21
Emergency and Disaster Nursing
Samantha J. Bonaduce and Mariann M. Harding
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Gas Exchange Perfusion
Interpersonal Violence Thermoregulation
LEARNING OUTCOMES
1. Apply the steps in triage, the primary survey, and the 4. Select appropriate nursing interventions for victims of
secondary survey to a patient with a medical, surgical, or violence.
traumatic emergency. 5. Distinguish among the responsibilities of health care
2. Relate the pathophysiology to the assessment and providers, the community, and select federal agencies in
interprofessional care of select environmental emergencies. emergency and mass casualty incident preparedness.
3. Relate the pathophysiology to the assessment and
interprofessional care of select toxicologic emergencies.
KEY TERMS
drowning primary survey
emergency secondary survey
frostbite submersion injury
heat exhaustion terrorism
heatstroke triage
hypothermia violence
mass casualty incident (MCI)
Entire books are dedicated to the nursing care of emergency More than 130 million people visit EDs each year.1 While the
patients. It is a unique specialty that requires a solid under- number visiting the ED is down slightly, the number of patients
standing of specific nursing concepts and approaches to patient admitted to the hospital is increasing. There are several reasons
problems. Nurses unaccustomed to the emergency department for this increase. Continued growth in retail clinics, telehealth,
(ED) often describe the flow as “chaotic” and uncertain. Indeed, and other sources of care for nonemergent problems has resulted
it may have this appearance. The challenge of the ED is that in the ED seeing older, sicker patients with more complex needs.2
the nurse does not know what patient will come through the ED nurses care for patients of all ages with a variety of prob-
doors. The ED nurse must be prepared to meet this challenge. lems. However, some EDs specialize in specific patient popu-
This chapter presents an overview of the triage process and care lations or conditions, such as pediatric ED or trauma ED. The
of select emergency patients. Common emergencies discussed Emergency Nurses Association (ENA) is the specialty organiza-
include heat- and cold-related emergencies, submersion inju- tion aimed at advancing emergency nursing practice. The ENA
ries, bites and stings, and various poisonings. The chapter con- provides standards of care for nurses working in the ED. They
cludes with a discussion of terrorism, mass casualty incidents, offer a certification process that allows nurses to become certi-
and the methods of response. fied emergency nurses (CENs).
The emergency management of various medical, surgical,
and traumatic emergencies is discussed throughout this book.
Tables outline the emergency management of specific problems.
CARE OF EMERGENCY PATIENT
Table 21.1 lists these emergency management tables by title, Recognizing life-threatening illness or injury is one of the most
chapter number, and page. important goals of emergency nursing. Starting interventions
385
,386 SECTION 4 Perioperative and Emergency Care
TABLE 21.1 EMERGENCY MANAGEMENT TABLE 21.2 Examples of Patients at Each
Emergency Management Tables Throughout the ESI Level
Book ESI Level Examples
1 Cardiac arrest, intubated trauma patient, overdose with
Title Chapter
bradypnea, severe respiratory distress, anaphylactic
Abdominal Trauma 47 shock, hypoglycemia with change in mental status
Acute Abdominal Pain 47 2 Chest pain from ischemia, multiple trauma unless
Acute GI Bleeding 46
responsive, suicidal patient, immunocompromised
Acute Soft Tissue Injury 67
patient with a fever, acute stroke
Acute Thyrotoxicosis 54
3 Abdominal pain or gynecologic disorders unless in
Anaphylactic Shock 14
severe distress, hip fracture in older patient, vomiting,
Chest Injuries 30
Chest Pain 37 hypertension
Chest Trauma 30 4 Closed extremity trauma, simple laceration, cystitis
Depressant Toxicity 11 5 Cold symptoms, minor burn, poison ivy, recheck (e.g.,
DKA 53 wound), prescription refill
Dysrhythmias 39
Eye Injury 22
Fractured Extremity 67
or ESI-2 for the number of expected resources they may need.
Head Injury 61
Hyperthermia 21 Assign patients to ESI-3, ESI-4, or ESI-5 based on this deter-
Hypoglycemia 53 mination. Vital signs are important. Patients assigned to ESI-3
Hypothermia 21 must have normal vital signs. Patients with abnormal vital signs
Inhalation Injury 26 may be reassigned to ESI-2.3
SCI 65
Shock 42
Stimulant Toxicity 11
CHECK YOUR PRACTICE
Stroke 62 You are working in the ED with your preceptor, who is a triage nurse. A
Submersion Injuries 21 24-year-old man arrives and states, “I think I have food poisoning. I’ve been
Tonic-Clonic Seizures 63 vomiting all night, and now I have diarrhea.” The patient reports abdominal
cramping that he rates as 6/10. He denies fever or chills. Vital signs: T = 97.8°F
(36.6°C), HR = 94, RR = 16, BP = 121/74 mm Hg.
to reverse or prevent a crisis is often a priority before making • Assign a triage acuity rating using the ESI.
a medical diagnosis. This process begins with your first con-
tact with a patient. Prompt identification of patients who need
immediate treatment and determining appropriate interven- After you complete the initial focused assessment to deter-
tions are essential nurse competencies. mine the presence of actual or potential threats to life, proceed
with a more detailed assessment. A systematic approach to
Triage this assessment decreases the time needed to identify potential
Triage refers to the process of rapidly determining patient acu- threats to life and limits the risk of overlooking a life-threaten-
ity. It is one of the most important assessment skills needed by ing problem. A primary and secondary survey is the approach
ED nurses. ED nurses often confront multiple patients who have used for all trauma patients. For nontrauma patients, the pri-
a variety of problems. The triage process works on the premise mary survey is followed by a focused assessment. Focused
that we must treat patients who have a threat to life before other assessments are discussed in Chapter 3.
patients.
A triage system identifies and categorizes patients so that Primary Survey
the most critically ill are treated first. The ENA and American The primary survey (Table 21.3) focuses on airway, breathing,
College of Emergency Physicians support the use of a 5-level circulation (ABC), disability, exposure, full set of vitals and
triage system.3 The Emergency Severity Index (ESI) is a 5-level family presence, and getting other monitoring devices. If there
triage system that incorporates concepts of illness severity and is uncontrolled external hemorrhage, the usual ABC assessment
resource use (e.g., electrocardiogram [ECG], laboratory tests, format may be reprioritized to <C>ABC. The C stands for cat-
radiology studies, IV fluids) to determine who we should treat astrophic hemorrhage. If present, it must be controlled first.4
first (Table 21.2). The ESI includes a triage algorithm that directs Apply direct pressure with a sterile dressing followed by a pres-
you to assign an ESI level to patients coming into the ED. The sure dressing to any obvious bleeding sites.
ESI Implementation Handbook details the triage algorithm.3 The primary survey aims to identify life-threatening problems
First, assess the patient for any threats to life (ESI-1) (Fig. so that we can start appropriate interventions (Table 21.4). You
21.1). Ask, “Does this patient need lifesaving intervention?” Or, may identify life-threatening problems related to ABCs at any
for ESI-2, is this a high-risk patient who cannot wait to be seen? point during the primary survey. When this occurs, start inter-
Next, evaluate patients who do not meet the criteria for ESI-1 ventions at once before moving to the next step of the survey.
, CHAPTER 21 Emergency and Disaster Nursing 387
Yes Resources: Count the number of different types of resources,
A Requires immediate not the individual tests or radiographs (e.g., complete blood
1
lifesaving intervention? count, electrolytes, and coagulants equals one resource,
while completed blood count plus chest radiograph equals
No
two resources).
B High-risk situation?
or Yes Resources Not resources
confused/lethargic/disoriented? 2
or • Labs (blood, urine) • History and physical exam
severe pain/distress? • Electrocardiogram, (including pelvic)
radiographs • Point-of-care testing
No • Computed tomography,
Consider magnetic resonance
C How many different imaging, ultrasound,
resources are needed? angiography
None One Many
• Intravenous fluids • Saline or heparin lock
(hydration)
D Danger zone vitals?
5 4
• Intravenous, intramuscular, • Oral medications
< 3 mo > 180 > 50
or nebulized medications • Tetanus immunization
SpO2 < 92%
3 mo 3 y > 160 > 40 • Prescription refills
3-8 y > 140 > 30
>8y > 100 > 20 • Specialty consultation • Phone call to primary care
physician
Age HR RR • Simple procedure = 1 • Simple wound care
(laceration repair, urinary (dressings, recheck)
No
catheter) • Crutches, splints, slings
3 • Complex procedure = 2
(procedural sedation)
Fig. 21.1 ESI Triage Algorithm.
TABLE 21.3 Emergency Assessment
Primary Survey
Assessment Interventions
Alertness (A1) and Airway (A2) With Cervical Spine
Stabilization and/or Immobilization
• Assess alertness (e.g., AVPU). • Maintain cervical spine stabilization and/or immobilization.
• Assess for respiratory distress. • Open airway using jaw-thrust maneuver.
• Determine airway patency. • Remove or suction any foreign bodies.
• Check for loose teeth or foreign bodies. • Insert oropharyngeal or nasopharyngeal airway, tracheostomy.
• Assess for bleeding, vomitus, or edema. • Begin rapid sequence intubation.
• Immobilize cervical spine using rigid cervical collar and cervical immobilization
device.
Breathing
• Assess ventilation. • Give supplemental O2 via appropriate delivery system (e.g., nonrebreather
• Scan chest for signs of breathing. mask).
• Look for paradoxical movement of the chest wall during inspiration and • Ventilate with bag-valve-mask with 100% O2 if respirations are inadequate or
expiration. absent.
• Note use of accessory muscles or abdominal muscles. • Prepare to intubate if severe respiratory distress (e.g., agonal breaths) or arrest.
• Observe and count respiratory rate. • Have suction available.
• Note color of nail beds, mucous membranes. • If absent breath sounds, prepare for needle thoracostomy and chest tube
• Auscultate lungs. insertion.
• Assess for jugular venous distention and trachea position.
Circulation and Control of Hemorrhage
• Assess for uncontrolled bleeding. • If absent pulse, start CPR and advanced life support measures.
• Check carotid or femoral pulse. • Control bleeding with direct pressure and pressure dressings.
• Palpate pulse for quality and rate. • If shock symptoms or hypotensive, start 2 large-bore (14- to 16-gauge) IVs and
• Assess skin color, temperature, moisture. start infusions of normal saline or lactated Ringer’s solution.
• Check capillary refill. • Consider intraosseous or central venous access if IV access cannot be rapidly
obtained.
• Give blood products if ordered.
Continued
Emergency and Disaster Nursing
Samantha J. Bonaduce and Mariann M. Harding
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Gas Exchange Perfusion
Interpersonal Violence Thermoregulation
LEARNING OUTCOMES
1. Apply the steps in triage, the primary survey, and the 4. Select appropriate nursing interventions for victims of
secondary survey to a patient with a medical, surgical, or violence.
traumatic emergency. 5. Distinguish among the responsibilities of health care
2. Relate the pathophysiology to the assessment and providers, the community, and select federal agencies in
interprofessional care of select environmental emergencies. emergency and mass casualty incident preparedness.
3. Relate the pathophysiology to the assessment and
interprofessional care of select toxicologic emergencies.
KEY TERMS
drowning primary survey
emergency secondary survey
frostbite submersion injury
heat exhaustion terrorism
heatstroke triage
hypothermia violence
mass casualty incident (MCI)
Entire books are dedicated to the nursing care of emergency More than 130 million people visit EDs each year.1 While the
patients. It is a unique specialty that requires a solid under- number visiting the ED is down slightly, the number of patients
standing of specific nursing concepts and approaches to patient admitted to the hospital is increasing. There are several reasons
problems. Nurses unaccustomed to the emergency department for this increase. Continued growth in retail clinics, telehealth,
(ED) often describe the flow as “chaotic” and uncertain. Indeed, and other sources of care for nonemergent problems has resulted
it may have this appearance. The challenge of the ED is that in the ED seeing older, sicker patients with more complex needs.2
the nurse does not know what patient will come through the ED nurses care for patients of all ages with a variety of prob-
doors. The ED nurse must be prepared to meet this challenge. lems. However, some EDs specialize in specific patient popu-
This chapter presents an overview of the triage process and care lations or conditions, such as pediatric ED or trauma ED. The
of select emergency patients. Common emergencies discussed Emergency Nurses Association (ENA) is the specialty organiza-
include heat- and cold-related emergencies, submersion inju- tion aimed at advancing emergency nursing practice. The ENA
ries, bites and stings, and various poisonings. The chapter con- provides standards of care for nurses working in the ED. They
cludes with a discussion of terrorism, mass casualty incidents, offer a certification process that allows nurses to become certi-
and the methods of response. fied emergency nurses (CENs).
The emergency management of various medical, surgical,
and traumatic emergencies is discussed throughout this book.
Tables outline the emergency management of specific problems.
CARE OF EMERGENCY PATIENT
Table 21.1 lists these emergency management tables by title, Recognizing life-threatening illness or injury is one of the most
chapter number, and page. important goals of emergency nursing. Starting interventions
385
,386 SECTION 4 Perioperative and Emergency Care
TABLE 21.1 EMERGENCY MANAGEMENT TABLE 21.2 Examples of Patients at Each
Emergency Management Tables Throughout the ESI Level
Book ESI Level Examples
1 Cardiac arrest, intubated trauma patient, overdose with
Title Chapter
bradypnea, severe respiratory distress, anaphylactic
Abdominal Trauma 47 shock, hypoglycemia with change in mental status
Acute Abdominal Pain 47 2 Chest pain from ischemia, multiple trauma unless
Acute GI Bleeding 46
responsive, suicidal patient, immunocompromised
Acute Soft Tissue Injury 67
patient with a fever, acute stroke
Acute Thyrotoxicosis 54
3 Abdominal pain or gynecologic disorders unless in
Anaphylactic Shock 14
severe distress, hip fracture in older patient, vomiting,
Chest Injuries 30
Chest Pain 37 hypertension
Chest Trauma 30 4 Closed extremity trauma, simple laceration, cystitis
Depressant Toxicity 11 5 Cold symptoms, minor burn, poison ivy, recheck (e.g.,
DKA 53 wound), prescription refill
Dysrhythmias 39
Eye Injury 22
Fractured Extremity 67
or ESI-2 for the number of expected resources they may need.
Head Injury 61
Hyperthermia 21 Assign patients to ESI-3, ESI-4, or ESI-5 based on this deter-
Hypoglycemia 53 mination. Vital signs are important. Patients assigned to ESI-3
Hypothermia 21 must have normal vital signs. Patients with abnormal vital signs
Inhalation Injury 26 may be reassigned to ESI-2.3
SCI 65
Shock 42
Stimulant Toxicity 11
CHECK YOUR PRACTICE
Stroke 62 You are working in the ED with your preceptor, who is a triage nurse. A
Submersion Injuries 21 24-year-old man arrives and states, “I think I have food poisoning. I’ve been
Tonic-Clonic Seizures 63 vomiting all night, and now I have diarrhea.” The patient reports abdominal
cramping that he rates as 6/10. He denies fever or chills. Vital signs: T = 97.8°F
(36.6°C), HR = 94, RR = 16, BP = 121/74 mm Hg.
to reverse or prevent a crisis is often a priority before making • Assign a triage acuity rating using the ESI.
a medical diagnosis. This process begins with your first con-
tact with a patient. Prompt identification of patients who need
immediate treatment and determining appropriate interven- After you complete the initial focused assessment to deter-
tions are essential nurse competencies. mine the presence of actual or potential threats to life, proceed
with a more detailed assessment. A systematic approach to
Triage this assessment decreases the time needed to identify potential
Triage refers to the process of rapidly determining patient acu- threats to life and limits the risk of overlooking a life-threaten-
ity. It is one of the most important assessment skills needed by ing problem. A primary and secondary survey is the approach
ED nurses. ED nurses often confront multiple patients who have used for all trauma patients. For nontrauma patients, the pri-
a variety of problems. The triage process works on the premise mary survey is followed by a focused assessment. Focused
that we must treat patients who have a threat to life before other assessments are discussed in Chapter 3.
patients.
A triage system identifies and categorizes patients so that Primary Survey
the most critically ill are treated first. The ENA and American The primary survey (Table 21.3) focuses on airway, breathing,
College of Emergency Physicians support the use of a 5-level circulation (ABC), disability, exposure, full set of vitals and
triage system.3 The Emergency Severity Index (ESI) is a 5-level family presence, and getting other monitoring devices. If there
triage system that incorporates concepts of illness severity and is uncontrolled external hemorrhage, the usual ABC assessment
resource use (e.g., electrocardiogram [ECG], laboratory tests, format may be reprioritized to <C>ABC. The C stands for cat-
radiology studies, IV fluids) to determine who we should treat astrophic hemorrhage. If present, it must be controlled first.4
first (Table 21.2). The ESI includes a triage algorithm that directs Apply direct pressure with a sterile dressing followed by a pres-
you to assign an ESI level to patients coming into the ED. The sure dressing to any obvious bleeding sites.
ESI Implementation Handbook details the triage algorithm.3 The primary survey aims to identify life-threatening problems
First, assess the patient for any threats to life (ESI-1) (Fig. so that we can start appropriate interventions (Table 21.4). You
21.1). Ask, “Does this patient need lifesaving intervention?” Or, may identify life-threatening problems related to ABCs at any
for ESI-2, is this a high-risk patient who cannot wait to be seen? point during the primary survey. When this occurs, start inter-
Next, evaluate patients who do not meet the criteria for ESI-1 ventions at once before moving to the next step of the survey.
, CHAPTER 21 Emergency and Disaster Nursing 387
Yes Resources: Count the number of different types of resources,
A Requires immediate not the individual tests or radiographs (e.g., complete blood
1
lifesaving intervention? count, electrolytes, and coagulants equals one resource,
while completed blood count plus chest radiograph equals
No
two resources).
B High-risk situation?
or Yes Resources Not resources
confused/lethargic/disoriented? 2
or • Labs (blood, urine) • History and physical exam
severe pain/distress? • Electrocardiogram, (including pelvic)
radiographs • Point-of-care testing
No • Computed tomography,
Consider magnetic resonance
C How many different imaging, ultrasound,
resources are needed? angiography
None One Many
• Intravenous fluids • Saline or heparin lock
(hydration)
D Danger zone vitals?
5 4
• Intravenous, intramuscular, • Oral medications
< 3 mo > 180 > 50
or nebulized medications • Tetanus immunization
SpO2 < 92%
3 mo 3 y > 160 > 40 • Prescription refills
3-8 y > 140 > 30
>8y > 100 > 20 • Specialty consultation • Phone call to primary care
physician
Age HR RR • Simple procedure = 1 • Simple wound care
(laceration repair, urinary (dressings, recheck)
No
catheter) • Crutches, splints, slings
3 • Complex procedure = 2
(procedural sedation)
Fig. 21.1 ESI Triage Algorithm.
TABLE 21.3 Emergency Assessment
Primary Survey
Assessment Interventions
Alertness (A1) and Airway (A2) With Cervical Spine
Stabilization and/or Immobilization
• Assess alertness (e.g., AVPU). • Maintain cervical spine stabilization and/or immobilization.
• Assess for respiratory distress. • Open airway using jaw-thrust maneuver.
• Determine airway patency. • Remove or suction any foreign bodies.
• Check for loose teeth or foreign bodies. • Insert oropharyngeal or nasopharyngeal airway, tracheostomy.
• Assess for bleeding, vomitus, or edema. • Begin rapid sequence intubation.
• Immobilize cervical spine using rigid cervical collar and cervical immobilization
device.
Breathing
• Assess ventilation. • Give supplemental O2 via appropriate delivery system (e.g., nonrebreather
• Scan chest for signs of breathing. mask).
• Look for paradoxical movement of the chest wall during inspiration and • Ventilate with bag-valve-mask with 100% O2 if respirations are inadequate or
expiration. absent.
• Note use of accessory muscles or abdominal muscles. • Prepare to intubate if severe respiratory distress (e.g., agonal breaths) or arrest.
• Observe and count respiratory rate. • Have suction available.
• Note color of nail beds, mucous membranes. • If absent breath sounds, prepare for needle thoracostomy and chest tube
• Auscultate lungs. insertion.
• Assess for jugular venous distention and trachea position.
Circulation and Control of Hemorrhage
• Assess for uncontrolled bleeding. • If absent pulse, start CPR and advanced life support measures.
• Check carotid or femoral pulse. • Control bleeding with direct pressure and pressure dressings.
• Palpate pulse for quality and rate. • If shock symptoms or hypotensive, start 2 large-bore (14- to 16-gauge) IVs and
• Assess skin color, temperature, moisture. start infusions of normal saline or lactated Ringer’s solution.
• Check capillary refill. • Consider intraosseous or central venous access if IV access cannot be rapidly
obtained.
• Give blood products if ordered.
Continued
