02-07-2025 Emergency and Disaster Nursing

As discussed by Mr. Jake Roger

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Emergency and Disaster Concepts

A disaster is determined by three criteria: (a) a force that overwhelms the community, (b) services and functions of the community are impaired, and (c) outside assistance is required. There are two types:

1. Natural Disaster: disasters produced by acts of nature, such as epidemics, typhoons, etc.
2. Man-made Disaster: disasters produced by acts of man, such as terrorism or global warming.

Disaster Management

1. Mitigation: long-term preparation to disasters, lasting for years to come. An example of mitigation is the legislation regarding disaster management such as laws addressing risk factors of disasters.
2. Preparedness: short-term preparation in the face of impending disaster. An example of mitigation is evacuation, fire drills, earthquake drills, and other training.
3. Response: activities done during and immediately after the disaster. This includes activities such as search and rescue, relief operations, etc.
4. Recovery: the phase where the community returns to its pre-disaster state, including activities such as rehabilitative services and re-construction of damaged infrastructure.

Legal Bases for Disaster Management

1. P.D. 1566: Disaster Response Law, discussing what to do during a disaster.
2. R.A. 10121: Risk Reduction Law, discussing what to do to prevent a disaster.
3. R.A. 7160: Local Government Code, discussing the responsibilities of LGUs during a disaster.

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Emergency Response

1. The first step to an emergency response is to Activate the Plan. The “plan” refers to a multitude of different protocols and procedures used for different emergency scenarios.
2. Next, prepare the team and equipment, also fit to the scenario.
3. Go to the scene.
4. Upon arriving at the scene, perform a scene survey to ensure that the scene is safe for rescue operations. This is the golden rule of rescue: the safety of the rescuers is always the top priority. The rescuer is of no use if they also become a victim.
   • Once the scene is considered safe, a member of the team exclaims “Scene is safe!”
5. Upon clearance, the triage team enters first (Triage Systems). They prioritize the victims for equitable distribution of rescue efforts, following the doctrine of utilitarianism— the greatest good or the greatest number.

Triage Systems

1. Military Triage: the oldest method of triage.

Category	Description
Emergent	Patients who require medical attention immediately.
Urgent	Patients who are able to wait for 12 to 24 hours.
Non-urgent	Patients who are able to wait for days or weeks.

2. North Atlantic Treaty Organization (NATO) Triage

Category	Description
Minimal	Minor injuries.
Delayed	Serious but not life-threatening.
Immediate	Life-threatening.
Expectant	Less likely to survive. This includes patients with cardiac arrest and respiratory arrest in cases of disaster due to the requisite efforts to perform resuscitation.

3. Simple Triage and Rapid Treatment (START) Protocol:
   1. Start with the victim nearest to you upon entering the scene.
   2. Determine the victim’s ability to walk. If they are able to, tag them as green and assist them to the treatment.
   3. Otherwise, determine if the victim is breathing. If the victim is not breathing, reposition the patient and open the airway (via jaw thrust).
      • If they continue to fail to breathe, tag them as black.
      • If they resume breathing, tag them as red.
   4. If the victim is breathing, assess the respiratory rate. The normal emergency respiratory rate is 12 to 30 RPM. Beyond this, the patient is tagged as red.
   5. If respirations are normal, proceed to assessing circulation. This is done by (a) checking the pulse, and more importantly, (b) capillary refill time that should be 2 seconds or shorter. If abnormal, tag the victim red.
   6. If circulation is normal, assess the level of consciousness. If they are disoriented or confused, tag the victim as red.
   7. If the level of consciousness is normal, tag the victim as yellow.

Category	Description
Green; Walking Wounded	Victims that are able to walk on their own.
Yellow	Coherent but unable to walk.
Red	Patients whose breathing is dependent on position or airway assistance, abnormal respiratory rate, abnormal perfusion, or abnormal LOC.
Expectant	Respiratory or cardiac arrest

4. Emergency Severity Index (ESI): a method of triage done in the emergency room when many victims arrive from a disaster. It also employs an algorithm:
   1. Assess the patient immediately if they are in need of life-saving interventions. If they require such interventions, they are classified as ESI Level 1.
   2. Otherwise, assess the patient if any of the following are present: (a) high clinical symptoms such as difficulty of breathing, (b) altered level of consciousness, and (c) in severe distress.
   3. If none of these are present, assess the patient for the number of resources required by the patient. These include the requirement of IV lines, catheters, bandages, etc.
      • If the patient requires multiple resources, assess for danger zone vitals: PR >100 BPM, RR >20 BPM, or an Oxygen Saturation of <92%. If these are present, Categorize the patient as ESI Level 2.
      • If the patient requires multiple resources but no danger zone vitals were present, categorize the patient as ESI Level 3.
      • If the patient requires only one resource for treatment, categorize the patient as ESI Level 4.
      • If the patient requires no resources for treatment, categorize the patient as ESI Level 5. t

Category	Description
ESI Level 1	Patients who require life-saving interventions.
ESI Level 2	Patients who exhibit any of (a) high clinical symptoms, (b) altered LOC, (c) severe distress, or (d) danger zone vitals.
ESI Level 3	Patients who require many resources for management but does not have any danger zone vitals.
ESI Level 4	Patients who only require one resource for treatment.
ESI Level 5	Patients who do not require any resources for treatment.

5. Reverse Triage: an inversion; prioritization of identifying the minimal cases rather than the immediate/emergent ones. This is done to efficiently remove cases that do not require emergent care to free up hospital bed space, and to leave behind the cases that are life-threatening.

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Concepts of Primary and Secondary Surveys

Trauma Assessment (DCAPBTLS)

1. Deformity: a displacement of a body part from its normal anatomical location.
2. Contusion: bruising, a bluish/purple discoloration as a result of blunt trauma.
3. Abrasions: superficial scratching of the skin.
4. Punctures or Penetrating Wounds: wounds that break the skin barrier.
5. Burns
6. Tenderness: areas with pain upon palpation.
7. Lacerations: irregular tears on the skin.
8. Swelling

SAMPLE History

1. Signs and Symptoms: ask the patient their chief complaints.
2. Allergies
3. Medications: which medications the patient is taking.
4. Pertinent Medical History
5. Last Oral Intake: foods and drinks that were recently consumed.
6. Events That Led to Status: what were the events that caused their chief complaint to appear?

Glasgow Coma Scale

A method for comprehensive level of consciousness assessment, scoring the patient from a maximum of 15 to a minimum of 3. The patients are scored based on their best performance in each category.

Category	Responses	Score
Eye Opening Response	Spontaneous eye opening	4
	To verbal command	3
	To pain (noxious stimuli)	2
	No response	1
Verbal Response	Oriented (time, person, place)	5
	Confused	4
	Inappropriate Words	3
	Incomprehensible Sound	2
	No response	1
Motor Response	Obeys command to perform basic movements	6
	Localizes pain; able to point to where pain is present	5
	Withdraws from pain	4
	Flexion (Decorticate posturing)	3
	Extension (Decerebrate posturing)	2
	No response	1

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First Aid and Emergency Room Management

CPR-requiring Conditions

These are conditions that require CPR such as cardiac arrest, arrhythmias, or dysrhythmias.

1. Check for Unresponsiveness: on the field, check by calling out “Are you okay?“. In the hospital, using the patient’s name is preferred as they are more likely to respond. If unresponsive, proceed
2. Check for breathing and pulse: for breathing, check for the rise and fall of the chest. For pulse, check the carotid pulse for adults, and the brachial pulse for infants.
3. If the patient does not have a pulse and is not breathing, (1) call for help (Activate Emergency Medical Services) and (2) perform chest compressions with rescue breathing.

High Quality CPR

1. Begin chest compressions. The prioritization for CPR is C-A-B, circulation, airway, breathing. The compression-breath ratio is 30:2 for all cases except for if there are two rescuers and the patient is an infant.
2. The minimum number of cycles of compressions and breathing is five cycles, done at a rate of 100 to 120 BPM, often to the tempo of the song “Stayin’ Alive”.
3. Hand placement is focused on the lower half of the sternum.

• For infants, the two-finger technique may be used to avoid injury.

4. Compression depth is:

• For adults, at least 2 inches, not more than 2.4 inches to avoid injury.
• For children, at least a third of the chest or 2 inches.
• For infants, at least a third of the chest or 1.5 inches.

5. Patient Position: the patient must be flat on a hard surface. CPR is ineffective on soft surfaces.

Epinephrine is the drug of choice for cardiac arrest.

Hemorrhage (Massive Bleeding)

Hemorrhaging may be internal or external. For identification, patients may be checked for signs and symptoms:

• Shock triad (hypotension, tachycardia, tachypnea). Hypotension is a result of blood loss, while tachycardia and tachypnea are compensatory mechanisms in order to attempt to maintain perfusion.
• Discoloration: pallor occurs from decreased blood volume.
• Lowered level of consciousness from decreased cerebral perfusion.
• Weak thready pulse from decreased blood volume.

For first aid,

1. Locate the sites of bleeding. Assess all areas of the body that may be bleeding.
2. Apply direct pressure. This is the gold standard as the initial action or bleeding. If bleeding persists, apply pressure on the proximal arteries.
3. Place the patient on a modified trendelenburg position (Shock position). This shifts blood flow from the legs to the vital organs, and the modification used to reduce pressure on the diaphragm. It is a position where the patient lies flat on the bed with the legs elevated.
4. Monitor for hypovolemic shock. Transport the patient to the nearest hospital once bleeding has been managed.

Epistaxis

In case of nose bleeding, the principle still applies: apply direct pressure on the nose bridge. The patient is positioned upright with the neck flexed, or leaning forward. A cold compress can be used for vasoconstriction to reduce bleeding.

In The Emergency Room

The patient in the hospital will:

1. Receive Oxygen Therapy
2. Receive Fluid Resuscitation/Fluid Volume Replacement with IV Fluids, best with NSS.
3. Receive Blood Transfusion. Blood type O is used in emergency cases as the universal donor.
4. Blood vessel repairs are performed by surgeons once managed.

Fractures

Signs and Symptoms:

1. Deformity is the classical sign of a fracture.
2. Pain of the acute, sharp type
3. Swelling
4. Crepitus: the sound of two bones grinding against each other.
5. Pulselessness may occur as the fractured bone damages or obstructs the blood supply. Assess distal pulses in order to avoid prolonged hypoxia.

First aid of fractures focuses on immobilization. There are no manipulations that should be done on the field as this results in more tissue damage.

1. Gold Standard: Immobilize with bandages and/or splints.
   • The only exemption to this gold standard is if the affected extremity is pulseless. Re-establishing circulation is a higher priority than further tissue damage.
2. Apply cold compress to reduce inflammation and pain. This is only used for 30 minutes, after which it becomes less effective.
3. Elevate the affected limb to reduce swelling.
4. Transport the victim.

In The Emergency Room

1. Administer analgesics. The patient with a fracture’s chief complaint is pain.
2. Continue Immobilization via cast or traction.
3. Repair the fracture

Foreign Body Airway Obstruction

Otherwise known as choking. This is most commonly caused by food in adults and small toys in children (Lego bricks, coins, marbles, etc.)

1. The universal sign of chocking is a patient who is clutching their neck.
2. Difficulty of breathing
3. Sound production will vary depending on the degree of blockage of the airway. In patients whose airways are only partially blocked, they may still produce noises or talk. If there is full blockage, the patient will produce no sound.
4. Restlessness
5. Stridor, a harsh, rough sound that appears during inhalation.
6. Color changes: initially pallor, then redness from pressure, then cyanosis.
7. Decreasing LOC as choking becomes prolonged.

First aid is not immediately applied. Most cases (80%) of FBAO resolves independently; first, ask the patient if they require help. If help is required:

1. Ask the patient to cough forcefully.
2. If the patient is unable to cough the obstruction out, perform the heimlich maneuver.
3. If the patient is unconscious, the heimlich maneuver may be performed while side-lying.
4. If the patient is unconscious, the abdominal/chest thrust may be used.
5. Once the foreign body has been dislodged (evidenced by the sound of air escaping the body in a pop-ish sound), assess for the foreign body and remove it with the finger sweep technique.
6. Once recovering, the patient is placed on the recovery position (side-lying), and the patient is transported to the hospital.

In The Emergency Room

If the obstruction has not been removed and the patient has been brought to the emergency room, a tracheostomy is immediately performed, followed by oxygenation.

1. Once an airway and oxygen has been established, the patient is scheduled for endoscopic extraction of the foreign body.

Anaphylaxis

A severe hypersensitivity reaction that results in airway closure. Its classical characteristics is bronchoconstriction. Without bronchoconstriction, reactions are not yet anaphylactic in nature.

The first step to first aid is to remove the allergen causing bronchoconstriction, or to remove the patient from the environment containing the allergen.

1. Check if the patient has emergency medications on hand, such as EpiPens.
2. Open the airway by positioning the patient at any position that opens the airway.
3. Improve breathing by removing constrictive clothing such as belts, brassieres, chokers, neck ties, bow ties, buttoned shirts, etc.
4. Transport the patient to the nearest hospital.

In The Emergency Room

1. Administer epinephrine, the drug of choice. It acts for both bronchodilation to reverse the effects of anaphylaxis and vasoconstriction to reduce swelling.
2. Administer oxygen
3. Administer antihistamines. These types of drugs often produce drowsiness, with the notable exception of Alerta, a non-drowsy antihistamine.

Hyperventilation

Deep rapid breathing is a respiratory pattern that excessively excretes carbon dioxide, which results in respiratory alkalosis. It may be caused by many factors, the most common of which includes:

• Acute asthmatic attack
• Anxiety
• Pain

First aid attempts to first correct the acid-base imbalance by (a) reducing hyperventilation and to promote re-breathing of carbon dioxide to return balance.

1. Ask the victim to calm down.
2. Ask the victim to breathe with you.
3. Provide a paper bag for the hyperventilating client to breathe into and out of. If this is unavailable, cupped hands can also suffice. A plastic bag is not used for this purpose; it lacks the porosity of a paper bag.
4. Transport the victim to the nearest hospital.

In The Emergency Room

1. Administer oxygen with a rebreather mask. This functions the same way a paper bag helps.
2. Address the cause, whether anxiety, pain, or an asthmatic attack.

Snake Bites

Snake bites may come from two types of snakes:

1. Venomous: snakes that instill venom upon biting.
2. Non-venomous: snakes that do not transfer venom upon biting.

Parameter	Venomous	Non-venomous
Head Shape	Diamond/Triangular	Rounded
Eye Shape	Elliptical-shaped, slit-like pupils	Rounded
Bite Shape	Fang markes	Rounded

First aid protocols involve capturing the snake that was involved (if possible) and reduction of the spread of venom:

1. Never suck the venom out of the wound. This is ineffective and also poses risk.
2. Capture the snake if possible for identification of the snake and venom.
3. Remain calm. Anxiety will increase heart rate, which circulates venom faster.
4. Remain still. Movement promotes circulation.
5. Wash the bite immediately with water. This applies to any and all animal bites.
6. Do not use a tourniquet. Concentration of the venom in the affected limb will increase the risk of amputation. While the DOH has changed their guidelines to this, the WHO has not.
7. Transport the patient to the nearest hospital.

In The Emergency Room

1. Administer the appropriate antivenin. This is a compound produced from the same venom identified to have been received by the patient. As such, it requires a skin test prior to administration, and also requires dilution in NSS prior to administration.

Stings

1. Bee Stings: a bee sting will leave its stinger on the skin. Pulling, squeezing, or other manipulations may cause this toxin to enter the body. The only proper method for removal is by scraping it off with something like a card. Anaphylaxis may occur. Refer to Anaphylaxis.
2. Stingray Stings: wash the area with warm water.
3. Jellyfish Stings: wash the area with acetic acid or vinegar.

Burns

Burns.

1. Thermal Burns: exposure to high temperatures, the most common form of burning.
2. Chemical Burns: exposure to highly acidic or highly alkaline substances.
3. Electrical Burns: exposure to electricity, the most lethal form of burning.
4. Radiation Burns: exposure to UV or gamma radiation.

Based on the extent of injury, burns may be categorized by degree:

Degree	Depth	Manifestations	Pain Level	Wound Healing
First Degree (Superficial)	Epidermis; Surface-level	Desquamation (unique)	Mild to moderate	5 to 7 days
Second Degree	Dermis; Partial Thickness	Blistering and weeping (unique)	Moderate to Severe	3 to 4 weeks
Third Degree	Beyond the dermis; Full Thickness	Charring	None	None; permanent disfigurement

Stages of Burns

1. Emergent Stage (Fluid Accumulation Stage; first 24-48 hours): the shifting of fluid from the intravascular space to the interstitial spaces.
   • This is the cause of hypovolemia, tachycardia, and weak pulses.
   • Fluid also includes sodium, which means hyponatremia occurs.
   • In cellular injury, the intracellular potassium leaks out, which produces hyperkalemia.
2. Acute Stage (Fluid Remobilization Stage; Diuretic Stage; 3 to 4 days): the shifting of fluid back from the interstitial spaces to the intravascular space.
   • This presents a problem when the shifted fluid has been replaced, and its return will result in hypervolemia.
   • Urine output will increase, giving this stage its alternate name.
   • Diuresis also involves the excretion of potassium, which results in hypokalemia.
   • Sodium levels become unstable. Both hyper- and hyponatremia can occur.
3. Recovery Stage (5 days+): normalization of the patient’s status.

First Aid

1. Extinguish the fire, if the patient is still actively on fire. Alternatively, “logrolling” the patient can be used to extinguish the patient.
2. If the patient has been extinguished, open the airway.
3. Cool water may be applied over the burns, but not ice. No other substances must be used, even burn ointments.
4. Remove clothing over burns.
5. Cover the wound with wet dressing (wet to avoid adhesion).
6. Transport the patient.

In The Hospital

1. Establish airway. This is always a priority.
2. Administer oxygen.
3. Start fluid replacement. The fluid of choice is Plain Lactate Ringer’s Solution. This is used to stimulate the body with lactic acid in order to stimulate the body to produce bicarbonate for correction of metabolic acidosis.

Parkland Formula

The Parkland Formula may be used to determine the amount of fluid to be infused into the patient. $LR=4\text{ mL}\times \text{TBSA\%}\times \text{Weight (kg)}$ The final volume to be given is divided into three segments in the first 24 hours, 8 hours each.

1. First 8 hours: 50% of the total volume to be given.
2. Next 8 hours: 25% of the total volume to be given.
3. Next 8 hours: 25% of the total volume to be given.

Total Body Surface Area is calculated with the Rule of 9s:

Part of the Body	Adult	Infant
Head	9%	18%
Anterior Trunk	18%	18%
Posterior Trunk	18%	18%
Upper Extremities	9% each	9% each
Lower Extremities	18% each	14% each
Genital	1%	0%

4. Antibiotics are given as prophylaxis. The drug of choice is Mafenide Acetate (Sulfamylon), a topical antibiotic.
5. Administer narcotic analgesics for pain. The drug of choice is Morphine sulfate.
6. Administer tetanus prophylaxis.
7. NGT Insertion may be used to remove gastric acids to avoid the occurrence of Curling’s ulcer.
8. Refer the patient for skin grafting.