Emergency and Disaster Nursing

Emergency and Disaster Nursing
Chapter 69 (p. 1765) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Emergency Nursing Triage Process of rapidly determining patient acuity Represents a critical assessment skill The triage process works on the premise that patients who have a threat to life must be treated before other patients. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Emergency Nursing Triage system: categorizes patients so most critical are treated first Emergency Severity Index: Five-level triage system that incorporates illness severity and resource utilization The ESI includes a triage algorithm that directs you to assign an ESI level to patients presenting to the ED. {See next slide for figure of algorithm.} Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Emergency Severity Index Triage Algorithm

Triage systems Color, words or numbers sorting system
Colors: Red/emergent, yellow/urgent, Green/non-urgent Numbers: Priority I/emergent, priority II/urgent, Priority III/non-urgent

Emergent Life/limb, or eye threatening; needs immediate attention
Trauma, chest pain, cardiac arrest, severe respiratory distress, chemicals in the eyes, limb amputation, acute neurological deficits

Urgent Needs treatment in 20 minutes to 2 hours
Fever > 104 F, diastolic BP > 130 mm Hg, kidney stone, simple fracture, abdominal pain, asthma/no respiratory distress

Non-urgent Can wait hours or days
Sprain, minor laceration, cold symptoms, rash, simple HA

Emergency Nursing Primary survey focuses on airway, breathing, circulation, and disability, exposure (ABCDE) Identifies life-threatening conditions If life-threatening conditions related to ABCD are identified during primary survey, interventions are started immediately and before proceeding to the next step of the survey! Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Primary Survey Airway with cervical spine stabilization and/or immobilization Signs/symptoms in patient with compromised airway Dyspnea Inability to vocalize Presence of foreign body in airway Trauma to face or neck Nearly all immediate trauma deaths occur because of airway obstruction. Saliva, bloody secretions, vomitus, laryngeal trauma, dentures, facial trauma, fractures, and the tongue can obstruct the airway. Patients at risk for airway compromise include those who have seizures, near-drowning, anaphylaxis, foreign body obstruction, or cardiopulmonary arrest. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Primary Survey Maintain airway: least to most invasive method Open airway using the jaw-thrust maneuver. Suction and/or remove foreign body. Insert nasopharyngeal/oropharyngeal airway. Provide endotracheal intubation. {See next slide for figure of jaw-thrust maneuver.} If unable to intubate because of airway obstruction, an emergency cricothyroidotomy or tracheotomy is performed. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Primary Survey Rapid-sequence intubation Preferred procedure for unprotected airway Involves sedation or anesthesia and paralysis {See next slide for figure.} Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Primary Survey Breathing Assess for dyspnea, cyanosis paradoxic/asymmetric chest wall movement, decreased/absent breath sounds, tachycardia, hypotension Many conditions, including fractured ribs, pneumothorax, penetrating injury, allergic reactions, pulmonary emboli, and asthma attacks, cause breathing alterations. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Primary Survey Breathing Administer high-flow O2 via a non-rebreather mask. Bag-valve-mask (BVM) ventilation with 100% O2 and intubation for life-threatening conditions Monitor patient response. Life-threatening conditions, such as tension pneumothorax and flail chest, can severely and quickly compromise ventilation. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Primary Survey Circulation Check central pulse (peripheral pulses may be absent because of injury or vasoconstriction). If a pulse is felt, assess the quality and rate. Assess the skin for color, temperature, and moisture. Altered mental status and delayed capillary refill (longer than 3 seconds) are the most significant signs of shock. Take care when evaluating capillary refill in cold environments because cold delays refill. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Primary Survey Circulation (cont’d) Insert two large-bore IV catheters. Initiate aggressive fluid resuscitation using normal saline or lactated Ringer’s solution. Insert intravenous (IV) lines into veins in the upper extremities unless contraindicated, such as in a massive fracture or an injury that affects limb circulation. Apply direct pressure to any obvious bleeding sites with a sterile dressing. Obtain blood samples for typing to determine ABO and Rh group. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Primary Survey Disability: measured by patient’s level of consciousness AVPU A = alert V = responsive to voice P = responsive to pain U = unresponsive Glasgow Coma Scale Pupils Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Primary Survey Exposure/environmental control Remove clothing to perform physical assessment. Prevent heat loss. Once the patient is exposed, it is important to limit heat loss, prevent hypothermia, and maintain privacy by using warming blankets, overhead warmers, and warmed IV fluids. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Secondary Survey Full set of vital signs/Five interventions/Facilitate family presence Complete set of vital signs Blood pressure (bilateral) Heart rate Respiratory rate Oxygen saturation Temperature At this point, determine whether to proceed with the secondary survey or perform additional interventions. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Secondary Survey Five interventions Initiate ECG monitoring. Initiate pulse oximetry. Insert indwelling catheter. Insert orogastric/nasogastric tube. Collect blood for laboratory studies. These focused adjuncts are considered for patients who sustain significant trauma and/or require lifesaving interventions during the primary survey. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Secondary Survey Facilitate family presence Family presence: family members who wish to be present during invasive procedures/resuscitation view themselves as participants in care Their presence should be supported. Patients report that having caregivers present comforts them; caregivers serve as advocates for them and help to remind the health care team of their “personhood.” Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Secondary Survey Give comfort measures. Pain management strategies— combination of Pharmacologic measures Nonpharmacologic measures General comfort measures such as verbal reassurance, listening, reducing stimuli (e.g., dimming lights), and developing a trusting relationship with the patient and caregiver should be provided to all patients in the ED. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Secondary Survey History and head-to-toe assessment Obtain history of event, illness, injury from patient, family, and emergency personnel. Perform head-to-toe assessment to obtain information about all other body systems. Details of the incident are extremely important because the mechanism of injury and injury patterns can predict specific injuries. For example, a restrained front-seat passenger may have a head injury or knee, femur, or hip fracture from hitting the dashboard, and an abdominal injury caused by the seat belt. The history should include the following questions: 1. What is the chief complaint? What caused the patient to seek attention? 2. What are the patient’s subjective complaints? 3. What is the patient’s description of pain (e.g., location, duration, quality, character)? 4. What are witnesses’ (if any) descriptions of the patient’s behavior since the onset? 5. What is the patient’s health history? The mnemonic AMPLE is a memory aid that prompts you to ask about the following: A: Allergies to drugs, food, environment M: Medication history P: Past health history (e.g., preexisting medical and/or psychiatric conditions, previous hospitalizations/surgeries, smoking history, recent use of drugs/alcohol, tetanus immunization, last menstrual period, baseline mental status) L: Last meal E: Events/environment leading to the illness or injury Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Secondary Survey Inspect the posterior surfaces. Logroll patient (while maintaining cervical spine immobilization) to inspect the posterior surfaces. Inspect the back for ecchymosis, abrasions, puncture wounds, cuts, and obvious deformities. Palpate the entire spine for misalignment, deformity, and pain. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Secondary Survey Evaluate need for tetanus prophylaxis. Provide ongoing monitoring, and evaluate patient’s response to interventions. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Secondary Survey Prepare to Transport for diagnostic tests (e.g., x-ray) Admit to general unit, telemetry, or intensive care unit Transfer to another facility The nurse may accompany critically ill patients on transports. The nurse is responsible for monitoring the patient during transport, notifying the health care team should the patient’s condition become unstable, and initiating basic and advanced life-support measures as needed. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Death in the Emergency Department
Must recognize importance of hospital rituals in preparing the bereaved to grieve (e.g., collecting belongings, viewing the body) These can include collecting the belongings, arranging for an autopsy, viewing the body, and making mortuary arrangements. Whenever possible, provide an area for privacy, and, if appropriate, arrange for a visit from a chaplain. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Death in the Emergency Department
Determine if patient could be candidate for non–heart beating donation. Tissues and organs (e.g., corneas, heart valves, skin, bone, kidneys) can be harvested from patient after death. Approaching caregivers about donation after an unexpected death is distressing to both the staff and the caregivers. For many, however, the act of donation may be the first positive step in the grieving process. Organ procurement organizations (OPOs) are available to assist in the process of screening potential donors, counseling donor families, obtaining informed consent, and harvesting organs from patients who are on life support or who die in the ED. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Gerontologic Considerations: Emergency Care
Elderly are at high risk for injury—primarily from falls. Important to determine whether physical findings may have caused fall or may be due to fall Causes Generalized weakness Environmental hazards Orthostatic hypotension Of the injury-related admissions for people ≥65 years old, most involve fractures, with many of these resulting from falls. The three most common causes of falls in the elderly are generalized weakness, environmental hazards (e.g., loose mats, furniture), and orthostatic hypotension (e.g., side effect of medications, dehydration). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Heat Exhaustion Prolonged exposure to heat over hours or days Leads to heat exhaustion This occurs when thermoregulatory mechanisms such as sweating, vasodilation, and increased respirations cannot compensate for exposure to increased ambient temperatures. Strenuous activities in hot or humid environments, clothing that interferes with perspiration, high fevers, and preexisting illnesses predispose individuals to heat stress. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Heat Exhaustion Clinical syndrome characterized by Fatigue Light-headedness Nausea/vomiting Diarrhea Feelings of impending doom Tachypnea Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Heat Exhaustion Clinical syndrome characterized by (cont’d) Tachycardia Dilated pupils Mild confusion Ashen color Profuse diaphoresis Hypotension and mild to severe temperature elevation (99.6º to 104º F [37.5º to 40º C]) due to dehydration Heat exhaustion usually occurs in individuals engaged in strenuous activity in hot, humid weather, but it also occurs in sedentary individuals. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Heat Exhaustion Place patient in cool area and remove constrictive clothing. Place moist sheet over patient to decrease core temperature. Provide oral fluid. Replace electrolytes. Initiate normal saline IV solution if oral solutions are not tolerated. Monitor the patient for ABCs, including cardiac dysrhythmias (due to electrolyte imbalances). Salt tablets are not used because of potential gastric irritation and hypernatremia. Consider hospital admission for the elderly, the chronically ill, and those who do not improve within 3 to 4 hours. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Heat Exhaustion vs. Heat Stroke

Seniors Elderly have decreased ability to perspire, less subq tissue, as well as decreased ability to vasodilate, decreased thirst mechanism, diminished ability to concentrate urine, may not drink enough water Tend to keep windows closed

Heatstroke Failure of the hypothalamic thermoregulatory processes Vasodilation, increased sweating, and respiratory rate deplete fluids and electrolytes, specifically sodium. Sweat glands stop functioning, and core temperature increases (>104º F [40º C]). Heatstroke is the most serious form of heat stress. The patient has core temperature greater than 104° F (40° C), altered mentation, absence of perspiration, and circulatory collapse. The skin is hot, dry, and ashen. Cerebral edema and hemorrhage may occur as a result of direct thermal injury to the brain and decreased cerebral blood flow. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Heatstroke Treatment: stabilize patient’s ABCs and rapidly reduce temperature Cooling methods Remove clothing. Cover with wet sheets. Place patient in front of large fan. Immerse in ice water bath. Administer cool fluids or lavage with cool fluids. Administration of 100% O2 compensates for the patient’s hypermetabolic state. Ventilation with a BVM or intubation and mechanical ventilation may be required. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Heatstroke Shivering: increases core temperature, complicates cooling efforts Aggressive temperature reduction until core temperature reaches 102º F (38.9º C) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Heatstroke Monitor for signs of rhabdomyolysis, myoglobinuria, and disseminated intravascular coagulation. The muscle breakdown leads to myoglobinuria, which places the kidneys at risk for acute failure. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hypothermia Core temperature <95º F (<35º C) Risk factors Elderly Certain drugs Alcohol Diabetes Core temperature <86º F (30º C) is potentially life-threatening. Wet clothing increases evaporative heat loss to 5 times greater than normal; immersion in cold water (e.g., near drowning) increases evaporative heat loss to 25 times greater than normal. Hypothermia mimics cerebral or metabolic disturbances causing ataxia, confusion, and withdrawal, so the patient may be misdiagnosed. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hypothermia Mild hypothermia (93.2º to 96.8º F [34º to 36º C]) Shivering Lethargy Confusion Rational to irrational behavior Minor heart rate changes Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hypothermia Moderate hypothermia (86º to 93.2º F [30º to 34º C]) Rigidity Bradycardia, bradypnea Blood pressure by Doppler Metabolic and respiratory acidosis Hypovolemia Shivering disappears at temperature 86º F (30º C). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hypothermia Severe hypothermia (<86º F [30º C]) makes the person appear dead. Bradycardia Asystole Ventricular fibrillation Metabolic rate, heart rate, and respirations are so slow that they may be difficult to detect. Reflexes are absent and pupils fixed and dilated. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hypothermia Warm patient to at least 90º F (32.2º C) before pronouncing dead. Cause of death—refractory ventricular fibrillation Treatment of hypothermia Manage and maintain ABCs. Rewarm patient. Correct dehydration and acidosis. Treat cardiac dysrhythmias. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hypothermia Mild hypothermia: passive or active external rewarming Passive external rewarming: Move patient to warm, dry place; remove damp clothing; place warm blankets on patient. Active external rewarming: body-to-body contact, fluid- or air-filled warming blankets, radiant heat lamps Gentle handling is essential to prevent stimulation of the cold myocardium. Closely monitor the patient for marked vasodilation and hypotension during rewarming. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hypothermia Moderate to severe hypothermia: active core rewarming Use of heated, humidified oxygen Warmed IV fluids Peritoneal, gastric, or colonic lavage with warmed fluids Consider cardiopulmonary bypass or continuous arteriovenous rewarming in severe hypothermia. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Hypothermia Risks of rewarming Afterdrop, a further drop in core temperature Hypotension Dysrhythmias Rewarming should be discontinued once the core temperature reaches 95º F (35º C). Afterdrop occurs when cold peripheral blood returns to the central circulation. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Submersion Injury Drowning: death from suffocation after submersion in fluid Immersion syndrome occurs with immersion in cold water, which leads to stimulation of the vagus nerve and potentially fatal dysrhythmias. Near-drowning: survival from potential drowning Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Pathophysiology of Submersion Injury
Fig Pathophysiology of submersion injury. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 49

Near drowning Delayed pulmonary edema
All victims of near drowning should be observed for 4-6 hours

Submersion Injury Treatment of submersion injuries Correct hypoxia. Correct acid-base and fluid imbalances. Support basic physiologic functions. Rewarm if hypothermia is present. Table lists other interventions. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Submersion Injury Initial evaluation: ABCD Mechanical ventilation with PEEP or CPAP to improve gas exchange when pulmonary edema is present Ventilation and oxygenation are the primary techniques for treating respiratory failure. Mannitol (Osmitrol) or furosemide (Lasix) is used to decrease free water and treat cerebral edema. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Submersion Injury Deterioration in neurologic status: cerebral edema, worsening hypoxia, profound acidosis Observe for minimum of 4 to 6 hours. Secondary drowning is a concern with patients who are essentially symptom-free. Near-drowning victims may also have head and neck injuries that cause prolonged alterations in level of consciousness. Complications can develop in patients who are essentially free of symptoms immediately after the near-drowning episode. This secondary drowning refers to delayed death from drowning due to pulmonary complications. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Animal Bites Children at greatest risk Animal bites from dogs and cats are most common, followed by bites from wild or domestic rodents. Complications Infection Mechanical destruction of skin, muscle, tendons, blood vessels, bone Every year, more than 5 million animal bites are reported in the United States. The most significant problems associated with animal bites are infection and mechanical destruction of the skin, muscle, tendons, blood vessels, and bone. The bite may cause a simple laceration or may be associated with crush injury, puncture wound, or tearing of multiple layers of tissue. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Animal and Human Bites Initial treatment: clean with copious irrigation, debridement, tetanus prophylaxis, and analgesics Prophylactic antibiotics for bites at risk for infection Wounds over joints Wounds less than 6 to 12 hours old Puncture wounds Bites on hand or foot Individuals at greatest risk of infection are infants, older adults, immunosuppressed patients, alcoholics, diabetic individuals, and those taking corticosteroids. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Animal and Human Bites Puncture wounds left open Lacerations loosely sutured Wounds over joints splinted The patient is admitted for IV antibiotic therapy when an infection is present. Incidence of cellulitis, osteomyelitis, and septic arthritis is increased in these patients. Report animal and human bites to the police as required. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Animal and Human Bites Rabies prophylaxis essential in management of animal bites Initial injection: rabies immune globulin Series of five injections of human diploid cell vaccine: days 0, 3, 7, 14, and 28 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Poisonings Chemicals that harm the body accidentally, occupationally, recreationally, or intentionally Severity depends on type, concentration, and route of exposure. More than 5 million cases of human poisonings occur each year in the United States. Poisonings can be accidental, occupational, recreational, or intentional. Natural or manufactured toxins can be ingested, inhaled, injected, splashed in the eye, or absorbed through the skin. Table presents common poisons. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Poisonings Management Decrease absorption (lavage, charcoal). Enhance elimination. Implement toxin-specific interventions per poison control center (antidotes). Options for decreasing absorption of poisons include activated charcoal, dermal cleansing, eye irrigation, and, less frequently, gastric lavage. Administration of cathartics, whole-bowel irrigation, hemodialysis, urine alkalinization, chelating agents, and antidotes promote the elimination of poisons. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Poisonings Decreasing absorption Gastric lavage Intubate before lavage if altered level of consciousness or diminished gag reflex Perform lavage within 2 hours of ingestion of most poisons. Contraindicated Caustic agents Co-ingested sharp objects Ingested nontoxic substances Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Poisonings Activated charcoal Most effective intervention: administer orally or via gastric tube within 60 minutes of poison ingestion Contraindications Diminished bowel sounds Paralytic ileus Ingestion of substance poorly absorbed by charcoal Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Poisonings Activated charcoal Charcoal can absorb and neutralize antidotes: do not give immediately before, with, or shortly after charcoal Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Poisonings Hemodialysis/hemoperfusion Reserved for severe acidosis Urine alkalinization Chelating agents Antidotes Hemodialysis is reserved for patients who develop severe acidosis from ingestion of toxic substances (e.g., aspirin). Sodium bicarbonate administration raises the pH (>7.5), which is particularly effective for phenobarbital and salicylate poisoning. Vitamin C is added to IV fluids to enhance excretion of amphetamines and quinidine. Chelation therapy is considered for heavy metal poisoning (e.g., edetate calcium disodium [Calcium EDTA] for lead poisoning). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Poisonings Enhance elimination. Cathartics (e.g., sorbitol) Give with first dose of charcoal to stimulate intestinal motility/increase elimination. Whole-bowel irrigation Whole-bowel irrigation can be effective for swallowed objects such as cocaine-filled balloons or condoms, and heavy metals such as lead and mercury. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Suicide attempts Must be evaluated by mental health provider
Screening tool exists to identify those at risk for suicide and/or repeat attempts

Violence Acting out of emotions (e.g., fear or anger) to cause harm to someone or something Organic disease Psychosis Antisocial behavior The patient cared for in the ED may be the victim of violence or the perpetrator of violence. Violence can take place in a variety of settings, including the home, community, and workplace. EDs have been identified as high-risk areas for workplace violence. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Family and Intimate Partner Violence
Pattern of coercive behavior in a relationship; involves fear, humiliation, intimidation, neglect, and/or intentional physical, emotional, financial, or sexual injury The ENA encourages ED nurses to become certified sexual assault nurse examiners (SANE). The SANE nurse provides expert emergency care, collects and documents evidence, participates in staff and community education, and advocates for sexual assault and rape victims. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Family and Intimate Partner Violence
Screening for domestic violence is required in ED. Appropriate interventions Make referrals. Provide emotional support. Inform victims about options. Barriers to conducting effective screening include limited privacy for screening, lack of time, and lack of knowledge about how to obtain information regarding family and IPV. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Domestic Violence *Intimate partner violence including sexual assault
*Nurse stays with client *Written consent to collect evidence including photos *Police report patient decision *Children and vulnerable adults exception (mandatory reporting)

Sexual assault Crisis intervention begins immediately
Patient is seen immediately Collection of forensic evidence Specially trained nurses; sexual assault nurse examiner (SANE) Patients reaction to rape; rape trauma syndrome

Terrorism Involves overt actions for the expressed purpose of causing harm Disease pathogens (e.g., bioterrorism) Chemical agents Radiologic/nuclear, explosive devices Table summarizes general information regarding biologic agents of terrorism. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Bioterrorism Anthrax, plague, and tularemia: treated with antibiotics, assuming sufficient supplies and nonresistant organisms Smallpox can be prevented or ameliorated by vaccination even when first given after exposure. Agents most likely to be used in a terrorist attack are anthrax, smallpox, botulism, plague, tularemia, and hemorrhagic fever. Botulism is treated with antitoxin. No treatment has been established for most viruses that cause hemorrhagic fever. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Chemical Agents of Terrorism
Categorized by target organ or effect Sarin: toxic nerve gas that can cause death within minutes of exposure Enters body through eyes and skin Acts by paralyzing respiratory muscles Antidotes for nerve agents: atropine, pralidoxime chloride See Table for more information. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Chemical Agents of Terrorism
Phosgene: colorless gas normally used in chemical manufacturing If inhaled at high concentrations for long enough period, causes severe respiratory distress, pulmonary edema, and death Mustard gas: yellow to brown in color with garlic-like odor Irritates eyes and causes skin burns/blisters Protocols to treat victims of chemical exposure vary according to the specific agent. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Radiologic/Nuclear Agents of Terrorism
Radiologic dispersal devices (RRDs) (“dirty bombs”): mix of explosives and radioactive material When detonated, blast scatters radioactive dust, smoke, and other material into environment, resulting in radioactive contamination. Main danger from RRDs: explosion Radioactive materials used in an RRD (e.g., uranium, iodine-131) do not usually generate enough radiation to cause immediate serious illness, except for those victims who are in close proximity to the explosion. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Radiologic/Nuclear Agents of Terrorism
Ionizing radiation (e.g., nuclear bomb, damage to a nuclear reactor): serious threat to safety of casualties and environment Exposure may or may not include skin contamination with radioactive material. Initiate decontamination procedures immediately if external radioactive contaminants are present. Acute radiation syndrome develops after substantial exposure to ionizing radiation and follows a predictable pattern. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Explosive Devices as Agents of Terrorism
Result in one or more of following types of injuries: blast, crush, or penetrating Blast injuries from supersonic overpressurization shock wave that results from explosion Damage to the lungs, middle ear, gastrointestinal tract Crush injuries (i.e., blunt trauma) often result from explosions that occur in confined spaces as the result of structural collapse (e.g., falling debris). Some explosive devices contain materials that are projected during the explosion (e.g., shrapnel), leading to penetrating injuries. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Emergency and Mass Casualty Incident Preparedness
Mass casualty incident (MCI) Manmade or natural event or disaster that overwhelms community’s ability to respond with existing resources MCIs usually involve large numbers of victims, physical and emotional suffering, and permanent changes within a community. In addition, MCIs always require assistance from people and resources outside the affected community (e.g., American Red Cross, Federal Emergency Management Agency [FEMA]). {See next slide for figure.} Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Do the greatest good for the greatest number. Maximize survival.
Daily Emergencies Do the best for each individual. Disaster Settings Do the greatest good for the greatest number. Maximize survival.

Military vs. Civilian Triage
Military model Those with the least serious wounds may be the first treatment priority Civilian model (Mass casualty, disaster) Those with the most serious but realistically salvageable injuries are treated first

Military vs. Civilian Triage
In both models, victims with clearly lethal injuries or those who are unlikely to survive even with extensive resource application are treated as the lowest priority.

Why triage in a crisis/disaster?
Way to find organization in the in the midst of chaos Helps to get care to those who need it and will benefit from it the most Helps in resource allocation Provides an objective framework for stressful and emotional decisions

When an emergency or MCI occurs, first responders (e.g., police, emergency medical personnel) are dispatched. Triage of casualties differs from usual ED triage and is conducted in <15 seconds. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

System of colored tags designates both seriousness of injury and likelihood of survival. Green (minor injury) or yellow (non–life-threatening injury) tag indicates noncritical injury. Red tag indicates life-threatening injury. Blue tag indicates those who are expected to die. Black tag identifies the dead. This slide is one example of a system used in MCI. Triage of victims of an emergency or MCI must be rapid and conducted in less than 15 seconds. In general, two thirds of victims will be tagged green or yellow, and the remaining will be tagged red, blue, or black. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Green Minor injuries that can wait for longer periods of time for treatment Minor lacerations, contusions, sprains, superficial burns, partial-thickness burns of < 20% BSA

Yellow Potentially serious injuries, but are stable enough to wait a short time for medical treatment Open thoracic wound, penetrating abdominal wound, severe eye injury, avascular limb, fractures, significant burns other than face, neck or perineum

RED Life-threatening but treatable injuries requiring rapid medical attention Airway obstruction, cardio-respiratory failure, significant external hemorrhage, shock, sucking chest wound, burns of face or neck

Black Dead or still with life signs but injuries are incompatible with survival in austere conditions Head injury with GCS<8, burns >85% BSA, multisystem trauma, signs of impending death

Total number of casualties a hospital can expect is estimated by doubling number of casualties that arrive in first hour. Generally, 30% will require admission to hospital, and half of these will need surgery within 8 hours. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Critical incident stress debriefing
Promote effective coping strategies to avoid PTSD or professional burn out Group leader encourages group discussion by asking a series of questions designed to make everyone involved tell his or her own story and explain the personal impact. Helps place incident in perspective and dispel any feelings of blame or guilt

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