known
mortality • Controlled but rapid rewarming; 37° to 40° C
circulating bath for 30- to 40-minute intervals
Neuroendocrine Stress Response • Administer analgesics for pain
- shortly after the trauma, the CNS triggers a series • Do not massage or handle; if feet are involved, do
of reactions that promotes cmpentation including not allow patient to walk
brain, blood, and bone marrow
- cathecolamines are released Environmental Emergencies—Hypothermia
- these hormones mobilizes glycogen stores, • Internal core temperate is 35° C or less
increases glucose availablty, suppresses pancreatic • Elderly, infants, persons with concurrent illness,
insulin, resulting in an increase net of glucose the homeless, and trauma victims are at risk
- centrally mediated release of ADH promotes water • Alcohol ingestion increases susceptibility
absorption, increasing intravascular volume and • Hypothermia may be seen with frostbite;
diminishes urine output treatment of hypothermia takes precedence
Systemic Inflammatory Response Syndrome • Physiologic changes in all organ systems
- the release of cathecolamine triggers massive • Monitor continuously
amount of WBC at the site of injury
- SIRS is used without he presence of infection; Management of Patients With Hypothermia
SEPSIS is termed in the presence of a widespread • Use ABCs, remove wet clothing, and rewarm
inflammation and infection • Rewarming
– Active core rewarming
Multi Organ Dysfunction Syndrome Cardiopulmonary bypass, warm fluid administration,
Coagulopathy warm humidified oxygen, and warm peritoneal
Hypothermia lavage
Psychologic Response – Passive external rewarming
Warm blankets and over-the-bed heaters
• Cold blood returning from the extremities has high
Environmental Emergencies—Heat levels of lactic acid and can cause potential cardiac
Stroke dysrhythmias and electrolyte disturbances
• A failure of heat regulating mechanisms
• Types Management Patients With
– Exertional: occurs in healthy individuals during Carbon Monoxide Poisoning
exertion in extreme heat and humidity
– Hyperthermia: the result of inadequate heat loss • Inhaled carbon monoxide binds to hemoglobin as
• Elderly, very young, ill, or debilitated—and persons carboxyhemoglobin, which does not transport
on some medications—are at high risk oxygen
• Can cause death • Manifestations: CNS symptoms predominate
• Manifestations: CNS dysfunction, elevated – Skin color is not a reliable sign and pulse oximetry
temperature, hot dry skin, anhydrosis, tachypnea, is not valid
hypotension, and tachycardia • Treatment
– Get to fresh air immediately
Management of Patients With Heat Stroke – Perform CPR as necessary
– Administer oxygen: 100% or oxygen under
• Use ABCs and reduce temperature to 39° C as hyperbaric pressure
quickly as possible • Monitor patient continuously
• Cooling methods
– Cool sheets, towels, or sponging with cool water Management of Patients With
– Apply ice to neck, groin, chest, and axillae Chemical Burns
– Cooling blankets • Severity of the injury depends upon the
– Iced lavage of the stomach or colon mechanism of action of the substance, the
– Immersion in cold water bath penetrating strength and concentration, and the
• Monitor temperature, VS, ECG, CVP, LOC, urine amount of skin exposed to the agent
output • Immediately flush the skin with running water
• Use IVs to replace fluid losses from a shower, hose, or faucet
– Hyperthermia may recur in 3 to 4 hours; avoid – Lye or white phosphorus must be brushed off the
hypothermia skin dry
• Protect health care personnel from the substance
• Determine the substance Terrorism, Mass Casualty, and Disaster
• Some substances may require prolonged Nursing
• Follow-up care includes reexamination of the area Emergency Operations Plan (EOP)
at 24 hours, 72 hours, and 7 days • Health care facilities are required by the Joint
Commission on Accreditation of Healthcare
Management of Patients With Organizations to create a plan for emergency
Substance Abuse preparedness and to practice this plan twice a year
• Essential components of the plan:
• Acute alcohol intoxication: a multisystem toxin – An activation response
– Alcohol poisoning may result in death – An internal/external communication plan
– Maintain airway and observe for CNS depression – A plan for coordinated patient care
and hypotension – Security plans
– Rule out other potential causes of the behaviors – Identification of external resources
before it is assumed the patient is intoxicated – A plan for people management and traffic flow
– Use a nonjudgmental, calm manner • Essential components of the plan:
– Patient may need sedation if noisy or belligerent – A data management strategy
– Examine for withdrawal delirium, injuries, and – Deactivation response
evidence of other disorders – Post-incident response
– A plan for practice drills
– Anticipated resources
Crisis Intervention—Rape Victims – Mass casualty incident planning
– An education for all of the above
• How the patient is received and treated in the ED
is important to his or her psychological well-being Managing Short- and Long-Term Psychological
• Crisis intervention begins as soon as the patient Effects After a Disaster
enters the facility; the patient should be seen • Provide active listening and emotional support
immediately • Provide information as appropriate
• Goals are to provide support, reduce emotional • Refer to therapist or other resources
trauma, and gather evidence for possible legal • Discourage repeated exposure to media regarding
proceedings the event
• Patient reaction; rape trauma syndrome • Encourage return to normal activities and social
• History taking and documentation roles
• Physical examination and collection of forensic • Critical incident stress management (CISM)
evidence • Programs that include education, field support,
• Role of the sexual assault nurse examiner (SANE) defusing, debriefing, demobilization, and follow-up
Psychiatric Emergencies • Persons with ongoing stress reactions should be
referred to mental health specialists
• Overactive, underactive, violent, and depressed or
suicidal patients
• Management
– Maintain the safety of all persons and gain control Personal Protective Equipment (PPE)
of the situation • Purpose: to shield the health care provider from
– Determine if the patient is at risk for injuring chemical, physical, biological, and radiologic hazards
himself or others that may exist when caring for contaminated
– Maintain the person’s self-esteem while providing patients
care • Categories of protective equipment:
– Determine if the person has a psychiatric history – Level A: self-contained breathing apparatus (SCBA)
or is currently under care to contact the therapist and vapor-tight chemical-resistant suit, gloves, and
• Crisis intervention boots
• Interventions specific to each of the conditions – Level B: high level of respiratory protection (SCBA)
but lesser skin and eye protection; chemical-
resistant suit
– Level C: air-purified respirator, coverall with splash
Roles and Function of the Nurse in Emergency hood, and chemical-resistant gloves and boots
and Disaster Nursing – Level D: typical work uniform
• Educator
• Counselor Isolation Precautions for
• Team member Biological Terrorism Agents
• Facilitator (include triaging) • Biological agents may be delivered or spread in a
• Advocate number of ways
• Researcher • Due to modern travel, spread of infection may
occur in areas thousands of miles apart into the body
• Health care providers need to be aware of
potential signs of biological weapon dissemination; Radiation Decontamination
signs and symptoms are similar to those of common • Triage outside the hospital
disease process • Cover floor and use strict isolation precautions to
• Isolation practices depend upon the infecting prevent the tracking of contaminants
agent • Seal air ducts and vents
• Always use Standard Precautions • Waste is double bagged and put in a container
• Some agents require Transmission-Based labeled radiation waste
Precautions • Staff protection
• Terminal disinfection and disposal of wastes – Water-resistant gowns, 2 pairs of gloves, caps,
depends on the infecting agent goggles, masks, and booties
– Dosimetry devices
Chemical Weapons • Patients are surveyed for radiation and directed to
• Chemical substances that quickly cause injury the decontamination area
and/or death and cause panic and social disruption • Each patient is decontaminated with a shower
• Agents outside the ED
– Nerve agents • Water, tarps, towels, soap, gowns, all the patient’s
– Blood agents belongings, etc., must be collected and contained
– Vesicants • Patients are surveyed and showered again as
– Pulmonary agents necessary
• Agents vary in volatility, persistence, toxicity, and • Showering should be performed so as not to
period of latency contaminate clean areas with runoff from the
• Limitation of exposure is essential with evacuation showering
and decontamination as soon possible and as close • Biologic samples: nasal and throat swabs; blood
to the scene of the incident as possible • Internal contamination requires additional
Nerve Agents treatment: catharsis and gastric lavage with
• Sarin and soman organophosphates chelating agents
• Inhibit cholinesterase-causing cholinergic
symptoms progressing to loss of consciousness, Radiation Injuries
seizures, copious secretions, apnea, and death • Acute radiation syndrome (ARS): dose of radiation
• Treatment: supportive care, atropine, determines if ARS will develop
benzodiazepine, and pralidoxime • All body systems are affected by ARS
• Decontaminate with copious amounts of soap and • Presenting signs and symptoms determine
water or saline for at least 20 minutes predicted survival
• Blot; do not wipe off • Probable survivors have no initial symptoms or
• Plastic equipment will absorb sarin gas only minimal symptoms
Vesicants • Possible survivors present with nausea and
• Lewisite, sulfur mustard, nitrogen mustard, and vomiting that persists for 24 to 48 hours
phosgene • Improbable survivors are acutely ill with nausea,
• Cause blistering and burning vomiting, diarrhea, and shock; neurologic symptoms
• Respiratory effects can be serious and cause suggest lethal dose; and survival time is variable
• Decontaminate with soap and water; do not scrub
or use hypochlorite solutions
• Eye exposure requires copious irrigation
• Treatment for lewisite exposure: dimercaprol IV or

Radiation Exposure
• Radiation exposure may occur due to nuclear
weapons, nuclear reactor incidents, or exposure to
radioactive samples
• Exposure to radiation is affected by time, distance,
and shielding
• Types of radiation exposure:
– External radiation: all or part of the body is
exposed to radiation; as decontamination is not
necessary, it is not a medical emergency
– Contamination: exposure to radioactive gases
liquids or solids; requires immediate medical
management to prevent incorporation
– Incorporation: uptake of the radioactive material