Management of Emergency Care

Emergency Management
Care that is being given to clients with urgent and critical needs. This is not like
nursing on the floor.
An emergency is whatever the client or their family considers it to be. Not
everyone that comes into the emergency room is an emergency, but you still
have to treat people courteously because this is an emergency to them even if
we don’t think it is.
This type treatment is provided under the direction of a physician or Emergency
Nurse Practitioner. Hopefully you have a real ER doctor with real ER nurses,
however; if you work at many places your ER doctor is a Rent-a-Doctor. If you
are an experienced ER nurse, you may have to step in a save someone’s life
because the Rent-a-Doctor is not trained in emergency medicine.

Skills Required of the Emergency Nurse

Assessment
o Ongoing and very high level – if make wrong decision, someone could die
o You need to be able to be able to make a good and quick decision based
on your assessment. If you are weak in assessments, the ER is not
where you need to be.
o Most ER’s will have protocols in place, but not every emergency is
covered under protocols. There will be times that you as a nurse have to
make a decision. This is how you save lives.
Anticipation of needs
o You have to already have enough confidence in your thinking abilities and
in your abilities in assessment and knowledge base to say okay, I know
this person seems to look fine, but there is just something that doesn’t
seem right. You need to be able to look at that client and know what you
need to do and the equipment that you will need.
Priority setting
o Need to be able to prioritize and be able to change the priorities rapidly
and easily because things can change rapidly.
Crisis intervention
o You need to have some psychiatric nursing skills. Most of the people that
show up in the ER are in crisis, they are scared or they are hurting. They
are concerned about their family member or their friend. They have very
high levels of stress and you have to be able to communicate with them
and be able to handle whatever comes your way.
Supervising
o Need to know the chain of command and policies are where you are
working. Depending upon where you work, the amount of authority that
you have will be different.
Therapeutic communication
o This goes along with crisis intervention. You have to be able to talk to
clients in a manner that you can find out what is going on. Some of the
big things are going to be domestic violence, rape, suicide attempts and
such. You are going to have to be very therapeutic because you don’t
want to say anything that is going to make it worse for the client.
Delegation
o Need to know what people can and can’t do because you need to be able
to delegate quickly. If you are saving someone’s life, you are going to

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 have to be able to think and act in a hurry. You also need to know what
you can do also and what is within your scope of practice.
Documentation
o This is “HUGE”. ER documentation frequently ends up in criminal cases.
ER’s are frequently sued. Your documentation could very likely end up in
court.
Technical nursing skills
o Need to have excellent technical clinical skills, you don’t have time to go
slow and try to figure things out. If you are not proficient in your technical
skills, you need to get some experience and then work in the ER.
Ability to think quickly
o Need to be confident enough to think quickly and act on it.
Problem solving skills
o A lot of problem solving goes on in the ER, especially if you are working in
a larger and busier emergency rooms.
Ability to deal with death and dying
o You will see death and dying in the ER. Most families have not had the
time to prepare for a death therefore; there will be a lot of drama, anger
and grief. These things can present themselves in many different ways.
o When you deal with death on a daily basis, need to learn how to cope with
it. Sometimes the ER staff will do things like laughing at things they
shouldn’t, while this is inappropriate, it is a coping method for most of
them.
Special certifications
o ACLS (Advanced Cardiac Life Support)
o CEN (Certified Emergency Room Nurse)
o CCRN (Critical Care Nursing)
o PALS (Pediatric Advanced Life Support)

If you work in the ER, you must know the norms for all age groups. Most
emergency rooms see the client from the womb to the tomb. You need to know
the appropriate pediatric doses, the appropriate pediatric injection sites. You
need to know the vital signs for all of the age groups.

Delivery of Emergency Care

Hospital Emergency Department

Diagnosis, treatment and stabilization of life threatening emergent conditions.
Symptomatic care and referral of non–urgent conditions. – give them something
to treat the symptoms and refer them to their primary physician.

Community Emergency Care

EMS System
o 80% of all emergency room visits are non-urgent; this causes
overwhelming delays in the emergency rooms. As a result many ER’s
have established fast tracks and emergency room clinics to make room for
the patients that are fixing to die or need true emergency care.
o Back in the 1960’s emergency rooms became more common in most
hospitals. The National Highway Safety Act was established and then
hospitals then got department of emergency medical services. The EMS

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 system came up with 911 for emergency. As a result of this there is much
more emergency access and care.

Protection of Legal Rights

Proper reporting to authorities
o Gun Shot Wounds – need to be reported no matter how they happened
o Intentional injuries – frequently reported to social work and the police
o Child and Elderly abuse – it is required by law to report to the police and
social work
o Certain diseases – syphilis and gonorrhea and such have to be reported
to the Health Department
o Deaths – all are reported – if someone shows up in the ER and dies, you
do not do anything with them until the coroner is called and he/she shows
up. If the patient is up on the floor, but initially came into the hospital via
the emergency room, the coroner must be called because by virtue of the
fact that they came into the hospital by way of the ER, it is officially the
coroner’s case. You should not even take any tubes out until the coroner
comes.
Any time you have trauma there is potential legal implications (criminal or civil)
because trauma usually caused from an accident or is deliberate act. If it is an
accident then someone is going to want to blame somebody for it. If it was
deliberate, someone is going to want to put someone in jail.
Preservation of evidence – don’t cut through any holes that anyone else had
made in the client’s clothes (if the knife went in there, cut on the opposite side)
o Rape Kit
 With rape victims, there is major evidence that is obtained, you
must be very careful with this. The chain of evidence must be
maintained and there are certain things that you have to do and there
are certain ways that things have to be sealed and documented.
There are certain people that have to be given things. What you need
to remember is that the evidence that you are collecting may mean the
difference between someone being incarcerated or out on the streets
where they will probably rape again.
o Weapons
o Clothing
 Clothing from any type of traumatic event, especially if it was a
criminal act. You are going to keep the clothing. It is going to be
bagged and tagged. If the clothing is soaked with blood, ideally hang it
somewhere and let it dry. Many times when doing this, the clothing
disappears, it goes out with the rest of the bloody stuff. So know the
facility protocol about handling bloody items. You do not want to put a
blood soaked garment in a plastic evidence bag because it will be
rotten before too long.
o Specimens
 As a nurse, you are going to have to obtain some of these
specimens and one such specimen is a blood alcohol level. When you
are taking a blood alcohol level, clean the site with betadine. Do not
use alcohol.

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 Emergency Department (ED) Classifications
Level I Trauma Center – we have one in Mississippi; it is the University Medical
Center. A Level I trauma center has 24/7 nurses and physicians. They have a
24/7 OR. They have a 24/7 diagnostics. You don’t have to wait for them to
call for an x-ray, x-rays are taken right there. They have the capability to
transport critically ill people to their institution. This could simply mean an
ambulance. We would like to think it was a helicopter, but it only needs to be
an ambulance. 24/7 whatever you need. In a Level I trauma center, you have
a bunch of ER physicians.
Level II – not really a trauma center, Level II is an emergency department; they
have 24 hour ER coverage by an RN and a physician. Level II, you may have
an ER physician, it might be a family practice physician. They have to be able
to give specialty consultation within 30 minutes. This means that you come in
with the open femur fracture, there will be a physician there to order some
blood work, x-rays, pain medicine and when they get on the phone, the
orthopedic surgeon can be there in 30 minutes.
Level III – You have 24 hour coverage with an RN and a doctor can get there
within 30 minutes. This is the doctor down the road. About all you can do
here as a nurse is know your ACLS protocol and try to save lives.
Level IV – This is where they have emergency service that offers reasonable
care in determining if an emergency actually exists. In other words, when you
go there, they can decide if they need to call 911. Level IV is going to be
hospitals way out in the rural communities. Level IV is a band aid station. We
are seeing more and more of these.

ED Layout
Triage area – to sort out clients – this is where the first decision is made as to
where you are going to live or die or keep that limb is going to be made. This
is where they sort the patients out and they decide who needs to be seen now
and who has to wait. Many places, you have to get by the guard first.
Trauma Room – this is where the trauma is usually going to go. There is usually
going to be one major trauma room and they have everything in there (trach
trays, they open chests in there). It is almost like a mini OR. It is a major busy
area.
Orthopedic Room – this is where they put on the casts and splints
Suture Room/Spot – good lighting in the room
Observation Area – usually going to be somewhere that they can keep an eye on
the client or if they just want to keep you for 23 hours or something and they
just want to make sure that you are going to be okay.
Clinic Area – big ER’s will have a clinic area or fast track area, this is a busy spot
because 80% of the people that show up in the ER will be getting attention
here.
ENT Room – bigger ER’s will have one of these, this is where they have the
microscopes to look in the ear and suction equipment and such.
Psych Holding – these are good things to have
X ray – bigger ER’s will have one in them
Close proximity to OR – all ER’s should be in close proximity to the OR or at
least should have their own elevator to get them there or at least their own hall
to get them straight from the ER to the OR.
Waiting Room – this is where most ER patients spend most of their time. Most
have a 4 hour wait.

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 Triage
Means “to sort”
A systematic approach to assessment that allows the ED nurse determines what
clients need immediate treatment and those who can safely wait.
Places clients in groups based on severity of problems and the immediacy of
needed treatment.
Triage is vastly different between the Emergency Department and in the “field
“(disasters) triage.
Ideally triage happens within 2 to 5 minutes of a person arriving into the
emergency room. Reality triage should happen before they have to go and
give their life history to the lady at the money desk. If they are well enough to
go see the money desk lady, they do not really need to be in the ER. Triage
should happen within 10 minutes of arrival at the emergency room.
Remember privacy is a big issue to day. The triage area is big open area and
questions need to be immediate, discreet and private. The questions should
be immediate and you should know right then if they need to go in to the room.
So be careful what you are asking if it is in an open area. Don’t ask how much
they weigh, when they last had sex and such. Triage should be as private as
possible.
With neonates, they really need to have care and somebody laying their hands
on them to find out what is going on within 10 minutes of their arrival. They
are sick and they can go down in a hurry.
One of the problems in triage is language barriers. If you do not understand, you
need to get someone there that does speak the language or can help you
understand each other. The problem falls in that it takes time to get someone
there to translate these patients. Having their children answer the questions if
the child speaks English is becoming questionable.

Nurses Role in Routine ED Triage

Collect critical, initial data (history) – when did it start hurting, how long has it
been hurting, how bad does it hurt, are you allergic to anything? It does not
need to be a long and drawn out history.
Assess vital signs – needs to be done quickly to gets some perimeters going on.
If the client is super sick, you are going to be getting their vital signs while
someone else is starting their IV.
Neurological assessment if indicated
In the hospital triage directs all available resources to clients who are the most
critically ill regardless of potential outcome. The care will be provided
regardless of whether they are going to live or die. This is the total opposite of
what happens in a disaster setting. We are going to try to keep them alive no
matter what the cost is in resources. It is not this way in field (disaster) triage.

ED Triage Categories
Emergent – highest priority (they are fixing to die)
o ER journals and the latest emergency room nursing exams and such are
now saying that there are certain things that are just going to be put here
(emergent). One of the things is that if someone is pregnant with a life
threatening problem to either them or their baby. This person is going to
be bumped up for treatment before someone else that has the same life
threatening situation because two lives are at risk. Another category that
is automatically going to go to emergent are infants that are less than 7

5
 days old that are symptomatic or any infant that is symptomatic and sick.
With babies it does not take a whole lot of boogers in a nose for them to
get respiratory distress.
Urgent – serious
o This is not immediately life threatening, but they need to be seen within an
hour. They are not going to die right this minute, but in 60 minutes or so, if
they don’t get care they are probably going to die or lose and extremity.
You might can put them off if you have somebody that is sicker, but you
only have an hour to put them off.
Non-urgent –less serious
o Episodic illness that can wait up to 24 hours to get treated. This is your
new onset of nausea, vomiting and diarrhea. You have 24 hours before
you seek care for these.
Fast-Track – first aide or basic care
o This is supposed to be first aid and basic care. They need the scratch
washed out and band aided. They need the Tylenol for their hurt toe.
They need some cough medicine.

There is another group of patients that is going to get priority over someone with
the same thing. If you have someone that was in the ER yesterday and they
were in there for nausea, vomiting and diarrhea. They were given some fluids
and some medicine and it has been 18 hours and they show back up with
worsening nausea, vomiting and diarrhea. They are going to be bumped up
because they had care less than 24 hours ago and it has gotten worse or has not
gotten better. These people will be bumped up in the seriousness of what is
going on.

Usually wherever you work, there may be guidelines that are specific to that
agency. These are very general guidelines, so you have to be aware of the
guidelines of the facility where you are an ER nurse.

(3) We have 60 year old that has vomited for 2 days (might aspirate)
(2) We have a 23 year old that has an obviously twisted right leg, pain is rated at
an 8 (we will see this client second because of the pain)
(4) We have a19 year old that has asthma and says that they are SOB, their O2
sats are 97% - if this person is speaking in sentences and is not in distress I will
see them last
(1) We have a 29 year old with lacerated hand spurting blood. – This person has
blood spurting. This is circulation. Remember ABC’s. With the spurting this
person has cut an artery (pulsing).

Emergency Planning
JACHO requires that every healthcare facility have an emergency plan.
The emergency plan must be practiced twice a year.
Communities also have emergency plans that work in conjunction with the
hospitals. They must work together. They have to actually practice the plan
and make sure that it is going to work.
All nurses should be aware of their employing agencies disaster plan so they can
respond appropriately. As registered nurses, when you go through orientation,
they are going to tell you about their plan. You need to think about putting

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 yourself in that situation, because it really could be you in this situation.
Nurses died in Hurricane Katrina.

Need to have an emergency plan and a disaster kit that you could live or take
care of yourself for 3 to 5 days without food, water or medicine. They are now
saying that individuals need to have 7 days worth of food, water and medical
supplies to last them 7 days because of the Katrina disaster.

Nursing Assessment in Emergencies

Primary Survey
A Airway
o Do they have an airway, is it working? If is not, you open it up and then
you worry about the breathing.
B Breathing
o Are they breathing? I just stuck a tube down their throat so I can bag
them and squeeze it. Now they are breathing. What about circulation?
C Circulation
o They have squirting blood coming out of them and we need to take care of
that.
D Disability/Neuro
o Take care of AB&C first, and then you are going to look and see what is
not moving and such.
E Exposure
o It means expose the patient, get their clothes off of them, and look at all of
their body surfaces. Make sure that there is nothing running out of
anywhere else. One of the first things that we were taught after a fresh
post-op mastectomy was when you get them off of the stretcher and onto
the bed, you need to turn them over to see because the blood pools in the
back. It is the same principle in emergency situations. You look
everywhere because there might be a life threatening injury that you
cannot see unless the patient is exposed and you can get to them.

You find the problem in emergency care and you take care of it, then you go
down to the next one on down the line.

You could call trauma situations systematic chaos. After you have done all of
this, then you can go on to the next step, but you have to take care the A, the B
and the C. Then you can take care of the D and the E.

Airway /Breathing Maintenance

Airway and breathing is first, this could take the form of a nasotracheal tube, an
endotracheal tube, it might be a trach, a trumpet. It could be any number of
things to get the airway open so that you can get them going. They must have
a patent airway. Remember if they are under C spine precautions, you have
to maintain them. If the airway problem is not related to trauma, the airway
problems are usually going to be from an obstruction like food or from
medications.
Oropharyngeal
Endotracheal Intubation

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Cricothyroidotomy
One thing to remember is that if you are looking at the Glasgow Coma scale and
the patient is at 8 or less, you need to be prepared for intubation. They may
not intubate them, but you need to be prepared for that as a nurse. This client
is getting some pretty significant brain injury and the literature says anywhere
from a 6 to 8 be prepared for intubation. Mrs. Batton says if it is an 8 be
prepared for it.
Most of your big trauma rooms have open crash carts, on the floor you have
close crash carts that have to be changed out and accounted for. In the ER
and critical care units you have open crash carts that are counted every shift.
Remember obstruction is a real common problem with children as far as an
obstructed airway. Make sure you check their C spine and give them an
airway

We have a client that has a severe chest injury, he has severe dyspnea, subq
emphysema is getting worse around the neck, the breathe sounds are
decreasing. What is the priority nursing diagnosis? Ineffective airway

Circulation
Always take care of airway/breathing first
If there is obvious external hemorrhaging – open airway and then control bleed,
especially if arterial bleed because they are going to continue to bleed. If it is
an arterial bleed, until the blood pressure is so low that it is not pumping it out
of the body any more, they are going to continue to bleed.
Make sure to apply pressure and elevate extremity for external bleed. If
someone is alert and oriented, they can apply pressure themselves.
Tourniquet is always last resort unless traumatic amputation has occurred. You
only use a tourniquet if you are willing to lose the limb. Use your direct
pressure, elevation, maybe ice and pressure points first.
Initiation of IV’s to restore volume. If you lose volume, the blood pressure drops
and the heart rate increases until there is no blood and then it is going to go
down pretty rapidly.
Draw blood for cross match. Almost anybody that comes in bleeding from
somewhere is going to have a blood drawn for type and match.
Any time that you have an external bleed and it is spurting or squirting, this is
high priority.
Always if they are bleeding, monitor for shock.
Remember that someone can lose 1500 cc’s of blood before they start showing
major signs of blood loss or shock. It is less than this in children.
People that are losing lots of blood are going to have at least 2 large bore IV’s
(16 – 18 gauge). The rule of thumb in the ER is that if people have medical
problems they are going to give them a fluid like D5W. If the client comes in
for trauma or general fluid replacement, they are going to go with Normal
Saline or Lactated Ringers because these fluids are isotonic and the fluid is
going to stay where they put it. If they have a blood pressure that is dropping
and you are trying to maintain vascular pressure, you want the fluid to stay
where you put it.
In the ER, women of child bearing age will usually receive O negative blood. For
men and post menopausal women, they will get O positive blood. If you are
having to replace large amounts of blood or fluids, they are going to have to be
warm. We don’t lower the core temperature too much.

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Female, sudden onset of left sided chest pain, short of breath, diaphoretic, pale
in acute respiratory distress with no trauma. She has nausea and vomiting. The
blood pressure is 100/60, pulse is 118, and respirations are 36. What is the
primary nursing diagnosis? Impaired Gas Exchange

You cannot take the obvious deformity or problem and assume that it is the
issue.

Disability /Neurological
Assess Mental Status
o Any change is going to be significant. It is going to mean something, but
remember that you can get a change in mental status from something as
simple as sleep deprivation, anxiety, or an intracranial bleed.
Glasgow Coma scale – if you have time, we are going to be prepared to intubate
at 8 or below.
Assess Anxiety level
AVUP
A – alert
V – responsive to voice
U – unresponsive
P – responsive to pain
This is a quick thing that places use in addition to the Glasgow coma scale.
Sometimes this is something that they will use in triage, before they have time
to see what the patient can move for.
If anything is running out of the ears or nose – this is not a good sign, it could be
cerebral spinal fluid. Blood and gray matter is never a good sign to come out
of someone’s ears and nose.
Battle sign (bruising behind the ear) is a sign of basilar skull fracture
DO NOT PUT NG TUBE in someone with a basilar skull fracture – it can go into
the cranial vault.
Raccoon sign – periorbital discoloration usually associated with basilar skull
fractures.

Exposure
This is the final component of the primary survey
Remove all clothing to allow for allow for a thorough assessment
Be aware of potential need for evidence collection
If you have a patient that you have taken off all of their clothes – keep them warm
and keep them covered up.

75% of people with chest trauma – they are going to have some degree of
underlying pulmonary contusions. With pulmonary contusions, you have to
remember the airway is probably going to be an issue.

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 Pain
Client's complaining of severe pain should be moved up in priority.
Severe pain is defined as client’s self rating of 8-10 on a scale of 1-10.
Severe pain is moved up as a priority, but it is not going to go above the A, the B
and the C.
We need to take care of their pain. Remember when you are giving pain
medication in the ER, you need to find out what they have already taken,
eaten or had to drink.

Emergency Drugs
Most emergency drugs are given intravenously; we are not going to give people
in trauma PO meds.
O2
o Usually in trauma and ER situations it is going to be given in high
concentrations and possibly through an ET tube
Epinephrine
o Cardiac stimulant – bronchodilator
o We are going to give it to stimulate the heart or for anaphylaxis
Atropine
o Given for bradycardia or PEA (pulseless electrical activity)
Lidocaine
o Given for PVC’s, V Fib, V tach
o Can be given IV or through the endotracheal tube
Amiodarone
o Given for V Fib, unstable V Tach
o Suppresses arrhythmias, don’t give to infants with gasping syndrome
Narcan
o To stop the effects of drugs (narcotics) that they took
o Given so the client will start breathing again
D50W
o This is given for hypoglycemia
NA Bicarb.
o This is given when the patient is acidotic
Magnesium
o Given for hypomagnesaemia, uterine problems and given sometimes for
cardiac arrest
Dopamine
o Is a vasopressor
o It increases the blood pressure, in smaller doses it improves renal function
Dobutamine
o Short term it is given to increase cardiac output
o It is a vasoactive adrenergic drug
o Do not usually use this on children

After Unsuccessful Code

Family is notified
Prepare family members before they come in and look at the body, let them know
what they are going to see
Family is supported
Body prepared

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Donor agencies are notified
Coroner contacted
Staff debriefing possibly about what could have been done differently.

Documentation in the ED
Document everything
o Assessment data
o History
o Vital Signs
o Allergies
o Medications
o Last meal eaten
o How they arrived
o Pertinent statements from client with quotations
o Make sure that you get all of this documented. Most ER’s have their own
documentation forms and you need to use them according to the policy of
the facility.

Secondary Survey
This is when you already have the client a patent airway, you have them
breathing, the circulation is being taken care of, neurologically they are stable,
now you can get down to the business of the complete health history. The
reality is that most of this is going to occur on the unit.
Complete health history
Head to toe assessment
Diagnostic and Labs
Monitoring, (EKG, Foley, Arterial lines)
Splinting fractures
Clean/dress wounds
Other interventions based on client needs
Remember in the ER, any woman that is of child bearing age that is sexually
active should be considered pregnant until determined otherwise. Even if they
say that they are not having sex and they are of child bearing age and you
look at them and you think that they might be of child bearing age, consider
them pregnant until you know that they are not.

(3) 61 year old with a wound draining purulent foul smelling secretions with a
temp of 101.4°, blood pressure 160/90
(1) 41 year old with bilateral rhonchi, rales and respirations of 36 (airway)
(2) 1 month old with increased ___, 2 diarrhea stools and 2 wet diapers in the
last 2.5 hours (this child has urinated twice in the last 2.5 hours, so it is not
dehydrated)
(4) 23 year old with a lacerated index finger

73 year old diabetic with glucose of 260 and a gangrenous right toe
66 year old cancer patient, painful chem. Port, fatigue and temp of 101° for 3
days

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Scoliosis patient who 2 weeks ago had surgery, now is having a lot of back pain
(1) MVA with chest pain, SOB and unilateral chest movement

Common Problems Seen in the ER

Wounds
Trauma (Stabs, Gun Shot Wounds)
Blunt Trauma
Crushing Wounds
Fractures
Substance Abuse
Suicidal Client’s
Poisoning
Frost Bite
Heat Stroke
Drowning
Burns
Anaphylactic Reactions
Violence, Abuse, Neglect

If you have a limb that has been cut off in an emergency and you want to try to
save it. Wrap it in sterile gauze, moisten in normal saline, and put it on ice in a
plastic bag.

Abdominal Trauma
ABC first
Goal – Control the bleeding and maintain the blood volume
Assess – nee to know what happened, knife, GSW, hit? When?, How many
times? Stay conscious?
Auscultate – you want to know if they have bowel sounds
Palpate – Rigidity? Guarding? Tenderness?, Measure abdominal girth (is it
getting bigger, if it is getting bigger they might be bleeding into it). If they are
bleeding into the abdomen, the blood pressure is dropping.
ABC always first, get rid of those clothes and see what else you see, control the
bleeding, start the IV, get ready to treat shock, NG tube and a Foley
If it is an evisceration, we are going to cover it, keep sterile and moist
Always an NG Tube with an abdominal trauma unless they have a basilar skull
fracture.

Abdominal Trauma - Emergency Management

A,B,C’s
Cut away clothes
Control bleeding
Start IV (be prepared to treat shock)
If evisceration – cover with sterile, wet, dressing
NG tube, Foley
Continuous Vital signs, Neuro status – continuous monitoring because if they are
bleeding, they could have a rapid change in status
X rays

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Labs
Meds
Peritoneal lavage or pericentesis – they are going to do this if there is a question
about intraperitoneal bleeding. Now depending upon where you work, the
frequency of this occurrence. Big centers have CT people there and they can
do a CT scan and look at the bleeding. You go to some of these smaller ER’s
that don’t have CT people there and if they need to know if the client needs to
go to surgery, they are going to do the paracentesis. They are going to cut a
couple of slits in the belly, put in a catheter, they are going to hold up the bag
of normal saline, and let it run in there and then they are going to hold the bag
down and let it sit it on the floor and let all of the fluid run back out. This used
to be all that you could do until they had CT scans. With the lavage, they are
looking to see if it is grossly bloody, if it is grossly bloody obviously there is a
bleed. If they look at it and they can’t decide, if they cannot read a newspaper
through it then they need to go straight to the OR.
Prepare for the OR

Near Drowning - Emergency Management

Salt water or fresh water the result is severe hypoxia and acidosis.
o If salt water it is going to be worse
Every drowning deserves a resuscitation attempt. The rule for drowning is that
you do CPR and you resuscitate them until they are warm. They are not dead
until they are warm and dead. People that have near drownings are going to
be cold because the water is almost always going to be colder than their body
temperature. If they are cold and dead, they are not dead yet. If the water is
extremely cold with our bodies the way that they are have been under water
for up to 30 minutes and have survived with no problems.
ABC’s
100% O2, PEEP to improve gas exchange
Cardiac monitoring
IV (salt water drowning give LR {isotonic solution}, Fresh water drowning
probably not going to give any fluids just start an INT for some access)
Labs
Meds
o Bicarb because of ABG’s (will be acidotic)
o Antibiotics because of the pneumonia
o Bronchodilators
NG tube/Foley
X-rays – to check their lungs
Monitor Vital Signs

Poisoning - Emergency Management

Ingested (plants, drugs, foods, chemicals)
o ABC’s (V/S, O2, ABG’s, EKG)
o Call Poison Control – 24 hours a day 7 days a week
o may be corrosive (determine type of product ingested) – we do not want
them to vomit, sometimes Poison Control will tell you to give this client
milk or water to dilute it, but if it is any kind of a corrosive never make
them vomit because if it burns going down, it is going to burn coming back
up again. If it is caustic, the airway becomes an issue because of the

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 corrosion to the esophagus. It can even go through the esophagus into
the trachea. Activated charcoal is very commonly given.
o Position on Left side
o Going to have an IV
o Treat the signs and symptoms that you see
o Try to find out what it is that they ate or ingested, if it is food and you get
several of them in, it is going to have to be reported
o Monitor Neuro status
o NGT for gastric lavage
o give milk or water to dilute
o do not make vomit if caustic
o If caustic assess for mouth, esophagus burns
o Activated Charcoal (PO- NGT)
o Cathartic (Mg. Citrate)
o Syrup of Ipecac (only if alert and able to swallow) – we seldom use this
any more, it is not something that is recommended, there is a huge risk for
aspiration
Food Poisoning
o ABC’s, V/S, , EKG, muscular activity
o Place on side
o IV
o Treat S/S N/V
o Determine source and type of food
o Reporting may be necessary
Inhaled (Carbon monoxide, gas, smoke, fumes)
o Carbon Monoxide most common
o Carboxyhemoglobin levels
o 100% O2
o Monitor for deterioration of mental status
o Notify Psych if attempted suicide and Health department if in the dwelling
o May cause permanent brain damage
Skin Contamination
o Remove clothes
o Profuse amounts of water to flush all traces of chemical away from body
(unless chemical was Lye or white phosphorus)
o Manage as a burn after removal of agent
Injected
o Insects
o Snakes
 Very common in Mississippi. More people die of insect bites than
snake bites.
 Pit vipers and coral snakes are the most poisonous
 Signs and symptoms can vary. The poisons are injected through
fangs. Just because someone has fang marks does not mean that
they have been invenomated. Usually going to immobilize the
bitten area. Try to find out what type of snake it was.
o Spiders
 Brown Recluse is pretty common. Brown recluse bites can be very
bad. They have a cytotoxic venom (kills the cells). Initially the
signs and symptoms may be very mild. There might be a little pain,
but then it starts getting worse over time. Then it becomes
ischemic, dark and hard in several days and then it begins to have
a bull’s eye appearance. The infection can be pretty severe with
fever and chills. There is lots of pain. They have to do

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 debridement in surgery. If the client is a diabetic, and it is on an
extremity, this is really bad.
 Black Widow spiders have a neurotoxic venom. This affects the
neuromuscular junctions. There is an immediate sharp pain when
you get bitten by a black widow spider. They may have stomach
pain and rigidity.

Heat Injuries-Emergency Management

Heat Exhaustion – happens when peripheral circulation starts to collapse
because you have so much of a depletion of your sodium. If you don’t take
care of heat exhaustion, then it can turn into heat stroke.
Heat Stroke – this is the worse, it is life-threatening and can kill you.
Heat Cramps
With all of these above, the ultimate thing that you want to do is get them cooled
off. Get them in the shade, get them cooled. But you don’t want to get them so
cold that they start shivering or develop goose bumps. Then their body will
actually try to heat up some more. You want to get them cool first and once you
get them cool, then you can get them hydrated and then they need to rest for a
couple of days.

Cold Injuries -Emergency Management

Hypothermia -Temp less than 95 degrees
Frost Bite – do not massage it, do not vigorously rub it, take very good care of
that extremity because it is very fragile. With the frostbite, you want it to warm
up and you start with tepid water and warm it that way. Do not run hot water
on it. Elevate the extremity. If it is severe frostbite, you will lose that extremity.
This is not that bad of a way to die, you usually go to sleep before you die. They
are not dead until they are cold and dead.

Disasters and Nursing

A sudden and massive disruption in health care service because of hostile
elements of any kind (Natural and man-made) requiring survival resources be
brought into action in the shortest possible time.
Does not necessarily mean numerous injured or dead; may be 5 critically injured
MVA clients taken to a small community hospital. You go into disaster mode
any time your resources are overwhelmed.

Disaster Types
Natural
o Tornadoes
o Hurricanes
o Earthquakes
o Blizzards
o Epidemics
Man-Made
o Fires

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 o Explosions
o Nuclear Accidents
o Bombings
o Biological
o Chemical
o Radiation
o War

Nurses Role in Disaster Triage

Now triage will based on utilization of resources to treat the most people.
Good of the “whole” becomes more important than good of the individual.
Potential outcomes/survivability and available resources is the issue - not degree
of injury.
Nurses will still be involved with assessment and basic treatment.

Disaster Triage Categories

Immediate – Priority 1 – Red
o These individuals are immediate care. They are tagged red with a red tag.
These are people that are life threatening, but they are viable with minimal
intervention diseases. This is going to be somebody that has a tension
pneumothorax. Maybe they have an airway obstruction that we can take
care of real quick. This is going to be your immediate, Priority 1. Airway,
circulation
Delayed – Priority 2 – Yellow
o This is going to be injuries that are significant, but they are survivable with
some medical care, but they can wait for several hours without loss of life
or limb. This might be stable abdominal injuries (without any
hemorrhage), soft tissue injuries, facial wounds (with no airway problems),
eye injuries,
Minimal – Priority 3 – Green
o This is kind of the walking wounded. Treatment can wait hours or even
days. Scratches, scrapes, sprains, lacerations, back problems
Expectant – Priority 4 – Black
o These are injuries that are significant. The injuries are extensive and
chances of survival are minimal, even with definitive care. When do
provide comfort measures when we can. This group is put by themselves
away from everybody else and left to die. If a client is in a nursing home
and they are a DNR patient, then they automatically go to the black
category, even if just an IV to hydrate them is all that they might need.
o In this category, there are going to be people with agonal respirations,
fixed and dilated pupils, burns over 60% of their body, gaping open
wounds where they are losing massive amounts of blood and then people
that are okay go up to the next level.
After Triage category decided the person is tagged and treated &/or transported,
triage continues at each point of care. When the client leaves the site, they go
to a hospital or emergency room where they are triaged again.
It goes against everything that nurses have ever been taught

Infant with scratches, lacerations, moderate breathing – yellow tagged

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Child with brain tissue from nose and bleeding from both ears – black tagged
Adult with a traumatic amputation of the hand – red tagged
Pregnant woman with swollen ankles – green tagged

21 year old with a penetrating eye injury – level 1

fractured pelvis – level 4 – black tagged – you would see this person second.
They might can be helped, but they can loose massive amounts of blood with
a pelvic fracture – chances are they will have to be left also
swollen and tender left arm – level 3 - green
short of breath and sunken chest wound – level 1 – go to this client first and if
you can do something real quick like put something over the chest wound then
he will be first and send them on. But if you cannot help this client by putting
something over the wound (quick), then they will be a level 4 and you will have
to leave them

Disaster Levels
Level I – Local emergency response personnel and organizations can contain
and effectively manage the disaster and it’s aftermath
Level ll – Regional efforts and aid from surrounding communities are sufficient to
manage the effects of the disaster
Level III - Local and regional assets are overwhelmed; state wide or federal
assistance is required (Katrina)

Terrorism - Recognition and Awareness

Be aware of an unusual increase in the number of people with fever or GI
problems
Unusual illness for time of year
Clusters of clients from a specific location
Large number of rapidly fatal cases with death in 72 hours
Increase in disease in otherwise healthy population

Levels of Protection for Health care Workers

Level A – highest level of respiratory, skin, eye, mucus membrane protection
Level B – Same respiratory but less skin and eye protection (don’t have to have
the vapor suit on)
Level C – Air purified respirator, with filters that remove harmful substances and
a chemical resistant coverall, gloves, boots and splash hood.
Level D – What you would normally wear plus universal precautions

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