DISASTER TRIAGE

NURSING

Cherry Joyce G. Basco, RN, LPT

 TRIAGE NURSING

• “Triage is a process which places the right patient in the right

place at the right time to receive the right level of care” (Rice &
Abel, 1992).
• The word “triage” is derived from the French word trier, which
means, “to sort out or choose.”
• Triage is the process of prioritizing which patients are to be
treated first and is the cornerstone of good disaster management
in terms of judicious use of medical resources.

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Personal abilities that are essential to be an
effective triage officer during a disaster:
1. Clinically experienced
2. Good judgment and leadership
3. Calm and cool under stress
4. Decisive
5. Knowledgeable of available resources
6. Sense of humor
7. Creative problem solver
8. Available
9. Experienced and knowledgeable regarding
anticipated casualties
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Disaster triage - is a general term employed when local EMS
and hospital emergency services are overwhelmed to the point
that immediate care cannot be provided to everyone who
needs it because sufficient resources are not immediately
available.

The terms “multiple casualty/multicausality” and “mass

casualty” triage (both also known as “MCI triage”) are often
used interchangeably with “disaster triage.”

The distinction between “multiple” and “mass” casualties is

principally in the number of victims and the degree of
restriction of resources.
5
• During a disaster, patients are usually
sorted into one of the following
categories:
• 1. Immediate (red)
• 2. Delayed (yellow)
• 3. Minimal or minor (green)
• 4. Deceased (black)

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20XX
 Types of triage
• Triage perform by nurse in the emergency room. It is a routine triage.
• The goal is to identify the sickest patients in order to assess and provide treatment to
1. DAILY them first, before providing treatment to others who are less ill.
TRIAGE • Performed by nurses on a routine basis in the ED, often utilizing a standardized
approach, augmented by clinical judgment. The goal is to identify the sickest patients
to assess and treat them first, before providing treatment to others who are less ill and
whose outcome is unlikely to be affected by a longer wait. The highest intensity of care
is provided to the most seriously ill or injured patients, even if those patients have a
low probability of survival.
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 Types of Triage
2. INCIDENT TRIAGE
• Occurs when the emergency department is stressed by a large number of
patients but is still able to provide care to all victims utilizing existing agency
resources.
• Acute incident or an ongoing medical crisis such as pandemic influenza, but is
still able to provide care to all patients utilizing existing agency resources.
• Additional resources (on-call staff, alternative care areas) may be used, but
disaster plans are not activated and treatment priorities are not changed. The
highest intensity of care is still provided to the most critically ill patients.
• ED delays may be longer than usual, but eventually everyone who presents for
care is attended to.
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 3. DISASTER TRIAGE
• Is employed when local emergency services are overwhelmed to the point that
immediate care cannot be provided everyone who needs it.
• During disaster triage, patients are usually sorted into:
✓ Critical- are those that are life threatening but likely to be amenable to rapid
intervention that does not require an inordinate amount of resources (e.g., upper
airway obstruction).
✓ Urgent- those conditions that are serious and if not treated in a timely manner are
likely to deteriorate to become critical (e.g., compound fracture of a long bone).
✓ Minor- the care required can be provided in a low tech tribute setting and a delay in
treatment would unlikely constitute to a significant deterioration in the victims
condition.
✓ Catastrophic- conditions that have either a very grave prognosis or would require an
amount of resources that are so large they would divert care from others with a much
better prognosis (e.g., cardiac arrest).
During a disaster, patients are usually sorted into one of the following categories:
1. Minimal or minor (green)
2. Delayed (yellow)
3. Immediate (red)
4. Deceased (black)
5. Expectant (gray)
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 Types of triage
4. Tactical Triage
• Is similar to disaster triage, only military mission objectives rather than traditional
civilian guidelines drive the triage and transport decisions.

5. Special Conditions Triage

• Is used when patients present from incidents such as radiation, biological or
chemical contamination.

6. Triage during an epidemic

• Usually use during mass casualty trauma situations (e.g., bioterrorism).
 SPECIAL CONDITIONS DURING TRIAGE

• Incidents involving chemical, biological, or radioactive agents may

be intentional or unintentional (e.g., a truck crash involving the
release of hazardous materials).
• These triage situations require personal protective equipment for all
responders coming into contact with potentially contaminated
patients and decontamination capabilities both in the field and at
receiving facilities.
• During any disaster, triage personnel must ensure that they
themselves do not become victims. One enters the scene for field
triage only when scene safety has been assured. 12
 POPULATION-BASED TRIAGE

➢Main goal of population-based triage is to prevent

secondary illness or injury such as disease transmission
from infectious individuals or foodborne illness from
contaminated or poorly refrigerated supplies.
➢The messages and directions sent during population-based
triage will depend on the type(s) of illness or injury that is
trying to be contained.
➢Depending on the severity, lethality, and/or transmissibility
of the illness or injury being prevented, these events can be
very serious and have a huge impact on a community.
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 SEIRV CLASSIFICATION:
❖Susceptible individuals—those individuals who are unexposed but susceptible.

❖Exposed individuals—susceptible individuals who have been in contact with the

disease and may be infected and incubating but still noncontagious.

❖Infectious individuals—persons who are symptomatic and contagious.

❖Removed individuals—persons who no longer can pass the disease to others

because they have survived and developed immunity or died from the illness.

❖Vaccinated or on prophylactic antibiotics—persons in this group are a critical

resource for the essential workforce
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Susceptible-Exposed-Infectious-Removed-Vaccinated (SEIRV) phase one triage categorization for the entire population
and phase two triage management of these subpopulation groups during a bio-event. *Percentages based on influenza and
severe acute respiratory syndrome outbreak data.

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 PHASES OF DISASTER TRIAGE: (From the field to the hospital)

o Primary Triage: The goal of primary triage is usually to sort patients into five
triage categories:
• Immediate, Delayed, Minimal, Expectant, and Dead.
o Secondary Triage: Additional information about each patient is obtained through a
more thorough physical assessment and history. This is similar to the traditional trauma
secondary survey, in which physiology is reassessed and obvious injuries are identified.
• When secondary triage is done in the field, one of the goals is to determine which
patients have conditions that can be temporarily but effectively treated on-scene using
available personnel and resources and identify those whose immediate needs can be met
only in a hospital setting.
o Tertiary Triage: Hospital personnel determine if the facility can provide appropriate
care or if the patient will require stabilization and transfer to a facility capable of a
higher level of care 16
 In-hospital Triage System for Daily Operations
❑ Typical Data Elements Gathered at ED Triage During Normal Operations

▪ Name
▪ Age
▪ Gender
▪ Chief complaint (CC) History of present illness (HPI)
▪ Mechanism of injury (MOI)
▪ Past medical or surgical history (PM/SHx.)
▪ Allergies to food or medication (Allergies)
▪ Current medications (Meds)
▪ Date of last tetanus immunization (other vaccinations)

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 IN-HOSPITAL TRIAGE SYSTEM FOR DAILY OPERATIONS

▪ Last menstrual period (for females between the ages of 11 and 60) (LMP)
▪ Vital signs: temperature, pulse, blood pressure, respiratory rate, oxygen
saturation (VS)
▪ Level of consciousness (LOC)
▪ Skin vital signs (skin vitals): temperature, color, moisture
▪ Visual inspection for obvious injuries
▪ Height and weight (pediatric patients) (ht./wt.)
▪ Mode of arrival (moa)
▪ Private medical provider (PMD)
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 Three-tier system
❖Emergent signifies a condition that requires treatment immediately or within
15 to 30 minutes.

❖Urgent category is assigned to patients with serious illness or injury that

must be attended to as soon as possible, but for whom a wait of up to 2 hours
would probably not add to morbidity or mortality.

❖Nonurgent status is used for any patient who can wait more than 2 hours to
be seen without the likelihood of deterioration.

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❖In a four-tier system, the Emergent category is usually subcategorized
to identify those conditions that must be treated immediately (STAT or
1A) versus rapidly (within a few minutes, 1B). STAT conditions would
include cardiac arrest, respiratory failure/arrest, airway obstruction,
shock, and seizure. Conditions classified as 1B would include moderate
to severe respiratory distress, cardiac dysrhythmia with adequate blood
pressure, or heavy bleeding without hypotension or tachycardia.
❖In a five-tier system, the Nonurgent category is also subcategorized.
Conditions that are nonacute, but require the technology of the ED to
diagnose or treat, are categorized as nonurgent ED (Class 3). This would
include conditions such as minor lacerations requiring sutures, or minor
musculoskeletal trauma requiring x-rays for diagnosis.

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 Mass Casualty Triage Concept
• Triage is the process of sorting patients into categories based on their level or severity of
illness.
• In the modern healthcare system centered around the hospital, this allows the sickest patient to
gain the immediate attention of the health care provider.
• Triage in mass casualty incidents has a slightly different purpose, and that is to guide the
allocation of limited resources, in a setting where there simply are not enough doctors, nurses,
medical supplies and time to treat or transport most patients.
• Mass casualty triage emerged as a concept during times of war, when triage on the battlefield
was necessary to identify which soldiers needed to be transported out and which soldiers could stay
and return to the fight.
• In the setting of mass casualty incidents in the civilian world (earthquakes, car bus or plane
crashes, floods) triage if the victims at the scene, often by a handful of medical care providers,
ensures that constrained medical resources are directed at achieving the greatest good for the
most number of people. Because of this, the patients that are helped first are the ones deemed
most likely to survive with emergent aid, not the most critically ill. 21
 SALT Triage
❖CDC-sponsored expert panel developed SALT Triage.
❖It is non-proprietary and meets the model uniform core criteria for
mass casualty triage.
❖SALT stands for Sort-Assess-Lifesaving interventions-Treatment/
transport, which describes the steps followed when performing
SALT triage.
❖Once any lifesaving interventions are performed, the responders
should evaluate the patient and prioritize him or her for
treatment and/or transport.
❖Dead: those who are not breathing even after lifesaving
interventions have been attempted.
❖Immediate: those with difficulty breathing, uncontrolled
hemorrhage, absence of peripheral pulses, and/or inability to
follow commands; who are likely to survive given the available
resources. 22
 SALT Triage
❖Expectant: those with difficulty breathing,
uncontrolled hemorrhage, absence of peripheral
pulses, and/or inability to follow commands; who are
unlikely to survive given the available resources.
❖Delayed: those who are alert and follow commands,
have palpable peripheral pulses, no signs of respiratory
distress, and all bleeding is controlled, with injuries or
an illness that in the opinion of the rescuer is more
than minor.
❖Minimal: those who are alert and follow commands,
have palpable peripheral pulses, no signs of respiratory
distress, and all bleeding is controlled, with
injuries/condition that in the opinion of the rescuer are
minor. 23
 SALT TRIAGE

presentation title 20XX 24

SALT triage algorithm

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 START
• SIMPLE TRIAGE AND RAPID TREATMENT (START)
• The five basic parameters assessed with START are:
✓ the ability to walk
✓ the presence or absence of spontaneous respirations
✓ the respiratory rate
✓ an assessment of perfusion
✓ the ability to obey commands.
• These parameters are often referred to as respirations, perfusion, and
mental status (RPM).

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 START METHOD

presentation title 20XX 27

START triage algorithm

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 The Job Of The Triage Officer

The primary responsibility of the triage officer is to ensure

that every victim has been found and triaged. Triage officers
and those responders assigned to perform triage do not
provide immediate treatment other than to provide lifesaving
interventions such as opening airways and trying to control
active bleeding.

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I. In-Hospital Triage Systems
• Utilize a triage system that has between three and five categories.
• The three main categories are:
i. Emergent- signifies a condition that requires treatment
immediately within 15mins.-30mins. (e.g., cardiac arrest, airway
obstruction).
ii. Urgent- utilized for serious illness or injury that must be
attended to but a wait of up to 2 hours would not add to the
morbidity and mortality of the patient.
iii. Non-urgent- is any condition that can wait for more than 2
hours to be seen without the likelihood of deterioration.
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 II. DISASTER TRIAGE SYSTEM

a) Simple Triage and Rapid Treatment System (START) for adults

b) JumpSTART system (for triaging pediatric patients)
c) Start/Save (when the triage process must be over an extended period of time)

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 1. Simple Triage and Rapid Treatment System (START) for adults
❖ A common algorithm that is used with adult pre-hospital triage.
❖ Developed by Newport Beach California, Fire and Marine Department and Hoag
Hospital.
❖ It is based on the person’s ability to respond verbally and ambulate and their
respirations, perfusion, and mental status (RPM). The system works as follows
I. All patients who can walk (walking wounded) are categorized as Delayed (Green)
and are asked to move away from the incident area to a specific location.
II. The next group of patients is assessed quickly (30-60 seconds per patient) by
evaluating RPM: respiration, perfusion and mental status.

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 START Method

This method can help determine what tag color a wounded victim is assigned. START stands for “Simple Triage And Rapid Treatment”. This
particular method is for the adult. It’s very easy to use and quick.

First, you want to look at the wounded individual and ask yourself “what is the wounded victim doing?” Are they able to walk around? OR Are they
unable to walk or move?

If the wounded individual can walk around and move, their breathing, circulation, and mental status are within normal range. Therefore, they are
tagged GREEN.

Walking? GREEN TAG

Unable to move or walk? Check these three things in this order: Breathing, Circulation, and Mental Status/Neuro. The wounded individual
that cannot walk will be tagged either RED, YELLOW, or BLACK.

Breathing?

 Yes, rate is greater than 30: RED TAG

 Yes, rate is less than 30: check circulation
 No, reposition airway:

• Still not breathing: BLACK TAG

• Yes: RED TAG

Circulation? (radial pulse present or less than 2 seconds capillary refill)

• Yes: check mental status

• No: RED TAG
Mental Status? (can they obey your commands?)
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• Yes: YELLOW TAG
• No: RED TAG
 2. JumpSTART

❑ Created to meet the unique needs of assessing children less than 8 years of
age.
❑ Should be used if t5he victim looks like a child and START should be sued
whenever the victim looks like a young adult or older.
❑ The JumpSTART Pediatric MCI Triage Tool is the first objective tool
developed specifically for the triage of children in the multicasualty/disaster
setting.
❑ The objective of JumpSTART are:
✓ To optimize the primary triage of injured children in the MCI setting
✓ To enhance the effectiveness of resources allocation for all MCI victims
✓ To reduce the emotional burden on triage personnel who may have to make
rapid life or death decision about injured children in chaotic circumstances.
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presentation title 20XX 37
 3. START/SAVE Triage for Catastrophic Disasters

❖ The SAVE Triage was developed to direct limited resources to the subgroup of
patients expected to benefit most from their use.
❖ The SAVE assesses survivability of patients with various injuries and on the basis
of relationship between expected benefits and resources consumed.

❖ Two types of area location in START Triage

❖ Expectant area- would require the use of significant medical resources.
❖ Treatment area- would use few resources and would have a reasonable
chance of survival.

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 DISASTER TRIAGE COLOR TAGS
There are four colors and a wounded individual will be tagged one
color based on their health status. The four colors include:
 RED
 YELLOW
 GREEN
 BLACK
To help you keep the meaning of the tag colors red, yellow,
and green separated, think of a traffic light and what you do at the
traffic light when it turns certain colors. The black tag color is easy to
remember because black is most commonly associated with death,
which is the meaning of this tag color.

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 RED TAG: IMMEDIATE
What do you do at a traffic light when it turns red? You stop! Therefore, when a patient is
tagged red, STOP and get them treatment because they have first priority in receiving care.
❖ Seen 1st
❖ Injuries are life-threatening but they could possibly survive if they are immediately treated.
❖ Severe alteration in breathing, circulation, and neuro/mental status
❖ Conditions that would cause a wounded individual to be tagged red (think of conditions or
systems of the body that if severely damaged could majorly alter the breathing, circulation,
and neuro system)
❖ Spinal cord injuries: remember various areas of the spinal cord control breathing, brain
and heart function…shock can occur like neurogenic, cardiogenic etc.
❖ Severe bleeding (internal or external): if the patient is treated immediately so the
bleeding could be stopped and transfused with blood products they may live
❖ Major burns that affects a high percentage of the body: burns can affect the circulation
and the respiratory system (depending on the burn type and where it’s located)
❖ Some types of major respiratory trauma: pneumothorax etc. 40
 Yellow Tag: Delayed
What do you do at a traffic light when it turns yellow? You slow down
or delay because you’re about to stop. Therefore, when a patient is tagged yellow their
treatment is delayed but for only about an hour or so because they could turn critical
based on their presenting injuries.
• Seen 2nd (second priority)
• Significant injuries BUT at this point their breathing, circulation, and mental status is
within normal range but this could change.
• Conditions:
• Bone fractures: major fractures that require medical treatment
Integumentary damages: open wounds, deep lacerations

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 Green Tag: Minor

What do you do at a traffic light when it turns green? You go! Many
times these wounded individuals are termed the “walking wounded”.
Therefore, these patients can get up and GO (move around). Their injuries
are minimal.
• Treatment can be delayed for several hours and some can treat
themselves.
• Breathing, circulation, mental status not expected to change

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 Black Tag: Expectant

➢ Wounded is dying or expired.

➢ Injuries are deadly to the point the individual will not survive.
➢ Absence of breathing, circulation, mental status

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I. Disaster Triage for Chemical and Hazardous Material Disasters
• Triage for chemical incidents will occur in several places

❑ In the field

o Hot Zone- this is the area immediately adjacent to the location of the incident.
o Warm Zone- this is the distance of at least 300 feet from the outer perimeter of the hot zone
and is upwind and uphill from the contaminated area.
o Cold Zone- this area is adjacent (and uphill and upwind) to the warm zone and is where
decontaminated victims enter

❑ In the hospital setting

o Warm Zone- this is an area that is adjacent to the hospital (usually the emergency
department), which has a source of water.
o Clean Zone- this is the treatment area inside of the emergency department or hospital where
newly arriving patients and victims are sent after having been triaged and decontaminated.
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 PRINCIPLES OF
EMERGENCY CARE
CHERRY JOYCE G. BASCO, RN, LPT
COMMON TERMS USED IN
EMERGENCY CARE
⚫ Trauma :Intentional or unintentional wounds/injuries on the human body from particular mechanical
mechanism that exceeds the body’s ability to protect itself from injury
⚫ Emergency Management: traditionally refers to care given to patients with urgent and critical needs
⚫ Triage: process of assessing patients to determine management priorities.
⚫ First Aid: an immediate or emergency treatment given to a person who has been injured before complete
medical and surgical treatment can be secured.
⚫ BLS: level of medical care which is used for patient with illness or injury until full medical care can be given.
⚫ ACLS: Set of clinical interventions for the urgent treatment of cardiac arrest and often life threatening
medical emergencies as well as the knowledge and skills to deploy those interventions.
⚫ Defibrillation: Restoration of normal rhythm to the heart in ventricular or atrial fibrillation
⚫ Disaster: Any catastrophic situation in which the normal patterns of life (or ecosystems) have been disrupted
and extraordinary, emergency interventions are required to save and preserve human lives and/or the
environment
⚫ Mass Casualty Incident: situation in which the number of casualties exceeds the number of resources
⚫ Post Traumatic Stress Syndrome: characteristic of symptoms after a psychologically stressful event was
out of range of an normal human experience
PRINCIPLES OF EMERGENCY
CARE
❑First Aid

❑First aid is the initial emergency care given immediately upon arrival at the
scene to an ill or injured person.
❑The first aider and people who are assisting should continue with assistance until
the professional medical assistance takes over the care of the casualty.
❑Medical professionals may include paramedics, doctors, or ambulance officers.
❑First aiders should always make notes or fill out a casualty report for any event
attended, no matter how minor. Proper records will help you to recall the incident
if you are ever asked about it at a later stage.
❑Records may be used in a court, so ensure your reports or notes are legible,
accurate, factual, contain all relevant information and are based on observations
rather than opinions.
❑Treatment

❑The last step is to actually provide care to the limits of the first aider's training, but never
beyond. In some jurisdictions, you open yourself to liability if you attempt treatment beyond
your level of training. Treatment should always be guided by
▪ the 3Ps:
❖Preserve life
❖Prevent further injury
❖Promote recovery

❑Treatment will obviously depend on the specific situation, but some situations will always
require treatment (such as shock). The level of injury determines the level of treatment
required. The principles first, do no harm and life over limb is essential parts of the practice
of first aid. Do nothing that causes unnecessary pain or further injury unless to do otherwise
would result in death.
 Aims

Although the 3p’s are outlined above, we will also include

two more areas that needs attention when conducting primary
emergency care:

Preservation of life.
Protection against further injury.
Promotion of recovery.
Prevention of injuries for people at any age.
Promotion of healthy lifestyles.
1. Preservation of life
❖ In order to stay alive, all persons need to have an open airway—a clear passage where air can move in
through the mouth or nose through the pharynx (part of the throat) and down in to the lungs, without
obstruction.
❖ Conscious people will maintain their own airway automatically, but those who are unconscious may be
unable to maintain a patent airway, as the part of the brain which automatically controls breathing in
normal situations may not be functioning.
❖ Once the airway has been opened, the first aider would assess to see if the patient is breathing. If there
is no breathing, or the patient is not breathing normally, such as agonal breathing (abnormal pattern of
breathing), the first aider would undertake what is probably the most recognized first aid procedure,
called cardiopulmonary resuscitation or CPR, which involves breathing for the patient, and manually
massaging the heart to promote blood flow around the body.
2. Protection against further injury
✓ No injured person should be moved if his or her life is not in danger.
✓ If a person is not breathing and has no pulse, his or her life is in danger.
✓ Life threatening situations exist where there is significant risk of loss of life.
3. Promoting Recovery

❑ The first aider is also likely to be trained in dealing with injuries such as cuts, grazes or bone fracture. They
may be able to deal with the situation in its entirety (a small adhesive bandage on a paper cut), or may be
required to maintain the condition of something like a broken bone, until the next stage of definitive care
(usually an ambulance) arrives.

4. Prevention of Injuries for people at any Age

The first aider must prevent injuries for all age groups. Age groups are categorized as follow:
❖ Infant: For purposes of first aid, an infant is defined as being younger than 1 year of age.
❖ Child: A child is categorized as being above 1 year of age
❖ Adult: For purposes of first aid, adults are defined as people about age 12 (adolescents) or older.

You need parental permission to give care to a child or an infant, even if it is an emergency. The only reasons
for which you could give care without permission are if the parent is not present or is injured and unable to
respond.
5. Promoting of Healthy Lifestyles

❑The upside to living healthy is that there are many different ways to go about doing
it. So many ways that there is no reason why you can't find a plan which suits you
well. But no matter which way you decide works best for you, here are some
general guidelines you are probably going to want to adhere to:
❖Be a role model.
❖Encourage healthy eating
❖Encourage physical activity.
• TRIAGE
The word triage comes from the French word trier, meaning “to sort.”
In the daily routine of the ED, triage is used to sort patients into groups based on the
severity of their health problems and the immediacy with which these problems must
be treated.
⚫ What were the circumstances, precipitating events, location, and time of the injury or
illness?
⚫ When did the symptoms appear?
⚫ Was the patient unconscious after the injury or onset of illness?
⚫ How did the patient get to the hospital?
⚫ What was the health status of the patient before the injury or illness?
⚫ Is there a medical or surgical history? A history of admissions to the hospital?
• TRIAGE
⚫ Is the patient currently taking any medications, especially hormones, insulin, digitalis,
anticoagulants?
⚫ Does the patient have any allergies? If so, what are they?
⚫ Does the patient have any bleeding tendencies?
⚫ When was the last meal eaten? (This is important if general anesthesia is to be given or
if the patient is unconscious.)
⚫ Is the patient under a physician’s care? What are the name and location of the
physician?
⚫ What was the date of the patient’s most recent tetanus immunization?
ASSESS AND INTERVENE
❑For the patient with an emergent or urgent health problem, stabilization, provision of critical
treatments, and prompt transfer to the appropriate setting (intensive care unit, operating room,
general care unit) are the priorities of emergency care. Although treatment is initiated in the
ED, ongoing definitive treatment of the underlying problem is provided in other settings, and
the sooner the patient is stabilized and moved to that area, the better.
❑ The primary survey focuses on stabilizing life-threatening conditions. The ED staff work
collaboratively and follow the ABCD (airway, breathing, circulation, disability) method:
▪ Establish a patent airway.
▪ Provide adequate ventilation, employing resuscitation measures when necessary. (Trauma
patients must have the cervical spine protected and chest injuries assessed first.)
▪ Evaluate and restore cardiac output by controlling hemorrhage, preventing and treating shock,
and maintaining or restoring effective circulation.
▪ Determine neurologic disability by assessing neurologic function using the Glasgow Coma Scale
▪ After these priorities have been addressed, the ED team proceeds with the secondary
survey. This includes:

▪ A complete health history and head-to-toe assessment

▪ Diagnostic and laboratory testing
▪ Insertion or application of monitoring devices such as electrocardiogram (ECG) electrodes,
arterial lines, or urinary catheters
▪ Splinting of suspected fractures
▪ Cleaning and dressing of wounds
▪ Performance of other necessary interventions based on the individual patient’s condition
▪ Once the patient has been assessed, stabilized, and tested, appropriate medical and nursing
diagnoses are formulated, initial important treatment is started, and plans for the proper
disposition of the patient are made.
 SCOPE AND
PRACTICE OF
EMERGENCY
NURSING

Cherry Joyce G. Basco, RN, LPT

 Scope and Practice of Emergency Nursing
• The emergency nurse has had specialized education, training, and experience.
• The emergency nurse establishes priorities, monitors and continuously assesses acutely ill and
injured patients, supports and attends to families, supervises allied health personnel, and teaches
patients and families within a time-limited, high-pressured care environment.
• Nursing interventions are accomplished interdependently, in consultation with or under the
direction of a licensed physician.
• Appropriate nursing and medical interventions are anticipated based on assessment data.
• The emergency health care staff members work as a team in performing the highly technical,
hands-on skills required to care for patients in an emergency situation.
• Patients in the ED have a wide variety of actual or potential problems, and their condition may
change constantly.
• Although a patient may have several diagnosis at a given time, the focus is on the most life-
threatening ones.
 Issues in Emergency Nursing Care
• Emergency nursing is demanding because of the diversity of conditions and situations
which are unique in the ER.
• Issues include legal issues, occupational health and safety risks for ED staff, and the
challenge of providing holistic care in the context of a fast-paced, technology-driven
environment in which serious illness and death are confronted on a daily basis.
• The emergency nurse must expand his or her knowledge base to encompass recognizing
and treating patients and anticipate nursing care in the event of a mass casualty incident.
• Legal Issues Includes:
o Actual Informed Consent
o Implied Consent
o Parental Consent
 “Good Samaritan Law”
- Gives legal protection to the rescuer who act in good faith and are not guilty of gross
negligence or willful misconduct.

Focus of Emergency Care Golden Rules of Emergency Care

• • Preserve or Prolong Life • DO’S
• • Alleviate Suffering • - Obtain Consent
• • Do No Further Harm • - Think of the Worst
• • Restore to Optimal Function • - Respect Victim’s Modesty &
Privacy
Guidelines in Giving Emergency Care
(A.I.D.) • DONT’S
• - let the patient see his own injury
 A – Ask for help • - Make any unrealistic promises
 I – Intervene
 D – Do no Further Harm
 Stages of Crisis
I. Anxiety and Denial
• encouraged to recognize and talk about their feelings.
• asking questions is encouraged.
• honest answers given
• prolonged denial is not encouraged or supported

II. Remorse and Guilt

• verbalize their feelings

III. Anger
• way of handling anxiety and fear
• allow the anger to be ventilated

IV. Grief
• help family members work through their grief
• letting them know that it is normal and acceptable
Core Competencies in Emergency Nursing Assess and Intervene
⚫ Assessment • Check for ABCs of life
⚫ Priority Setting/Critical Thinking Skills
⚫ Knowledge of Emergency Care
⚫ Technical Skills • A – Airway
⚫ Communication
• B – Breathing
• C - Circulation

Team Members
⚫ Rescuer
⚫ Emergency Medical Technician
⚫ Paramedics
⚫ Emergency Medicine Physicians
⚫ Incident Commander
⚫ Support Staff
⚫ Inpatient Unit Staff
 Emergency Action Principle

I. Survey the Scene

✓ Is the Scene Safe?
✓ What Happened?
✓ Are there any bystanders who can help?
✓ Identify as a trained first aider!
 Emergency Action Principle
II. Do a Primary Survey E-stimated Blood Pressure
- organization of approach so that immediate threats
to life are rapidly identified and effectively manage.
SITE SBP
- Radial ≥ 80
Primary Survey (A-B-C-D-E)
A- Airway/Cervical Spine - Femoral ≥ 70
- Establish Patent Airway - Carotid ≥ 60
- Maintain Alignment
- GCS ≤ 8 = Prepare Intubation D – Disability
- Evaluate LOC
B – Breathing
- Re-evaluate clients LOC
- Assess Breath Sounds
- Observe for Chest Wall Trauma - Use AVPU mnemonics
- Prepare for chest decompression
E – Exposure
C – Circulation - Remove clothing
- Monitor VS - Maintain Privacy
- Maintain Vascular Access
- Prevent Hypothermia
- Direct Pressure
 Emergency Action Principle

III. Activate Medical Assistance

• Information to be Relayed:
• - What Happened?
• - Number of Persons Injured
• - Extent of Injury and First Aid given
• - Telephone number from where you’re calling
 Emergency Action Principle

IV. Do Secondary Survey

• Interview the Patient (SAMPLE)

• S – Symptoms
• A – Allergies
• M – Medication
• P – Previous/Present Illness
• L – Last Meal Taken
• E – Events Prior to Accident
• Check Vital Signs
 Emergency Action Principle
V. Triage
• Categories:
1. Emergent
• - highest priority, conditions are life threatening and need immediate attention.
• - Airway obstruction, sucking chest wound, shock, unstable chest and abdominal wounds, open
fractures of long bones
2. Urgent
• - have serious health problems but not immediately life threatening ones. Must be seen within 1 hour
• - Maxillofacial wounds without airway compromise, eye injuries, stable abdominal wounds without
evidence of significant hemorrhage, fractures
3. Non-urgent
• - patients have episodic illness than can be addressed within 24 hours without increased morbidity
• - Upper extremity fractures, minor burns, sprains, small lacerations without significant bleeding,
behavioral disorders or psychological disturbance.
DISASTER PREPAREDNESS:
UNDERSTANDING THE
PSYCHOSOCIAL IMPACT OF
DISASTERS

Cherry Joyce G. Basco, RN, LPT

 Overview
• Disasters, by their very nature, are stressful, life-altering
experiences, and living through such an experience can cause
serious psychological effects and social disruption.
• Disasters affect every aspect of the life of an individual,
family, and community. Depending on the nature and scope
of the disaster, the degree of disruption can range from mild
anxiety and family dysfunction (e.g., marital discord or
parent–child relational problems) to separation anxiety,
posttraumatic stress disorder (PTSD), engagement in high-
risk behaviors, addictive behaviors, severe depression, and
even suicidality.
• While there are common mental health effects across
different types of disasters, each disaster is unique and many
factors can determine a given disaster’s effect on survivors.
• Natural disasters, such as floods, hurricanes, forest fires,
and tornadoes most often result in property loss and
dislocation.
• When physical injury and loss of life are minimal, the
incidence of psychiatric sequelae may be reduced.
• The mental health effects of any type of disaster, mass
violence, or terror attack are well documented in the
literature to be related to the intensity of exposure to
the event.
• Documented potential indicators of mental health
problems following the event are: sustaining personal
injury, death of a loved one due to the disaster, disaster-
related displacement, relocation, and loss of property
and personal finances (Neria & Shultz, 2012).
• BIOTERRORISM AND TOXIC EXPOSURES

• Bioterrorism is an act of human malice intended to injure and kill civilians and is associated
with higher rate of psychiatric morbidity than are ‘Acts of God’”

• COMMON PSYCHOLOGICAL REACTIONS TO BIOTERRORISM

• Horror, anger, or panic

• Magical thinking about microbes and viruses
• Fear of invisible agents or fear of contagion
• Attribution of arousal symptoms to infection
• Anger at terrorists, the government, or both
• Scapegoating, loss of faith in social institutions
• Paranoia, social isolation, or demoralization
• The following are recommended interventions to minimize the potential
psychological and social consequences of suspected or actual biological exposures:

1. Provide information on the believed likelihood of such an attack and of possible

impact.
2. Communicate what the individual risk is.
3. Clarify that negative health behaviors, which may increase during time of stress (i.e.,
smoking, unhealthy eating, excessive drinking), constitute a greater health hazard than
the hazards likely to stem from bioterrorism.
4. Emphasize that the only necessary action against terrorism on the individual level is
increased vigilance of suspicious actions, which should be reported to authorities.
• The following are recommended interventions to minimize the potential
psychological and social consequences of suspected or actual biological exposures:

5. Clearly communicate the meaning of different levels of warning systems when such
warnings are issued
6. When issuing a warning, specify the type of threat, the type of place threatened, and
indicate specific actions to be taken.
7. Make the public aware of steps being taken to prevent bioterrorism without
inundating people with unnecessary information.
8. Provide the public with follow-up information after periods of heightened alert
 NORMAL REACTIONS TO ABNORMAL EVENTS
▪ Normal reactions to stress and bereavement can and do vary— sometimes even among
members of the same family.
▪ Factors that affect expressions of stress and bereavement include age, gender, ethnicity,
religious background, personality traits, coping skills, and previous experience with loss,
especially traumatic loss.
▪ Stress symptoms can occur due to secondary exposure, meaning that those
experiencing distress need not have been present at the site of the disaster but may
have witnessed it secondhand either via media coverage or through retelling of the
event by a person who was present.
▪ As these reactions can be quite startling and overwhelming to those who have not
experienced them before, it is helpful for survivors to hear that their experiences are
entirely normal, given the tremendous stress to which they have been exposed.
 Common Reactions of Disaster Survivors

⚫ Emotional ⚫ Interpersonal ⚫ Cognitive ⚫ Physical

➢ Shock, ➢Distrust ➢ Confusion ➢ - Tension,
feeling numb ➢Conflict ➢ Indecisivenes edginess
➢Withdrawal s ➢ - Fatigue,
➢ Fear ➢Work or school ➢ Worry insomnia
➢ Grief, problems ➢ Shortened ➢ - Body aches,
sadness ➢Irritability attention pain, nausea
➢ Anger ➢Loss of span ➢ - Startling easily
➢ Guilt, intimacy ➢ Trouble ➢ - Racing
shame ➢Feeling concentrating heartbeat
rejected or ➢ - Change in
➢ Feelings of abandoned appetite
helplessness ➢ - Change in sex
drive
 Special Needs of Population

• Children and Youth - while most children are resilient, many children do experience
some significant degree of distress. Poverty and parents with mental health challenges
put children at higher risk for long-term impairments (McLaughlin et al., 2009).
• Older Adults - Older adults are particularly vulnerable to loss. Factors such as age and
disability affect vulnerability to a disaster. Both of these vulnerability traits are apparent
in the elderly population. They are often lacking in social supports, may be financially
disadvantaged, and are traditionally reluctant to accept offers of help. Older adults are
also more likely to have preexisting medical conditions that may be exacerbated, either
directly because of the emotional and psychological stress, or because of disruptions to
their care, such as loss of medications or needed medical equipment, changes in primary
care providers, lack of continuity of care, or lack of consistency in self-care routines due
to relocation.
 Special Needs of Population
• The Seriously Mentally Ill - According to Austin and Godleski (1999), the most psychologically
vulnerable people are those with a prior history of psychiatric disturbances. Although previous
psychiatric history does not significantly raise the risk of PTSD, exacerbations of preexisting
chronic mental disorders, such as bipolar and depressive disorders, are often increased in the
aftermath of a disaster. Those with a chronic mental illness are particularly susceptible to the
effects of severe stress, as they may be marginally stable and may lack adequate social support to
buffer the effects of the terror, bereavement, or dislocation.
• Cultural and Ethnic Groups - Sensitivity to the cultural and ethnic needs of survivors and the
bereaved is key not only in understanding reactions to stress and grief but also in implementing
effective interventions. Mental health outreach teams need to include bilingual, multicultural
staff and translators who are able to interact effectively with survivors and the bereaved.
• Disaster Relief Personnel - The list of those vulnerable to the psychosocial impact of a disaster
does not end with the survivors and the bereaved. Often victims can include emergency
personnel: police officers, firefighters, military personnel, Red Cross mass care and shelter
workers, cleanup and sanitation crews, the press corps, body handlers, funeral directors, staff at
receiving hospitals, and crisis counselors.
 COMMON STRESS REACTIONS BY DISASTER WORKERS (DISASTER NURSES)

Psychological Behavioral
• Change in activity level
✓ Denial • Decreased efficiency and effectiveness
✓ Anxiety and fear • Difficulty communicating
✓ Worry about the safety of self or
others • Outbursts of anger, frequent arguments, irritability
✓ Anger • Inability to rest or “let down”
✓ Irritability and restlessness • Change in eating habits
✓ Sadness, moodiness, grief, depression • Change in sleeping patterns
✓ Distressing dreams • Change in patterns of intimacy, sexuality
✓ Guilt or “survivor guilt”
✓ Feeling overwhelmed, hopeless • Change in job performance
✓ Feeling isolated, lost, or abandoned • Periods of crying
Apathy • Increased use of alcohol, tobacco, and drugs
• Social withdrawal/silence
• Vigilance about safety of environment
• Avoidance of activities/places that trigger memories
 COMMON STRESS REACTIONS BY DISASTER WORKERS (DISASTER NURSES)

Cognitive Physical
• Increased heart/respiratory rate/blood pressure
• Memory problems • Upset stomach, nausea, diarrhea
• Disorientation • Change in appetite, change in weight
• Confusion • Sweating or chills
• Tremor (hands/lips)
• Slowness of thinking and comprehension
• Muscle twitching
• Difficulty calculating, prioritizing
• “Muffled” hearing
• Poor concentration • Tunnel vision
• Limited attention span • Feeling uncoordinated

• Loss of objectivity • Proneness to accidents

• Headaches
• Unable to stop thinking about disaster
• Muscle soreness, lower back pain
• Blaming • “Lump” in the throat
• Exaggerated startle reaction
• Fatigue
• Menstrual cycle changes
• Change in sexual desire
• Decreased resistance to infection
 COMMUNITY REACTIONS AND RESPONSES

It is important to understand common responses and needs after a disaster, regardless of

the type of disaster. It is important to recognize:
• 1. Everyone who sees or experiences a disaster is affected by it in some way.
• 2. It is normal to feel anxious about your own safety and that of your family and close
friends.
• 3. Profound sadness, grief, and anger are normal reactions to an abnormal event.
• 4. Acknowledging your feelings helps you recover.
• 5. Focusing on your strengths and abilities helps you heal.
• 6. Accepting help from community programs and resources is healthy.
• 7. Everyone has different needs and different ways of coping.
• 8. It is common to want to strike back at people who have caused great pain.
 COMMUNITY REACTIONS AND RESPONSES

• Large-group preventive techniques for children have been used for some time in
California during the aftermath of community-wide trauma (Eth, 1992). This type of
school-based intervention occurs as soon after the event as possible, and follows three
phases:

• 1. Pre-consultation—identifying the need; preparing the intervention with school

authorities
• 2. Consultation in class—introduction, open discussion (fantasy), focused discussion
(fact), free drawing task, drawing or story exploration, reassurance and redirection, recap,
sharing of common themes, and return to school activities
• 3. Post-consultation—follow-up with school personnel and triage/referrals, as needed.
 MOURNING, MILESTONES, AND ANNIVERSARIES

• The normal process of mourning is often facilitated by the use of rituals, such as
funerals, memorials, and events marking key time intervals, such as anniversaries. It is
important to include the community in the services, as well as the immediate family
members. Community-wide ceremonies can serve to mobilize the supportive network
of friends, neighbors, and caring citizens and provide a sense of belonging,
remembrance, and letting go.
• Websites and social media groups link the bereaved and can also provide special
support during important anniversaries or milestones. Ceremonies or memorials in
schools should be developmentally appropriate and involve students in the planning
process. Websites and pages to be created in the aftermath of a disaster serve as a
place for people, both directly and indirectly impacted, to express their condolences
and offer support.
 MOURNING, MILESTONES, AND ANNIVERSARIES

• The phases of the mourning process have much in common with the emotional phases
of disaster recovery, and has identified specific tasks that need to be accomplished at
each phase of mourning for successful resolution:
1. Period of shock, or “numbness.” The task is to accept the reality of the loss (as opposed
to denying the reality of the loss).
2. Reality, or “yearning,” and “disorganization and despair.” The tasks are to accept the
pain of grief (as opposed to not feeling the pain of the loss) and to adjust to an
environment in which the deceased is missing (as opposed to not adapting to the loss).
3. Recovery, or “reorganized behavior.” The task is to reinvest in new relationships (as
opposed to not loving).
 NORMAL MANIFESTATIONS OF GRIEF
➢ Feelings ➢ Physical Sensations
• Sadness • Hollowness in stomach
• Anger • Tightness in chest
• Guilt and self-reproach • Tightness in throat
• Anxiety • Oversensitivity to noise
• Loneliness • Sense of depersonalization/derealization
• Fatigue • Breathlessness, shortness of breath
• Helplessness • Weakness in muscles
• Shock (most often after sudden death) • Lack of energy
• Yearning (for the deceased person) • Dry mouth
• Emancipation
• Relief
• Numbness
 NORMAL MANIFESTATIONS OF GRIEF

➢ Behaviors ➢ Thoughts
• Sleep disturbance • Disbelief
• Appetite disturbance • Confusion
• Absentmindedness • Preoccupation
• Social withdrawal • Sense of presence
• Avoiding reminders (of deceased) • Hallucination
• Dreams of deceased
• Searching, calling out
• Restless overactivity
• Crying Treasuring objects
• Visiting places/carrying objects of remembrance
CJGB