Emergency, Terrorism, Disaster Nursing and Eye Trauma

  • Goal: Apply sequential steps in triage, primary survey, and secondary survey to emergency patients; differentiate MCI triage tags; manage face/eye trauma; understand ethical/practical implications.

Objectives

  • Apply sequential steps for emergency patient triage, primary, and secondary surveys.

  • Differentiate MCI triage tags.

  • Apply correct steps for face and eye trauma.

  • Integrate ethical, practical, and real-world considerations.

Emergency Department Context & EMTALA

  • EDs face rapid changes, high risk for errors, and require multispecialty care in often crowded, noisy, potentially hostile environments.

  • EMTALA: Requires medical screening exams, emergency services, and stabilizing treatment for all, regardless of ability to pay; restricts patient transfers.

Collaborative Teams

  • Includes prehospital (EMS), ED physicians, nurses (BLS, ACLS, PALS, TNCC certified), and various support staff and specialists.

ED Visits & Crowding

  • Rising ED visits are due to poor outpatient access, aging population, shorter hospital stays, mental health crises, and insurance gaps, leading to overcrowding and delayed care.

Emergency Nurses Association (ENA)

  • Advances emergency nursing, provides care standards, and certifies Emergency Nurses (CEN).

Care of the Emergency Patient: Core Concepts

  • Early recognition of life-threatening issues.

  • Rapid intervention to prevent/reverse crises.

  • Prompt identification of patients needing immediate treatment.

Nursing Roles

  • Assessment, triage, primary/secondary surveys, standing orders, provider assessment, disposition, and client/family teaching.

Triage: Concept & System

  • "To sort" patients rapidly by acuity, treating life threats first.

  • 5-level Emergency Severity Index (ESI): Assigns priority based on illness severity and resource use.

    • ESI-1: Immediate, life-threatening intervention.

    • ESI-2: High-risk/severe pain, rapid assessment.

    • ESI-3: Stable, requires resources, not immediately life-threatening.

    • ESI-4: Stable, minor resources, non-urgent.

    • ESI-5: Minimal workload, no resources.

Primary Survey (ABCDE)

  • Focuses on identifying and intervening in life-threatening conditions.

  • If uncontrolled hemorrhage, prioritize C (catastrophic hemorrhage) first.

    • A: Alertness & Airway (AVPU): Assess LOC to guide airway management.

    • B: Breathing: Identify compromised breathing, provide supplemental O2; may need BVM, decompression, intubation.

    • C: Circulation: Assess central pulses, skin, mental status; prepare for large-volume resuscitation (two large-bore IVs).

    • D: Disability (Neurologic Status): Brief neuro exam, GCS, pupil assessment.

    • E: Exposure & Environmental Control: Remove clothing for thorough exam (preserve forensic evidence); warm patient to prevent hypothermia; do not remove impaled objects.

    • F: Full Set of Vitals & Family Presence: Obtain vitals (BP in both arms for chest trauma); facilitate family presence during resuscitation.

    • G: Get Resuscitation Adjuncts (LMNOP):

    • L = Lab tests

    • M = Monitor ECG

    • N = Nasogastric tube (or orogastric for head/facial trauma)

    • O = Oxygenation & ventilation assessment

    • P = Pain assessment & management.

Secondary Survey: Head-to-Toe to Identify ALL Injuries

  • Aims to identify all injuries after initial stabilization.

    • H = History (SAMPLE) & Head-to-Toe Assessment:

    • S = Symptoms

    • A = Allergies/tetanus

    • M = Medications

    • P = Past Medical History (PMH)

    • L = Last meal/oral intake

    • E = Events leading to injury.

    • Head-to-Toe Assessment: Covers head, neck, face, chest, abdomen, pelvis, perineum, extremities.

    • Key: Protect C-spine, stabilize impaled objects, assess for bruising/deformities, check pulses, assess for compartment syndrome.

    • I = Inspect Posterior Surfaces: Logroll with C-spine immobilization to inspect the back and palpate the spine.

Acute Care & Evaluation

  • Tetanus prophylaxis, ongoing monitoring, diagnostic testing, and disposition planning.

Death in the ED

  • Provide privacy/comfort for families, chaplain support, notify medical examiner/coroner, and organ procurement organization.

Agents of Terrorism

  • Biologic (anthrax, smallpox), chemical (nerve gas like sarin), radiologic/nuclear (acute radiation syndrome), and explosive devices.

  • Bioterrorism education (4-hour CEU) is mandated for nurses for license renewal.

Mass Casualty Incidents (MCI): Tagging & Triage

  • Triage Tags:

    • Green = minor

    • Yellow = urgent, non-life-threatening

    • Red = life-threatening, immediate intervention

    • Black = deceased/expected to die.

  • Triage in 15 seconds per person; decontamination if applicable.

  • Hospitals need emergency response plans and Community Emergency Response Teams (CERTs).

Eye Trauma: Emergency Management

  • Etiology: chemical, foreign bodies, thermal burns, trauma.

  • Key steps: Assess tissue integrity, visual field, drainage.

Eye Trauma: Nursing Management

  • Determine mechanism/exposure; irrigate for chemical exposure; do not apply pressure or remove impaled objects; cover injured eye; elevate head of bed.

Ethical, Philosophical, & Practical Implications

  • Balance patient autonomy vs. triage efficiency, family presence in resuscitation, forensic considerations, resource allocation, healthcare worker safety, and bioterrorism readiness.

Quick Reference Mnemonics & Key Points

  • ESI: 1→51 \rightarrow 5 (threat to life to minimal workload).

  • ABCDEFG: Airway, Breathing, Circulation, Disability, Exposure, Full vitals, Get resuscitation adjuncts.

  • AVPU: Alert, Voice, Pain, Unresponsive.

  • LMNOP: Labs, Monitor ECG, Nasogastric tube, Oxygenation, Pain management.

  • SAMPLE: Symptoms, Allergies, Meds, PMH, Last meal, Events.

  • Logroll for posterior exam with C-spine immobilization.

  • MCI tags: Green, Yellow, Red, Black.

Final Takeaways

  • Mastery of primary/secondary surveys and ESI triage is critical.

  • Ethical considerations are integral to practice.

  • Eye trauma requires careful assessment and injury prevention.

  • MCI preparedness relies on teamwork, protocols, and ongoing education.