EMERGENCY AND DISASTER NURSING

DEFINITION OF TERMS BURNS

→ EMERGENCY – serious, unexpected, and often
dangerous situation requiring immediate action
→ DISASTER – sudden event, such as accident or natural
catastrophe, that causes great damage or loss of life
○ E.g., earthquakes, typhoon
○ E.g., manmade terrorism, war
Who is your priority patient?
a. Patient with hantavirus syndrome- respiratory disorder r/t
ingestion/inhalation of rodent body fluids (common in floods,
urine of rats)
b. Patient with takutsubi disorder- cardiomyopathy
c. Patient with alice in wonderland syndrome- visual disorder
(small things look bigger, c/c)
d. Patient with Zollinger ellison syndrome- increases GIT
functioning that leads to possibility of ulcers
→ Priority is fluid losses d/t fluid shifting from burns
→ Fluid shifting → cellular injury → albumin loss →
decreased oncotic pressure → prevent pulling of water
from the interstitial to intravascular space → stasis of
water in the interstitial space (third spacing) → edema,
ascites, fluid at pericardium
• Fluid shifting happens from intravascular/blood
vessel (functional) to interstitial/third space (non-
functional)
→ If no scenario, fluid is priority

DEGREE DEPTH LAYER PAIN EDEMA CHARACTERISTICS

Superficial/
No Red, blanching - not
superficial partial
FIRST Epidermis Yes (X) third space → included in parkland
(X) fluid losses formula
E.g., sunburn

Red, blisters, weeping,

Deep partial/ partial
mottled (nagkukulubot)
thickness
Yes → Blisters and weeping
SECOND Dermis Yes third spacing → are d/t third spacing
E.g., scald burn
fluid losses → edema
(talsik ng mainit na
→ Included in parkland
mantika)
formula

No
Red, mottled, yellow
d/t very deep
Epidermis, dermis, (subcutaneous), brown
burn (burned Yes
subcutaneous/ (muscle), white (bone),
THIRD Full thickness burns nerves, third spacing →
hypodermis, black charred, leathery-
destroyed fluid losses
muscles, bones Included in parkland
nerve
formula
endings)

PARKLAND FOR (4) MULA Adult

→ Total ml of fluid to be replaced in the first 24 hours → Head and neck: 9
• 50% first 8 hours = 5000ml • Anterior: 4.5
• 50% in the last 16 hours = 5000ml • Posterior: 4.5
• Example total ml in the first 24 hours = 10,000ml → Trunk: 36
→ TBSA (total body surface area) x body weight in kg x • Anterior Trunk: 18
4ml (constant) o Chest: 9
→ Example: Adult 28% TBSA burn, weighs 100lbs. What o Abdomen: 9
is the total ml in the last 16 hours? • Posterior Trunk: 18
• 100lbs/2.2 = 45.5 kg → Arm: 9
• 28 x 45.5 x 4ml = 5096ml (first 24 hours) • Anterior: 4.5
• 5096/2 = 2548 ml (last 16 hours) • Posterior: 4.5 or
• Volume is greater in the first 8 hours d/t risk for fluid • Upper arm: 4.5
collapse • Forearm: 4.5
→ Leg: 18
RULE OF NINES • Anterior: 9
→ In palmar method, the palm of the patient is used. This • Posterior: 9
is not accurate → Perineum: 1
→ Example: Adult 200lbs with first degree burns at
anterior chest and posterior right leg. Deep partial
burns at arms and left anterior leg. What is the ml in the
first 24 hours?
• Body weight 200 lbs = 90.9 kgs
• TBSA = 9 x 2 (18) + 9 = 27% TBSA
• 90.9 kg x 27% TBSA x 4 mL = 9817.2 ml for first
24 hours
• 9817 ml / 2 = 4908.6/4909 ml in the first 8 hours
→ Example: Adult 72 kg with full thickness burns at
anterior trunk (18%) and perineum (1%), deep partial
 burns at anterior right leg (9%) and posterior left leg
(9%). What is the ml in the first 8 hours?
• BW 72 kgs
• TBSA = 18 + 18 + 1 = 37% TBSA
• 72 kgs x 37 x 4 ml = 10,656 mL in the first 24 hours
• 10,656 ml/2 = 5328 mL in the first 8 hours
→ Example: Adult 150lbs suffered burns, third degree at
right anterior arm (4.5%), left arm (9%). First degree at
right leg. Second degree at anterior head (4.5%). What
is the ml in the last 16 hours?
• BW 150 lbs = 68.2 kgs
• TBSA = 4.5 + 9 + 4.5 = 18% TBSA
• 68.2 kgs x 18 x 4 ml = 4910.4 ml for the first 24
hours
• 4910.4/2 = 2455.2 for the last 16 hours
Infant
→ Head: 18
• Anterior: 9
• Posterior: 9
→ Trunk: 36
• Anterior Trunk: 18
o Chest: 9
o Abdomen: 9
• Posterior Trunk: 18
→ Arm: 9
• Anterior: 4.5
• Posterior: 4.5 or
• Upper arm: 4.5
• Forearm: 4.5
→ Leg: 14
• Anterior: 7
• Posterior: 7
→ Perineum: not counted
→ Example: The patient suffers superficial burns on the
chest, posterior left leg, and anterior right thigh; deep
partial burns on the whole head (18%), posterior trunk
(18%), right and left forearm (4.5% + 4.5%); and full
thickness burns of the abdomen (9%), and anterior left
leg (7%). How much is the TBSA of the patient that
would be included in the parkland formula? = 61%
TBSA
• TBSA = 18 + 18 + 4.5 + 4.5 + 9 + 7 = 61% TBSA
→ Example: 12 lbs sustained full thickness burns at right
leg (14%), abdomen (9%) and perineum (X). Superficial
burns at the head and neck. Partial thickness at arms
(18%) and posterior trunk (18%). What is the mL in the
first 8 hours?
• BW 12lbs = 5.5 kgs
• TBSA = 14 + 9 + 18 + 18 = 59% TBSA
• 5.5 kgs x 59 TBSA x 4mL = 1,298mL in the first 24
hours
• 1,298 ml/2 = 649 mL in the first 8 hours
→ Example: 4kgs with second degree burn at the anterior
trunk (18%) and left leg (14%). Third degree burns at
the right arm (9%) and posterior left arm (4.5%), head
and neck are also affected (18%). What is the mL in the
first 24 hours?
• BW = 4kgs
• TBSA = 18 + 14 + 9 + 4.5 + 18 = 63.5%
• 4 kgs x 63.5% TBSA x 4 mL = 1,016 mL in the first
24 hours
PHASES OF BURN INJURY
First Phase: Emergent Phase/Shock/Resuscitative
→ 24-48 hours
→ Problem: fluid deficit
→ Priority: fluid resuscitation/replacement
• Best fluid: PLR
• Situational: Airway is Priority when,
o (+) inhalation injury (facial burns, singed facial
hair, soot, bronchospasm - AEB wheezes/
stridor/DOB)
→ Priority assessment: vital signs
→ Priority laboratory value: HCT
→ Symptoms:
• ↓BP- compensatory mechanism (↑RR, ↑HR)
• ↓Urine output- compensatory mechanism to
conserve fluid
• ↑hematocrit- concentrated blood d/t dehydration
• Hyperkalemia and hyponatremia - presence of
cellular injury → shifting of electrolytes
o Normal: potassium in, sodium out (PISO)
→ Management (in the EMERGENT PHASE):
• Priority is fluid; if (+) inhalation injury- airway
o It is vital to replace fluids immediately
• WOF: severe pain- administer
morphine/fentanyl/demerol (opioids)
o Do not put toothpaste on burns as it may cause
further irritation
o First aid management:
▪ Running water
▪ Wash with soap and water to prevent
tetanus
▪ Moist to dry, apply antibiotic ointment
• WOF: curling's ulcer- stress ulcer r/t burn (↑HCl) →
administer antacids, PPIs (-zoles), H2 blockers (-
dine)
Second Phase: Acute Phase/Diuretic
→ Post 48 hours-5 days
→ Risk for infection
→ Symptoms:
• ↑BP, ↑RR, ↑HR d/t vascular resistance
o Blood vessels are forced d/t accumulation of
fluids (expected)
• ↑Urine output- fluids are replaced already
o Best determinant for effectiveness of the fluid
therapy
• Hypokalemia and hyponatremia
o Diluted sodium d/t abundance of fluids
• ↓Hematocrit- overhydrated → diluted blood
(expected)
→ Management:
• Priority is to prevent infection
o Teach the patient to do handwashing
o Use PPEs
o Place the patient in a private positive pressure
room
o Assist in wound/scab/eschar debridement
(sterile) to promote wound healing, promote
absorption of antibiotic ointment that doesn't
pass the eschar
▪ Silver nitrate (sulfadiazine)- faster healing
▪ Mafenide acetate - new drug (more
expensive) - passes the eschar, offers
lesser pain
❖ AE: hemolytic anemia
➢ To prevent AE, apply drug thinly-
1/16 - 1/18 inch
 o Situational: (+) Circumferential burn →
↑pressure → compartment syndrome (pallor,
pain, paresthesia, paralysis, pulselessness,
poikilothermia- from hot to cold)
▪ Compartment syndrome is d/t
compression of the muscles → ↓blood flow
→ necrosis → amputation
▪ Management: fasciotomy
Simple Triage
→ Easy to perform because patient status is considered
→ START- Simple Triage And Rapid treatment
• 3 main groups:
o Respiration - airway and breathing problems
o Perfusion - circulation: blood or fluid losses
o Mental status- disability, psychological
disorders (LOC)

Prioritization Rules
→ Adult
• If age is not given
• Prioritization: ABCD
o Bronchospasm before bleeding
• For cardiac arrest: CompressionAB
• Unexpected > expected symptoms
• Systemic > localized
o Acute before chronic
→ Pedia: danger signs (CUVA)
• Convulsions
• Unable to feed
• Vomits everything
• Abnormally sleepy
→ Geria- confusion
Third Phase: Recovery Phase • Safety issue
→ >5days • Sign of infection
→ Focus: rehabilitation • Bleeding
→ Symptoms: all stable including lab values • Dehydration
→ Goal: Promote/restore optimal function • Cerebral hypoxia
• Scars - body image disturbance - refer to plastic → Psychiatric disorders (physiological > psychological)
surgery • E.g., Anorexia nervosa- meal planning > coping
• Contractures - prevention: functional position → Pedia (most vulnerable) > geria > adult
(extend/flex)
Priority
A. MI with severe substernal crushing chest pain -
PRIORITY
B. Myasthenia Gravis with Ptosis - not life threatening

A. Multiple Myeloma with bone pain and lesions - expected

(ABC disability)
B. Internal radiation with weakness and pallor - expected
• Skin Graft to promote wound healing C. Chemotherapy patient with mild fever - unexpected =
o Ensure blood perfusion neutropenic fever (priority: risk for infection)
o Avoid dislodgement D. Testicular cancer with groin pain and enlargement -
o Place the patient on the unaffected site expected
o Bed cradle with blanket
A. Angina pectoris patient with stabbing pain after
nitroglycerin administration - unexpected
B. Patient for angiography who is anxious about the surgery
- expected
C. Cardiac tamponade with hypotension and heart murmurs
- expected
D. Abdominal Aortic Aneurysm (AAA) with mild leg pain
and pulsating abdominal mass - expected; leg pain
indicates rupture
Types of Skin Graft
A. Patient with conjunctivitis with redness and crusting on
→ Autograft- from self
the eyes- expected
→ Isograft/Synergistic- from twin
B. Patient with rocky mountain spotted fever with rashes
→ Homograft/Allograft- from another human and fever- expected
→ Heterograft/Xenograft - from animals (fish skin) C. Patient with HIV with decreased WBC levels and raise
• Porcine- pig skin purplish lesion - unexpected (Kaposi Sarcoma - patient
o Contraindicated to Muslims progressed to AIDS)
• Bovine- cow skin D. Patient with meningitis with arching of the back and
nuchal rigidity - expected
TRIAGE
A. Patient third trimester with BP of 159/95 with mild pre-
→ to sort of classify patients according to priority
eclampsia - expected; >160 = eclampsia
→ Most important ethical principle is justice (fairness, B. Patient post shoulder dystocia delivery with grade 2
equity- based on the need) episiotomy - expected
 C. Patient with ectopic pregnancy with unilateral
• Unequal pupils > fracture
abdominal pain and shoulder pain - shoulder pain → External – pre-hospital, unstructured, limited resources,
indicates rupture → sepsis focus is first aid, priority is high survival over low survival
D. Patient first trimester pregnancy who is unsure of the • Cardiac arrest < chest pain
current status - expected • Unequal pupils < open fracture
• Chest pain (needs care) > fracture
A. 2-year-old with DOB and severe pneumonia -
• Red > yellow > green > black (low survival)
unexpected
→ Reverse triage - DISASTER, massive, military scenario.
B. 5-year-old with asthma and wheezing - airway problem
C. 15-year-old adolescent drunk with stab wound on the
Obsolete resources. Priority is most stable
chest - breathing and bleeding problem • War, terrorisms, earthquake
D. 2-year-old with food poisoning who vomits • Priority is green > yellow > red > black
everything - dehydration, danger signs are priority in • Principle of utilitarianism: greatest good for the
pediatric clients greatest number
E. 1 year old post head trauma who is difficult to awaken -
Sample Question
LOC (neuro); expected
Building collapse - external (high survival- red)
1. Cardiac arrest - black
Advanced Triage 2. Chest pain - red
→ Patient status and resources are considered 3. Leg fracture - yellow
4. Sprain - green
• War - reverse (4; same situation)
Types of Advanced Triage
• ward - internal (1; same situation)
→ Internal – hospital, structured (+) resources, focus is
• 20 patients rushed to the emergency department -
definitive care, priority is sickest > well
shift to external (2; same situation)
• Cardiac arrest > chest pain

Cases/patient Time 3 tier External Examples

UNRESPONSIVE WITH UNSTABLE VS

→ Cardiac arrest
→ Cervical SCI - phrenic nerve which is
Life threatening
responsible for the control of respiration
ABCD, low Immediate Emergent Black
(diaphragm)
survival
• Neck brace is important
→ Fixed/ unequal pupils
→ Blood/fluid loss >60%

UNRESPONSIVE WITH STABLE VS

→ Chest pain
→ Chest injuries
→ Blood/fluid loss 40-60%
LT condition, high → SCI below the cervical
15-30 min Emergent Red
survival → Cerebral embolism- Stroke
→ Cardiac embolism -possible angina/MI
→ Pulmonary embolism- rashes/petechiae at the
chest
→ Flat bone fracture as it can lead to bleeding

Non-LT, but → Stable head/eye/ear/ abdominal injuries

treatment needed <2 hours Urgent Yellow → Blood/fluid loss <40%
ASAP → Fractures

AMBULATORY
Non-LT, treatment Non-urgent/TIA → Sprain
<24 hours Green
non-ASAP - May go home → Strain
→ Minor cuts or bruises

GOALS OF EMERGENCY CARE •

Activate the plan! - Incidence Command System
→ Prevent injury- Mitigation/Preparedness phase (The plan is activated when there is an increase of
→ Preserve life- Response admissions)
→ Promote recovery- Recovery phase • Priority: Physio over Psycho, TRIAGE!
4. Recovery - post disaster
DISASTER PHASES MANAGEMENT • Promote rehabilitation
1. Mitigation - before disaster • Priority: Physio over Psycho
• Lessen the damages and loss of life • After physio is stabilized, psych first aid
• Focused on architectural adjustments (e.g., o Diffusion- done in the first 36 hours, informal
earthquake proof buildings), urban planning, psychological help (all have the capacity to be
information dissemination therapeutic)
2. Preparedness - before disaster o Debriefing- done after 36 hours, formal help
• Create a plan to determine roles, leaders, (done by professionals)
intercommunication ▪ Prevent PTSD, suicide, depression
• Training and drills - most expensive phase
3. Response - intra disaster
PRINCIPLES OF EMERGENCY CARE •Chin lift- (-) cervical injury; best way to open airway;
→ Assess applied if there is no situation
• Patient status and environment for SAFETY (The • Tubes
patient and nurse should be safe!) o Oropharyngeal/mouth guard - contraindication
→ Ask for help first (team approach); outside - activate if with (+) gag, vomiting, aspiration risk, (+)
EMS (emergency medical services) or ERS (emergency facial trauma
response services) ▪ Inserted upward → downward
• Ask for resources ▪ Downward can cause injury to the hard
• It is safer if there are more resources palate
→ Intervene ▪ (+) facial trauma- can aggravate injury
• Based on assessment o Nasopharyngeal - contraindicated (+) CSF
• Stabilize the patient leakage
→ Do no harm - non-malfeasance ▪ Sign of basilar/skull fracture
→ Advanced - longer tubes, direct to the lungs; done by
TYPES OF SURVEY AND ASSESSMENT MD
→ Primary Survey: Rapid • Laryngeal tube - if not available proceed to ET
• Goal: Establish the priority problem (to determine • Endotracheal tube
the priority intervention) • Tracheostomy - last resort because it is most
• Disadvantage – incomplete invasive
o Initial assessment, unstable client (lesser time
to assess) EMERGENCY MANAGEMENT - BLS
• After primary survey → primary intervention (to
stabilize the patient) Respiratory Arrest (-RR, +PR, UNRESPONSIVE)- rescue
• Airway, Breathing, Circulation, Disability breathing
(neurologic) → Bag valve mask (ambu bag) ideally
• IF CARDIAC ARREST: CompressionAB
• Primary check is LOC
o Responses (AVPU- alert verbal pain
unresponsive)

• (-) BVM: one way valve or face shield is ideal

o GCS takes time to obtain

• Demographics
o Name
o Mouth to mouth is not recommended
o Contact person
o Religion- to know contraindications (e.g., → Adult and advanced airway
Jehovah’s witness) • E.g., advanced airway: with tracheostomy, 5 years
• Pulse checking: old- 10 rescue breaths
o Adult/Child - carotid • Frequency: 10/min, 1 breath/6sec (too much may
o Infant - Brachial compress the heart)
• RR check - rise and fall of the chest → Children - 12/min, 1 breath/5sec
• Skin check for perfusion • If vomiting is present, stop → left side lying →
o Pallor suction
o Cyanosis • Vomiting could lead to aspiration
o Jaundice
→ Secondary Survey: complete and thorough Cardiac Arrest (-PR, -RR, UNRESPONSIVE) - SARAP
• Disadvantage – takes time → Survey scene/responder
• Done after stabilization → Announce/introduce self
• Assess Cephalocaudal- head to toe → Response
• Baseline VS, GCS → Activate ERS
• History of complaint → Pulse and respiration check- within 10 seconds to
• Diagnostics and laboratory prevent delay in CPR
→ CPR- push hard and fast
EMERGENCY MANAGEMENT - AIRWAY • INTERVENE: compress q 2min
→ Airway management- basic/advanced • RATE: 120 max (100-120/min)
→ Basic - easy to perform, done by RN, BLS, jaw thrust, • QUALITY: push hard and fast
chin lift • ADULT: 30 compressions: 2 breathing
• Jaw thrust- (+) cervical injury to maintain the neck o 2-man pedia rescue - 15:2
at neutral position; hit by a vehicle • LANDMARK: lower half of sternum
 o Lock elbows in place
o Allow chest recoil FIRST AID MANAGEMENT: MARINE STINGS
• HAND POSITION: → Consequence: Severe inflammation
o Adult (>9yo): 2 hands → Signs and Symptoms:
o Child (1-8yo): 1 hand • Itching
o Infant: 2 fingers (index & middle or both • Redness
thumbs) • Swelling
• DEPTH: • Redness
o Adult: 2-2.4 inches • Warm sensation
o Child: max 2 inches → Management:
o Infant: max 1.5 inches 1. Flush with saline water
• Stop CPR if: 2. Apply acetic acid (vinegar)
• Defibrillation: pulseless, vtach, vfib 3. Warm compress
• Exhausted
• ERS arrival FIRST AID MANAGEMENT: SNAKE BITES
• Physician declared death of px → Consequence: Blood clots, respiratory depression
• Px is revived/Return of Spontaneous Circulation → Venomous Snake:
(ROSC) • Triangular head
o (+) HR • Pit nostril for heat senses
o No RR, stop CPR → rescue breathing • Stir/vertical eyes
• With fangs
FIRST AID MANAGEMENT: HEMORRHAGE
→ TYPES:
• Arterial – bright red, spurting
o Oxygenated blood, ↑pressure
• Venous – dark red, oozing (↓pressure)
→ Management:
→ Management:
• Do not suck the site
1. Wear gloves to protect self from infections
• Do not cut
2. Apply pressure (tourniquet is allowed for severe
bleeding) • No warm or cold compress
3. Elevate the site to promote venous return o Cold compress will restrict blood flow
4. PNSS for BT o Warm compress → vasodilation → rapid blood
▪ Universal donor: O- flow → rapid spread of toxin
• Allow constrictive bands
FIRST AID MANAGEMENT: ANIMAL BITES - Dogs, Cats, • Proper management: Priority is safety
Bats 1. Lower the site
→ Consequence: Rabies, Tetanus 2. Immobilize to prevent flow of toxin
• Rabies - dangerous: neck 3. Clean the wound
4. Anti-venom ASAP (SE: arthralgia)
• Tetanus came from soil
→ Signs and Symptoms:
FIRST AID MANAGEMENT: POISONING
• Bite marks
→ Consequence: depends on the poison
• Swelling
• Common: Toddler - they explore via mouth
• Redness
→ Prevention:
→ Management: Anti Rabies/Anti Tetanus
• Avoid storage of poison at food containers
• GOAL: To slower down the movement of the
• Lock poison at cabinet out of children’s reach
tetany
→ Management: If (+) poisoning
1. Lower site
2. Immobilize • Do not stimulate vomiting- avoid emetics (syrup of
3. Cold compress ipecac) d/t risk of aspiration
4. Klean the wound • Position the client left side lying to prevent gastric
emptying (prevent absorption in the intestines)
FIRST AID MANAGEMENT: BEE STINGS • Assess type of poison and amount - call poison
→ Consequence: center
• Allergic - antihistamine • Activated charcoal - 1-2g/kg every 4-8 hours/ burnt
• Anaphylactic - epinephrine > bronchodilator > bread
steroids • Gastric lavage - within 4 hours
→ Signs and Symptoms: • Chelation therapy - blood cleansing (via binding
• Swelling agent - succimer/chemet); if the poison reached
the blood already
• Redness
• Itchy Skin
COMMON ANTIDOTES
→ Management:
→ Anticholinergics SNS - cholinergics PSNS
• PRIORITY: Remove stinger, scrape with card
→ Acetaminophen - N acetylcysteine
1. Lower site
→ Benzodiazepine - flumazenil
2. Immobilize
3. Cold compress → Beta blockers - glucagon
4. Klean the wound (first thing to do) → Calcium channel blockers - glucagon
→ Digoxin - digibind/digifab
→ Heparin - protamine sulfate
→ Iron - defuroxime
→ Magnesium sulfate - calcium gluconate
→ Nitrate - methylene blue
→ Opioid - naloxone
→ Thrombolytics - aminocaproic acid
→ Warfarin - vitamin K, green leafy vegetables