2. Learning objectives
• Apply the steps in triage, the primary survey, and the secondary
survey to a patient with a medical, surgical, or traumatic emergency.
• Relate the pathophysiology to the assessment and interprofessional
care of select environmental emergencies.
• Relate the pathophysiology to the assessment and interprofessional
care of select toxicologic emergencies.
• Select appropriate nursing interventions for victims of violence.
• Distinguish among the responsibilities of health care providers, the
community, and select federal agencies in emergency and mass
casualty incident preparedness.
3. Nursing management of patient in emergency and
disaster situations.
• Concepts and principles of disaster nursing
• Causes and types of disaster : natural and man made
• Earthquakes, floods, epidemics, cyclones.
• Fire , explosions, accidents Violence, terrorism; biochemical, war
• Policies related to emergency / disaster management at international,
national, state, institutional level.
4. Continued..
• Disaster Management :
• Team, guidelines, protocols, equipments, resources.
• Coordination & involvement of ;community, various govt department,
non-govt. organization , international agencies.
• Role of nurse : working
• Legal aspects of Disaster Nursing
• Impact on health & after effects ;
• Post Traumatic Stress Disorder
• Rehabilitation ; Physical, Psychosocial, Financial, Relocation
5. Emergency Nursing :
• Concept, priorities, principles & scope of emergency nursing
• Organization of emergency services: physical set up, staffing,
equipment & supplies, protocols, Concepts of triage role of triage
nurse.
• Coordination & involvement of different departments & facilities
• Nursing assessments – history & physical assessments.
• Etiology, Pathophysiology, Clinical manifestation, diagnosis, medical
and
surgical treatment modalities, alternative therapies, dietetics and
6. Continued..
Nursing Management (Nursing process including nursing procedures) of medical
and surgical emergencies.
• Principles of emergency management
• Common Emergencies
• Respiratory Emergencies
• Cardiac Emergencies
• Shock & Haemorrhage
• Pain
• Poly-Trauma, road accidents,
• crush injuries, wound.
• Bites
• Poisoning ; food, gas, drugs & chemical poisoning.
• Seizures
7. Continued..
• Thermal Emergencies ; Heat Strokes & Cold Injuries
• Paediatric emergencies
• Psychiatriac emergencies
• Obstretical emergencies
• Violence, abuse, sexual assault
• Cardiopulmonary resuscitation
• Crisis intervention
• Role of the nurse ; communication & interpersonal relations
• Medico-Legal Aspects
8. Care of Emergency Patient
• Recognizing life-threatening illness or injury is one of the most
important goals of emergency nursing.
• Initiating interventions to reverse or prevent a crisis is often a priority
before making a medical diagnosis.
• This process begins with your first contact with a patient. Prompt
identification of patients who need immediate treatment and
determining appropriate interventions are essential nurse
competencies.
9. Triage
• Triage, a French word meaning “to sort,” refers to the process of
rapidly determining patient acuity
• Most often you will confront multiple patients who have a variety of
problems.
• The triage process works on the premise that we must treat patients
who have a threat to life before other patient.
10. Continued..
• A triage system identifies and categorizes patients so that the most
critically ill are treated first.
• The ENA and American College of Emergency Physicians support the
use of a 5-level triage system.
• The Emergency Severity Index (ESI) is a 5-level triage system that
incorporates concepts of illness severity and resource use (e.g.,
electrocardiogram [ECG], laboratory tests, radiology studies, IV fluids)
to determine who should be treated first
12. • First, assess the patient for any threats to life (ESI-1).
• Ask “Is the patient in imminent danger of dying?” Or, for ESI-2, is this
a high-risk patient who should not wait to be seen?
• Next, evaluate patients who do not meet the criteria for ESI-1 or ESI-
2 for the number of anticipated resources they may need.
• Assign patients to ESI-3, ESI-4, or ESI-5 based on this determination.
Vital signs are important.
• Patients assigned to ESI-3 must have normal vital signs. Patients with
abnormal vital signs may be reassigned to ESI-2
13. • A 24-yr-old man arrives and states, “I think I have food poisoning. I’ve
been 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.
• Assign a triage acuity rating using the ESI.
14. Primary Survey
• The primary survey focuses on airway, breathing, circulation (ABC), disability,
exposure, facilitation of adjuncts and family, and other resuscitation aids.
• If uncontrolled external hemorrhage is noted, the usual ABC assessment
format may be reprioritized to <C> ABC. (catastrophic hemorrhage.
• IF present, it must be controlled first.
• Apply direct pressure with a sterile dressing followed by a pressure dressing to
any obvious bleeding sites.
• You may identify life-threatening conditions
related to ABCs at any point during the primary
survey.
• When this occurs, start interventions immediately,
before moving to the next step of the survey.
15. A = Alertness and Airway
Causes:
• Saliva, bloody secretions, vomitus, laryngeal trauma, dentures, facial
trauma, fractures, and the tongue can obstruct the airway.
Patients at risk for airway compromise :
• Those who drown or have seizures, anaphylaxis, foreign body
obstruction, or cardiopulmonary arrest.
16. Continued..
• Signs and symptoms in a patient with a compromised airway include:
• dyspnea, inability to speak, gasping (agonal) breaths, foreign body in
the airway, and trauma to the face or neck.
• The patient’s alertness level is a crucial factor for choosing the right
airway interventions.
• Level of consciousness (LOC)
17. Airway maintenance
• Airway maintenance should progress rapidly from the
least to the most invasive method.
• Treatment includes opening the airway using the jaw-
thrust maneuver (avoiding hyperextension of the neck)
suctioning and/or removal of foreign body, inserting a
nasopharyngeal or oropharyngeal airway (in unconscious
patients only), and endotracheal intubation.
• If intubation is impossible
• an emergency cricothyroidotomy or tracheotomy is done.
• Ventilate patients with 100% O2 using a bag-valve-mask
(BVM) device before intubation or cricothyroidotomy
18. Rapid-sequence intubation
Preferred procedure for securing an
unprotected airway in the ED.
It involves the use of
sedatives and paralytic drugs.
• These drugs aid in intubation
and reduce the risk for aspiration and airway trauma
19. Continued..
• If the patient has a suspected spinal cord injury and is not already
immobilized, the cervical spine must be stabilized at the same time as
the assessment of the airway.
• This can be done with manual stabilization or the use of a rigid cervical
collar (C collar).
• Keep the bed flat and continue to monitor airway patency and
breathing effectiveness
20. Breathing
• Adequate airflow through the upper airway does not ensure
adequate ventilation.
• Many problems cause breathing changes. Common ones include
fractured ribs, pneumothorax, penetrating injury, allergic reactions,
pulmonary emboli, and asthma attacks.
• Patients with these conditions may have a variety of signs and
symptoms.
• The patient may have dyspnea, paradoxical or asymmetric chest wall
movement, decreased or absent breath sounds on the affected side,
visible wounds to the chest wall, cyanosis, tachycardia, and
hypotension
21.
22. • Give high-flow O2 (100%) via a nonrebreather mask and monitor the
patient’s response.
• Life-threatening conditions (e.g., flail chest, tension pneumothorax)
can severely and quickly compromise ventilation.
• Interventions may include BVM ventilation with 100% O2 , needle
decompression, intubation, and treatment of the underlying cause
23. Circulation
• An effective circulatory system includes the heart, intact blood vessels,
and adequate blood volume.
• Uncontrolled internal or external bleeding places a person at risk for
hemorrhagic shock.
• Check either a femoral or carotid pulse.
• Peripheral pulses may be absent due to direct injury or
vasoconstriction.
• Assess the quality and rate of the pulse if found.
• Assess the skin for color, temperature, and moisture.
• Altered mental status and delayed capillary refill (longer than 3
seconds) are common signs of shock.
• When evaluating capillary refill in cold environments, remember that a
cold temperature delays refill
24. • Insert IV lines into veins in the upper extremities unless contraindicated,
such as in an open fracture or an injury that affects limb circulation.
• Insert 2 large-bore (14- to 16-gauge) IV catheters.
• Start aggressive fluid resuscitation using normal saline or lactated Ringer’s
solution.
• Consider intraosseous or central venous access if unable to rapidly obtain
venous access.
• The HCP may order type-specific packed red blood cells if needed.
• In an emergency (life-threatening) situation, give blood that is not cross-
matched (e.g., O negative) if immediate transfusion is needed.
25. Disability
• Conduct a brief neurologic examination as part of the primary survey.
• The patient’s LOC is a measure of the degree of disability.
• Use the Glasgow Coma Scale (GCS) to determine the LOC
• This allows for consistent communication among the
interprofessional care team.
• Remember! The GCS is not accurate for intubated or aphasic patients.
Last, assess the pupils for size, shape, equality, and reactivity
28. Exposure
• Remove clothing from all trauma patients to perform a thorough
physical assessment.
• This often requires cutting off the patient’s clothing.
• Be careful not to cut through any area that is forensic evidence (e.g.,
bullet hole).
• Do not remove any impaled objects (e.g., knife).
• Removing these could result in serious bleeding and further injury.
• Once the patient is exposed, use warming blankets, overhead
warmers, and warmed IV fluids to limit heat loss, prevent
hypothermia, and maintain privacy
29. Facilitate adjuncts and family
• Research supports the benefits for patients, caregivers, and staff of
allowing family presence during resuscitation and invasive
procedures.
• Patients report that caregivers provide comfort, serve as advocates
for them, and help remind the care team of their “personhood.”
• Caregivers who wish to be present during invasive procedures and
resuscitation view themselves as active participants in the care
process.
• They believe that they comfort the patient and that it is their right to
be with the patient.
