Emergency care

Prepared by
Nisha Bhandari
MNC, IOM
• An emergency is a situation which poses an
immediate risk to health, life, property or
environment.

• Most emergencies require urgent intervention

to prevent a worsening of the situation,
although in some situations, mitigation may
not be possible and agencies may only be able
to offer palliative care for the aftermath.
Contd….
• Emergency medicine is a medical specialty in
which physicians care for patients with acute
illnesses or injuries which require immediate
medical attention.

• It usually don’t provide long-term or

continuing care instead it diagnose a variety of
illnesses and undertake acute interventions to
stabilize the patient.
Emergency Department
• An Emergency Department (ED), also known as
Accident & Emergency (A&E), Emergency
Room (ER), Emergency Ward (EW), or
Casualty Department is a medical treatment
facility either hospital or primary care department
that provides initial treatment to patients,
specializing in acute care of patients who
present without prior appointment.

• Emergency departments developed during 20th

century in response to an increased need for rapid
assessment and management of critical illnesses.
Contd….
• Due to the unplanned nature of patient
attendance, the department must provide
initial treatment for a broad spectrum of
illnesses and injuries, some of which may be
life threatening and require immediate
attention.

• The emergency departments of most hospitals

operate 24 hours a day.
 Contd….
• With the arrival of the patient in the ED, people
undergo a brief triage, or sorting, by determining
nature and severity of their illness.
• Individuals with serious illnesses are then seen by
a physician more rapidly than those with less
severe symptoms or injuries.
• After initial assessment and treatment patients are
either admitted to hospital, stabilized and
transferred to another hospital for various
reasons, or discharged.
 Emergency nursing
• Emergency nursing is a nursing specialty in
which nurses care for patients in the emergency
or critical phase of their illness or injury.

• While this is common to many nursing

specialties, the key difference is that an
emergency nurse is skilled at dealing with
people in the phase when a diagnosis has not yet
been made and the cause of the problem is not
known.
Scope of Emergency Nursing
• Triage and Prioritization
• Stabilization and resuscitation
• Assessment, Diagnosis, Planning, Implementation and
evaluation of patient response
• Provisions of care in uncontrolled and/or unpredictable
situations
• Crisis interventions to meet the needs of unique patient
situations
• Emergency Operations Preparedness
• Education of the patient and community to facilitate
attainment of an optimal level of wellness
• Research
• Forensic Nursing
 Components of emergency care
• Registration, Screening, Triage, Establishment of
priorities
• Rapid assessment and assimilation of information
often beyond the presenting problem
• Resuscitation
• Monitoring and Revaluation
• Detailed Assessment
• Diagnostic Studies
• Additional Therapeutics
• Establishing Diagnoses
Components contd…
• Communication System with Protocols
• Early Operative Care, Early Critical Care
• Supporting and attending to family
• Discharge or referral to other sources of care
according to agency policy
• Patient education
• Public relations
• Management of waiting area
• Records pertinent past medical history, current
medications, allergies
Principles of emergency care
Triage: It includes:
• Rapid assessment
• Identifying life threatening problems
• Initiation of investigations
• Providing analgesia
• Controlling patient flow
Principles contd…
Emergency nursing assessment
Primary assessment
A – Airway
B – Breathing
C- Circulation
D – Disability
Secondary assessment
E- Expose/ Environmental Control
F -Full set of vitals, Five interventions, Facilitate family
presence
G -Give comfort measures / glucose
Principles contd…
Immediate (or primary) assessment and
management of the patient
A – Airway: The airway may be patent, partially
obstructed or completely obstructed
• Establish and maintain a clear airway.
• Ensure airway protection.
• Consider the need for cervical protection.
Principles contd…
B – Breathing: Look, listen and feel for
breathing: The absence of breath sounds
indicates the need to attempt airway opening
manoeuvres and if unsuccessful consider the
possibility of a foreign body obstruction.
• Give high-concentration oxygen.
• Ensure adequate ventilation of the lungs.
• Decompress pneumothoraces.
• Begin to correct severe respiratory problems.
Principles contd…

C – Circulation: Check for a central pulse

(over 5 s): The absence of a central pulse (or a
rate of less than 60 beats per min in infants)
indicates the need to follow procedures for
cardio-respiratory arrest.
• Restore the circulating blood volume.
• Ensure adequate cardiac function.
• Commence monitoring.
Principles contd…

D – Disability: it is brief assessment of

neurological functioning
• Assess cerebral functioning.
• Consider causes of depression of
consciousness: Hypoxia, hypovolaemia or
cerebral ischaemia, Hypoglycaemia,
Hypothermia, Poisoning or gross metabolic
disturbance
Principles contd…

Further (or secondary) assessment and

management of the patient
E – Environment and exposure
• Check the body temperature and positioning.
• Ensure protection from further harm.
• Expose the whole body for examination.
Contd….
F –full set of vitals/five interventions and Fits,
Facilitate family presence :
• Take Vitals
• Five interventions: ECG, SpO2, Catheterization,
NG tube insertion, investigations as needed
• Termination of the convulsion must be an
immediate aim
• The needs of the relatives and friends: The needs
of the carers cannot be ignored. These may vary
from simple reassurance to medical treatment. As
soon as practicable, the relatives must be
informed of the patient’s current situation and
what is going to happen next.
Contd….
G – Glucose, give comfort: Correct hypoglycemia
or hyperglycemia, provide comfort as per patient

H – History and head to toe assessment: Take

history as AMPLE and perform rapid top-down
assessment
A: Allergies.
M: Medication.
P: Past and present illnesses of significance.
L: Last food and drink.
E: Events leading up to the patient’s presentation.
Contd….
I – Immediate analgesia and inspect for
posterior surfaces: Immediate relief of
suffering include:
• Provide analgesia and splintage.
• Relieve remaining dyspnea.
• Give reassurance.
The traumatic patient should be log-rolled to
inspect the patient’s posterior surfaces or any
spinal injury is suspected.
Contd….
Investigations: Investigations should only be
requested if the results could have an impact
on immediate care or disposal.

Definitive care: This may involve:

• accurate liaison with other specialists in the
hospital or the community;
• safe transport to another facility;
• careful follow-up arrangements;
• rehabilitation.
Contd….
Homelessness: Many patients who come to an
ED have nowhere to sleep or to shelter. People
suffering from psychiatric disease often
become homeless and there are many other
illnesses (such as tuberculosis and alcohol
abuse), which are associated with
homelessness.
Contd….
Placebo therapy: Human health is inextricably
linked with mental functioning and fear and
worry play a large part in many consultations.
Improvement rates of up to 40% may be
obtained with placebo therapy. The doctor’s
reassurance is the greatest placebo.
Contd….
Communication: Good communication is the
hallmark of the good doctor, the good nurse and
the good ED. In addition to the obvious patience
and direct verbal skills required, this may
encompass:
• information cards to take out;
• telephone advice help-lines;
• translation facilities;
• good quality records and letters.
• Special care is also needed with: relatives; other
health professionals in the hospital; paramedics;
 Contd….
Teamwork: Emergency care is one area of health care
where multidisciplinary teamwork is fundamental.
Patient with learning disabilities: It requires specific
attention in the emergency care setting. This
setting can cause considerable distress,
exacerbating challenges to understanding
communication.
Major incidents and terrorism:
• The situation which demands extra resources are
the major incidents
• When considering major incident planning,
managing terrorist attacks should form the part of
the plan.
Contd….
Infection control: Each health care provider
should have an understanding of infection
control and be aware of how they can prevent
hospital acquired infection.
Legal and ethical issues: consent, capacity of
decision making, confidentiality
Dealing with difficult situation: Abuse, sexual
assault, forensic issues, resuscitation, death
and communicating bad news, tissue and organ
donation
contd…
Documentation
• What is the presenting complaint
• What is the history presenting complaint
• Medical History especially relevant history related to this
presentation
• Medications relevant to their presentation
• Allergies
• Social history where they live and with whom
• Any associated symptoms
• What is done to help their situation
 DISASTER
• A
„ n EVENT that causes serious disruption of the
functioning of a society: widespread human, material, or
environmental losses, including loss of lives and
deterioration of health and health services. „This disruption
is: on a scale sufficient to warrant an extra ordinary
response from out side the affected community or area.
• Disaster is a sudden, unpredictable, unfamiliar,
calamitous event, bringing great damage, urgency,
uncertainty, threat, loss, and destruction and devastation to
life and property.
• The damage caused by disasters varies with the
geographical location, climate and the type of the earth
surface, degree of vulnerability.
Types of disaster
• Natural disaster
– Sudden Catastrophic Events -like earthquakes and
hurricanes „
– Slow-onset processes -such as droughts, economic
crises, environmental degradation or the increasing
prevalence of fatal HIV infection. „
• Man-made disaster
– Complex and Continuing Emergencies –War
– Political, Social, Extremism: Conflict, Terrorism
– Industrial/ Technical: unplanned nuclear release,
release of toxic chemicals
– Transportation disaster
Disaster Management
• Disaster Management is defined as the
systematic process of using administrative
decisions, organization, operational skills
and capacities to implement policies and
strategies and enhance coping capacities of the
society and communities to lessen the impacts
of hazards and related environmental and
technological disasters
Disaster Management
Disaster management as a continuous and integrated
process of planning, organizing, coordinating and
implementing measures which are necessary or
expedient for:
a) Prevention of danger or threat of any disaster;
b)Mitigation or reduction of risk of any disaster or its
severity or consequences;
c) Capacity building;
d) Preparedness to deal with any disaster;
e) Prompt response to any threatening disaster situation or
disaster;
f) Assessing severity or magnitude of effects of any
disaster, evacuation, rescue and relief;
g) Rehabilitation and Reconstruction
Nurses responsibility during each
phase
• Prevention/Mitigation: Identifying individuals at
risk for disaster , performs assessment in
community to determine prevalence of disease,
availability of health facilities, identification of
vulnerable populations.

• Preparedness phase: Plan the structure for disaster

response with the help of other disaster team
members, also act as health educator trainer and
educate about disaster risk and plan to the
community people such as essential equipment,
safety.
Contd….
• Response phase: Mobilize respondents to the
disaster area, provide mental and physical care
as per need.

• Recovery/ Rehabilitation phase: Assist the

community and the affected population to
recover from the impact of the disaster which
might be physical, psychological, emotional or
occupational.
Mass Casualty Management
• Mass Casualty is an event that overwhelms the
local healthcare system, with number of
casualties that vastly exceeds the
local resources and capabilities in a short
period of time.

• The definitions of a mass casualty incident

depend on the resources of the admitting
institutions.
Contd….
“Response measures are those which are taken
immediately prior to and following disaster.”
Such measures are directed towards:
• saving life
• protecting property
• dealing with the immediate damage caused by
the disaster
Contd….
• Response always starts from Search and rescue
(SAR).
• Search And Rescue (SAR) is the process of locating
and recovering disaster victims that may be trapped
or isolated and bringing them to safety and provide
basic medical attention as required.
• Search And Rescue (SAR) is the most significant
response problem generated after the big disasters e.g.
earthquakes.
• The probability of survival is greatly increased if victim
in a collapsed building rescued within 24 HOUR which
we called “GOLDEN 24 HOURS”
Contd….
• The probability of survival is greatly increased if
injured can be transported to definite care within
ONE HOUR of injury, which we called
“GOLDEN HOUR”.

• During a mass casualty incident, triage may occur

at multiple points as patients progress from pre-
hospital management to definitive care in
operating rooms or ICUs. At the various points
triage is usually classified as primary, secondary,
or tertiary.
Establishing a Mass Casualty Management System

RESCUE CHAIN---SECTORAL
Impact Zone
Command Post

*SEARCH*
Triage
ER
*RESCUE* Stabilization
Traffic Control

Evacuation
Regulation of Evacuation or
*First Aid*
A&ED

Pre-Hospital
Organization Hospital Organization
39
Triage
• The term “triage” originates from the French
word “trier” which means to sort, pick out,
classify or choose.
• The triage principle of prioritizing care to large
groups of people has been adapted from its
military origin for use in the civilian context of
initial emergency department care.
• Triage is the process by which victims are
sorted, prioritized, and distributed according to
their need for first aid, resuscitation,
stabilization, evacuation, and hospital care.
Contd….
• Triage is the point at which emergency care
begins. Triage is an ongoing process involving
continuous assessment and reassessment.
• Triage decisions are made in response to the
patient’s presenting signs or symptoms and no
attempt to formulate a medical diagnosis is made.
• The allocation of a triage category is made on the
basis of necessity for time-critical intervention to
improve patient outcome, potential threat to life
or need to relieve suffering.
Contd….
• Triage sieve : Quick survey to separate the
dead and the walking from the injured
• Triage sort : Remaining casualties are assessed
and allocated to categories
 Primary objective of ED triage is:
• Identify patient requiring immediate care
• Determine the appropriate area for treatment
• Facilitate patient flow through ED and avoid
unnecessary congestion
• Provide continuous assessment and reassessment
of arriving and waiting patient
• Provide information and referrals to patients and
families
• Allay patient and family anxiety and enhance
public relations
Can be triaged as:
A. Primary Triage: Primary triage occurs in the field. It is
often performed by paramedics and based on very
simple criteria that can be rapidly assessed.

B.Secondary Triage: Secondary triage is typically

performed by emergency physicians or surgeons
immediately upon a patient’s arrival at the hospital.
They prioritize patients by assigning them to treatment
areas for initial interventions. Efficient flow of
critically injured or ill patients through this part of the
system to definitive care is critical.
Contd….
C. Tertiary Triage: Tertiary triage should be
conducted by surgeons or intensivists in keeping
with the best practices for triage officers. At each
stage of the triage process accuracy can be
increased by measuring physiologic parameters
and introducing structured physical examination.
This third stage of triage is of primary relevance
to critical care physicians because the situation
and the patients’ characteristics call for definitive
critical care management.
Contd….
Triage decisions can be divided into primary
and secondary triage decisions.
• Primary triage decisions relate to the triage
assessment, allocation of a triage category
and patient deposition while
• Secondary triage decisions relate to the
initiation of nursing interventions in order to
expedite emergency care and promote patient
comfort
TAGGING
TAGGING is the procedure where
identification, name, age, place of origin,
triage category, diagnosis and initial treatment
are tagged on to every victim of disaster
through a Colour Coding.
COLOR CODES
• Triage system uses FOUR color code system according
priorities :
• Red (Highest Priority): Immediate resuscitation or
limb/life saving surgery in next 6 hours. High priority is
granted to victims whose immediate or long term
prognosis can be extensively affected by simple
intensive care.
• Yellow (Medium Priority): Possible resuscitation or
limb/life saving surgery in next 24 hours.
• Green (Low Priority): Victims whose injuries are so
minor that they can be managed by self-help or
volunteer assistance, /AMBULATORY patients.
• Black (Least Priority): Dead and moribund patients.
Moribund patients who require a great deal of attention,
with questionable benefit, have the least priority.
Triage category
Category -1 (Red): Patient has life-threatening condition
and must be seen within one minute. It includes:
• Cardio-respiratory arrest
• Major trauma
• Ingestion of rapidly acting poison
• Anaphylaxis
• Extreme respiratory distress
• Shock
• Ongoing prolong seizure
• Coma (GCS < 9 or responding to pain/unresponsive)
• Tachy/bradyarrhythymia
Contd….
Category -2 (Yellow): These case must be seen within 15
minutes and it includes:
• Chest pain of likely cardiac nature
• Any type of severe pain
• Blood sugar level <84%
• Drowsy and decreased responsiveness (GCS < 13)
• Descriptive and violent behaviour
• Drug overdose
• Eye injury partial or complete loss of vision
• Seizures
• Multiple fractures
• Severe blood loss
• Respiratory distress
• Emotional disturbance
• Hypotension and hemodynamic effect
Contd….
Category 3 (Green): Patient has acute condition and must be
seen within 30 minutes like:
Severe hypertension
Moderate chest pain
Back injuries
Abdominal pain
Diarrhoea with normal vital sign
Slight vaginal bleeding
Moderate limb injury
Nose bleeding
Head injury with short LOC now alert
Mild fever/ persistent vomiting
Minor trauma
Minor head injury
Contaminated Patients
• Patients with exposure (potential or real) to
contaminants should be tagged as BLUE
• This category will continue to stay until patient is
adequately decontaminated then follow START as
usual
• Some recommend a “double tagging” with blue
and the standard START color
Types of triage
There are 3 types of triage:
• Mass triage: divides patients into triage
categories based on their ability to move

• START triage: determines the severity of

illness

• Advanced triage: more fully assess injury

priorities
Contd….
• Reverse Triage : In addition to the standard
practices of triage as mentioned above, there are
conditions where sometimes the less wounded are
treated in preference to the more severely
wounded. This may arise in,
• A situation such as war where the military setting
may require soldiers be returned to combat as
quickly as possible
• Disaster situations where medical resources are
limited in order to conserve resources for those
likely to survive but requiring advanced medical
care.
MASS triage
• Move: “Everyone who can hear me and needs
medical attention, please move to a designated
area now !” Green “Minimal or Ambulatory”
• Assess: Non- ambulatory “ Everyone who can
raise leg or arm.” Doing the most good for the
most victim.
• Sort: Proceed immediately to remaining
victims. Re-assess
• Send
START SYSTEM
• “ Simple Triage and Rapid Treatment”
• Created in the 1980’s by Hoag Hospital and the
Newport Beach CA Fire Dept
• Allows rapid assessment of victims
• It should not take more than 15 sec/ Pt
• The START system is designed to assist
rescuers to find the most seriously injured
patients.
START SYSTEM

Classification is based on three items

• Respiration
• Perfusion
• Mental status evaluation
START First Step

Can the Patient Walk?

YES NO

Evaluate Ventilation
Green
(Step-2)
(Minor)
START Step-2
Ventilation Present?

NO YES

Open Airway

Ventilation Present? > 30/Min < 30/min

NO YES
Red/ Immediate

Black Evaluate Circulation

Red/ Immediate
(Step-3)
 START Step-3
Circulation

Absent Radial Pulse Present Radial Pulse

Control Hemorrhage
Evaluate Level of
Consciousness
Red/ Immediate
START Step-4
Level of Consciousness

Can’t Follow Simple Can Follow Simple

Commands Commands

Red/ Immediate Yellow/ Delayed

Advanced Triage
• Advanced triage will be performed on all
victims in the treatment area by medical teams.
• Utilize the triage tags and attempt to assess for
and complete all information required (as
patient permit).
• The triage priority determined in the treatment
area should be the priority used for transport.
Contd….
Advanced colour coding includes:
• Red (immediate-1): who cannot survive without
immediate treatment but who have a chance of
survival
• Yellow (Urgent-2): Those who are not immediate
danger of death but still need hospital care and
would be treated immediately under normal
circumstances
• Green (Delayed-3): they are walking wounded
who will need medical care at some point, after
critical injuries have been treated.
Contd….
• White (dismiss): given to those with minor
injuries for whom doctor’s care is not required.

• Black (dead-0): are used for deceased and for

those whose injuries are so extensive that there
is no chance of survival.
References
• http://www.sgnor.ch/uploads/tx_frptaggeddownlo
ads/edupack_Triage_ATS.pdf
• http://www.doctoralerts.com/medical-triage-
tagging-color-codes/
• https://www.medicinenet.com/medical_triage_cod
e_tags_and_triage_terminology/views.htm
• http://sdmassam.nic.in/download/modules/Hospit
al%20Preparedness%20and%20Mass%20Casualt
y%20Management_Operational%20Level.pdf