EMERGENCY AND DISASTER NURSING

(Doing the best for the most, with the least, by the fewest)

LECTURE NOTE

Prepared For:
POST-BASIC & GENERAL NURSING
STUDENTS
BY
COMRADE NURSE ISMAIL ISHAQ MTEL
(07033331353)
[email protected], [email protected]

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 JANUARY, 2023
COURSE INTRODUCTION
The course; Emergency and Disaster Nursing is designed to prepare students Nurses to
care for patients suffering from sudden and or life-threatening injury or illness. The
students will be equipped with the knowledge and skills required for caring for a wide
range of life-threatening conditions. The students will also be able to provide priority
care to victims of accidents/disaster before transfer for specialized care.
Course Objectives
After successful completion of this course, the students are expected to:
1. Explain the concepts and principles associated with emergency and disaster care.
2. Identify and sort emergency and life-threatening conditions.
3. Demonstrate the ability to use relevant Basic Life-Saving and support aids.
4. Manage emergencies and life-threatening situations.
Course Content:
Unit I: Concepts and Principles of Emergency Care

 Definition of terms and concepts

 Aims, elements and principles associated with emergency and disaster care.

 Disaster: human and natural disasters

 Disaster preparedness
 Agencies for disaster Management; local, state, national and
international organizations.
 Global and local burden of disaster management.
Unit II: Emergencies and Life-Threatening Situations

 Classifications of Emergencies and life-threatening conditions

 Causes of emergencies and life-threatening conditions

Unit III: Management of Emergencies Using Basic Life-Saving and Support Aids

 Triage system

 Assessment

 Crowd management

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  ABCDEF of resuscitation

 Artificial respiration

 Mechanical ventilation

 Cardio-Pulmonary Resuscitation (CPR)

 Medical Evacuation

 Management of victim en-route the hospital

Unit IV: Management of Patient in Hospital Emergency Department (ED) and Advanced
Life-Support

 Tracheotomy

 Use of electronic monitor

 Automatic external Defibrillator

 Advanced Cardiovascular Life-Support

Unit V: Disaster Management (Basic)

 Rapid Response Centers

 Disaster Monitoring

 Search and Rescue

 Medical Intervention and Relief

 Physical and Psychological Support

 Multi and Inter-sectoral Collaboration in Disaster Management

 Public information, Education and Disaster Prevention.

UNIT I: CONCEPTS AND PRINCIPLES OF EMERGENCY AND DISASTER CARE

Introduction

 Emergency and Disaster Nursing is a Specialty within the field of Nursing

Profession focusing on the care of patients with Traumatic and Medical
Emergencies that is, those who require prompt Medico-Surgical attention to
avoid long term disability or death.
 The scope of Emergency Nursing practice involves the assessment, diagnosis
and treatment or evaluation of actual or potential sudden or urgent physical or

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 psychological problems that are primary episode or acute that occurs in variety
of settings.
 The term emergency management traditionally refers to care given to patients
with urgent and critical needs. Because many people lack access to health care,
however, the emergency department (ED) is increasingly used for non-urgent
problems. Therefore, the philosophy of emergency management has broadened
to include the concept that an emergency is whatever the patient or the family
considers it to be.

Note:this lecture note covers unit I-III only.

Definitions of Terms and Concepts in Emergency and Disaster Nursing

 The term Emergency: is referred to as an unforeseen combination of

circumstances which calls for an immediate action.
 Emergency Nursing: Can be define as the provision of immediate nursing care to
people who have defined their problems as an emergency, or where nursing
intervention may prevent an emergency crisis.
 Disaster: Disaster refers to a sudden event such as a flood, storm, or accident
which causes great damage or suffering.
 Disaster can also be defined as an occurrence disrupting the normal conditions
of existence and causing a level of suffering that exceeds the capacity of
adjustment of the affected community.
 Disaster Nursing: can be defined as the adaptation of professional nursing
knowledge, skills and attitude in recognizing and meeting the nursing, health and
emotional needs of disaster victims.
 Accident: Is an unpleasant, unfortunate or undesired event or incident that
occurred without notice resulting to damage or injury to life, property or death.
Different types of accident includes; Road traffic accident or crashed popularly
known as (RTA), Domestic accident, occupational accident, Fall from height,
Cases of assaults, Armed robbery attacks, Gunshots injuries among others.
 Resuscitation: is referred to as restoration to life or consciousness of one
apparently dead, or whose respirations had ceased. It can also be defined as
administering emergency measures to sustain life.
 Cardiopulmonary resuscitation (CPR): Is an Emergency procedure that contains
chest compression with artificial ventilation in an effort to preserve brain
function to restore blood circulation or breathing
 First Aid: is the immediate treatment of any injury or sudden illness before
professional medical and nursing care can be provided to preserve life.
 Hazard: is referred to a natural or human-made event that threatens to adversely
affect human life, property or activity to the extent of causing an emergency or
disaster.
 Vulnerability: Vulnerability is the condition determined by physical, social,
economic and environmental factors or processes, which increase the
susceptibility of a community to the impact of hazards.
 Risk: Risk is the probability of harmful consequences, or expected losses (deaths,
injuries, property, livelihoods, economic activity disrupted or environment

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 damaged) resulting from interactions between natural or human-induced hazards
and vulnerable conditions. Risk is conventionally expressed by the equation: Risk
= Hazard x Vulnerability
 Trauma: Is a sudden physical or psychological injury caused by external force or
distress.
 Preparedness: Preparedness is referred to as the measures that ensure the
organized mobilization of personnel, funds, equipment and supplies within a safe
environment for effective relief
 Mitigation: Permanent reduction of the risk of disaster
 Resilience: Adaptability, or capacity to recover from emergency or disaster
 Response: The set of activities implemented after the impact of an emergency or
disaster in order to assess the needs, reduce the suffering, limit the spread and
the consequences of the emergency or disaster, and open the way to
rehabilitation of emergency and disaster victims.
 Rehabilitation: The restoration of basic social functions of an emergency or
disaster victims.

Concept of Emergency Nursing

 The word "Emergency" means different things to different people. Emergency

can be defined as any trauma or sudden illness that requires immediate
interventions to prevent inmate severe damage or death.
 The term emergency is used for those patients who require immediate action to
prevent further deteriorations or stabilizing the condition till the availability of the
services close to the patients is attained.
 Emergency care is giving to patients and people of all ages with diagnosis,
undiagnosed or misdiagnosed problems of varying complexity.
 We do not expect emergency or disaster, but they happen with living, as a result
of natural calamities, the individual and technological advances; from expedient,
socio-economic and political stagnation and war etc.
 Disaster either man-made or natural may be inevitable, but there are methods to
prevent or manage the way, people and their communities respond to disaster.
 Therefore, nurses have an important role to play during a disaster to save the
lives and to provide healthcare to the victims.
 It is the people who matter most, and without the people we have no
Emergency and no disaster.

There are various types of Emergency viz:

Traumatic Emergency Respiratory Emergency
Cardiovascular Emergency Neurological Emergency
Gastrointestinal Emergency Musculoskeletal Emergency
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Hematological Emergency ENT Emergency
Endocrine and Metabolic Emergency Obstetrics & Gynecology Emergency
Genitourinary Emergency Poisoning and Substance abuse
Burns and Shock etc

Scope of Emergency Nursing

The scope of Emergency Nursing practice involves the assessment, diagnosis and
treatment or evaluation of actual or potential sudden or urgent physical or psychological
problems that are primary episode or acute that occurs in variety of settings.

AIMS, ELEMENTS AND PRINCIPLES OF EMERGENCY AND DISASTER CARE

Principles of Emergency Nursing (ABCD)

 Airway (Establish a patent airway)

 Breathing (Provide adequate ventilation)
 Circulation (Control hemorrhage, prevent and manage shock, maintain and
restore effective circulation)
 Disability (Evaluate the neurological status of the client, check and manage
disability)
 Carry out a rapid initial and ongoing physical assessment

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Priority of Emergency Management

 The first priority is to save lives

 A patient who is unconscious and severely injured may be close to death;

therefore, the rescuers must assess the situation and begins prompt treatment
as needed as possible.

 Maintain ABCs i.e. Patient airways, breathing, and circulations.

 In case of injuries, and if many people were involved and injured, the most
serious injured victims should be treated first.

 Assessment should take place less than one (1) minute per injured patient.

 In each case, you should consider whether the situation is:

a. Life threatening
b. Urgent but not life threatening
c. Not urgent

 Difficulty in breathing and massive bleeding are life threatening, but a broken
bone (Fractures) can almost always wait for treatment no matter how painful.

 When there are many people with serious injuries and resources are limited, you
may need to provide treatment only to those who you believe have a chance of
surviving.

Four Basic Emergency Action Principles

1. Survey the Scene

 If any kind of danger is threatening, do not approach the casualty; call EMS
immediately for professional help
2. Check the Casualty for any Unresponsiveness
3. If the person does not respond, call EMS immediately
4. Check the casualty’s Airway, Breathing, Circulation and Disability (ABCD’s)

 Try to clear the airway without moving the patient

ASSESSMENT AND INTERVENENTION FOR EMERGENCY VICTIMS IN EMERGENCY
DEPARTMENT (ED)

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  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.

 A systematic approach to effectively establishing and treating health priorities is

the primary survey/secondary survey approach.

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:

 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

Nurses Roles in Emergency Care

 The emergency nurse has had specialized education, training, and experience to
gain expertise in assessing and identifying patients’ health care problems in
crisis situations.
 The emergency nurse establishes priorities
 Monitors and continuously assesses acutely ill and injured patients
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  Supports and attends to families of the victims of emergencies
 Supervises allied health personnel
 Teaches patients and families within a time-limited high-pressured care
environment.
DISASTER
What is a Disaster?
1. WHO (2014), defines Disaster as any occurrence that causes damage, ecological
disruption, loss of human life, deterioration of health and health services, on a
scale sufficient to warrant an extraordinary response from outside the affected
community or area.
2. Red Cross (1975) defines Disaster as “An occurrence such as hurricane,
tornado, storm, flood, high water, wind-driven water, tidal wave, earthquake,
drought, blizzard, pestilence, famine, fire, explosion, building collapse,
transportation, wreck, or other situation that causes human suffering or creates
human that the victims cannot alleviate without assistance.”
3. UNDP (2004) defines Disaster “as a serious disruption triggered by a hazard,
causing human, material, economic or (and) environmental losses, which exceed
the ability of those affected to cope.”
4. Disaster can be defined as “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.”
5. Disaster may also be termed as “a serious disruption of the functioning of
society, causing widespread human, material or environmental losses which
exceed the ability of the affected society to cope using its own resources.”
6. Disaster is an occurrence arising with little or no warning which causes serious
disruption of life and perhaps death or injury to large number of people.
7. Disaster is a result of vast ecological breakdown in the relation between humans
and their environment, as serious or sudden event on such scale that the stricken
community needs extraordinary efforts to cope with outside help or international
aid.
8. It may be manmade or natural event that causes destruction and devastation
which cannot be relieved without assistance.
Features of Disaster

 Unpredictability

 Unfamiliarity

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  Speed

 Urgency

 Uncertainty

 Threat

Aims/Goals of Disaster Management: The overall goal of disaster nursing is to achieve

the best possible level of health for the people and the community involved in the
disaster.
1. Reduce, or avoid, losses from hazards
2. Assure prompt assistance to victims
3. Achieve rapid and effective recovery.
Types of Disasters

 Natural e.g. earthquake, floods, hurricane.

 Manmade e.g. nuclear accidents, industrial accident.

 Hybrid e.g. spread of disease in community, global warning

Levels of Disaster

 Level III: Considered a minor disaster; this involves minimum level of damage.
Local emergency response personnel and organization can contain and
effectively manage the disaster and its aftermath.

 Level II: Moderate disaster; local and community resource has to be mobilized to
manage the situation. State and aid from surrounding communities are sufficient.

 Level I: Massive disaster; this involve massive level of damage with severe
impact. Local and State assets are overstretched, Federal Assistance is required.
Phases of a Disaster
There are four phases of disaster:

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 Figure 1 Phases of Disaster

1. Pre-Impact Phase
 It is the initial phase of disaster, prior to the actual occurrence.
 A warning is given at the sign of the first possible danger to a
community.
 With the aid of weather, networks and satellite many
meteorological disasters can be predicted. Communication is a
very important factor during this phase.
 The role of the nurse during this warning phase is to assist in
preparing shelters and emergency aid stations and establishing
contact with other emergency service group.
2. Impact Phase
 The impact phase occurs when the disaster actually happens.
 It is a time of enduring hardship or injury, and of trying to survive.
 This phase may last for several minutes (e.g. after an earthquake,
plane crash or explosion.) or for days or weeks (e.g. in a flood,
famine or epidemic).
 The nurse is responsible for security, shelter and psychological
support to victims.

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 3. Post – Impact Phase
 Recovery begins during the emergency phase and ends with the
return of normal community order and functioning.
 For persons in the impact area this phase may last a lifetime (e.g. –
victims of the boko-haram bombings in Borno).
4. Rehabilitation Phase
 It involves those activities undertaken by a community and its
components after an emergency or disaster, to restore minimum
services and move towards long-term restoration
The victims of disaster go through four stages of emotional response:
1. Denial: The victims may deny the magnitude of the problem or have not fully
registered the problem.
2. Strong Emotional Response: The person is aware of the problem but regards it
as overwhelming and unbearable. Common reaction is tightening of muscles,
speaking with the difficulty, etc. The victim may want to retell or relieve the
disaster experience over and over.
3. Acceptance: The victim begins to accept the problems caused by the disaster
and makes a concentrated effect to solve them. It is important for victims to take
specific action to help themselves and their families.
4. Recovery: The period of recovery from the crisis reaction. Victims feel that they
are back to normal. A sense of well-being is restored. Victims develop the
realistic memory of the experience.
EMERGENCY AND DISASTER PREPAREDNESS
 Emergency preparedness and response is a program of long-term development
activities whose goals are to strengthen the overall capacity and capability of a
country to manage efficiently all types of emergency and bring about an orderly
transition from relief through recovery and back to sustainable development.
 Disaster preparedness is an ongoing multi-sectoral activity.
 It forms an integral part of the national system responsible for developing plans
and programs for disaster management.
 It is essential for instance, to consider the healthcare delivery system and the
public health infrastructure as an integrated whole in planning for, responding to
or recovering from large-scale disasters.
 We can do better by applying lessons learnt from previous disasters to the
planning for future events. Even though experience is the best teacher, basic
science can and should form disaster policy.

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 DISASTER MANAGEMENT CYCLE
Disaster Management: Disaster management can be referred to as the organization
and management of resources and responsibilities for dealing with all humanitarian
aspects of emergencies, in particular preparedness, response and recovery in order to
lessen the impact of disasters.
Disaster Event
This refers to the real-time event of a hazard occurring and affecting the elements at
risk. The duration of the event will depend on the type of threat, for example, ground
shaking may only occur for a few seconds during an earthquake while flooding may
take place over a longer period of time.

Figure 2 Disaster Management Cycle

Phases of Disaster Management Cycle
There are five basic phases of disaster management cycle:
1. Mitigation

 Minimizing the effects of disaster.

 Examples: building codes and zoning; vulnerability analyses; public

education.

2. Preparedness

 Planning how to respond

 Evaluate the facility’s vulnerabilities or propensity for disasters

 Issues to consider include; weather patterns, geographic location,

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 location of the facility, and industries in close proximity to the hospital
(e.g., nuclear power plant or chemical factory).

 Examples: preparedness plans; emergency exercises/training; warning

systems.
3. Response:

 Efforts to minimize the hazards created by a disaster

 It is a series of activities a hospital, healthcare system, or public health

agencies take immediately during, and after a disaster or emergency.

 Examples: search and rescue; emergency relief.

4. Recovery:

 Returning of the community to normal

 Recovery is usually easier if, during the response, some of the staff have
been assigned to maintain essential services while others were assigned
to the disaster response. Examples: temporary housing; grants; medical
care.
5. Evaluation/Development

 After a disaster, employees and the community are anxious to return to

usual operations.

 It is essential that a formal evaluation be done to determine what went

well (what really worked) and what problems were identified.

 A specific individual should be charged with the evaluation and follow-up

activities.
AGENCIES FOR DISASTER MANAGEMENT (Local, National, and International
Organizations)
Emergency and relief agencies play a major role when disasters occur. Federal, state-
wide, and local, non-governmental and or volunteer organizations all offer important
resources for disaster preparedness and recovery
International Organizations (Agencies)
 The International Committee of the Red Cross (ICRC)
 World Health Organization (WHO)
 The International Federation of Red Cross and Red Crescent Societies (IFRCRCS)
 United Nations Development Programme (UNDP)

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  Food and Agriculture Organisation of the UN (FAO)
 United Nations High Commission for Refugees (UNHCR)
 Medicines Sans Frontieres (MSF)
 United Nations Children’s Emergency Fund (UNICEF)
 Oxfam International

National Agencies/Organisations
 National Emergency Management Agency (NEMA)
 National Orientation Agency (NOA)
 National Environmental Standards and Regulations Enforcement Agency
(NESREA)
 Federal Emergency Management Association (FEMA)
 Federal Fire Service (FFS)
 Federal Road Safety Commission (FRSC)
Local/State Agencies
 States’ Emergency Management Agencies (SEMAs)
 Federal Fire Service (FFS)
 Youths Against Disasters (YADI)
 Executive Volunteer Group (EVG)
 Emergency Youth Vanguards (EYV)
 Journalists Against Disasters (JAD)
 Man O War among others.
Global and Local Burden of Disaster Management
 Natural and man-made catastrophes have caused significant destruction and
loss of lives throughout human history.
 Disasters accompany a wide variety of events with multiple causes and
consequences often leading to a cascade of related events. African continent
has not been spared of these events.

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  A new phenomenon in the continent is terrorism that is fuelled by globalization of
arms trade and has contributed significantly to escalation of conflicts in sub-
Saharan Africa (SSA) resulting in complex emergencies and destruction of
socioeconomic structures.
 Complex emergencies, including; religious, ethnic and social conflicts, continue
to affect tens of millions of people, causing internal and external displacement of
people. In 2010, there were an estimated total of 27 million persons who
remained internally displaced by armed conflict across the world.
 On August 2011, the city of Ibadan in Oyo state witnessed some of the worst
flood disasters in Nigeria’s history which inevitably resulted in the death of
scores of persons and the destruction of property worth more than N20 Billion
and in all of these unfortunate natural disaster which was made worst by total
lack of enforcement of building standards, the quality of disaster management
experienced by the victims can at best be described as disastrous.
 It is estimated that about 1 million lives are lost from 2010-2017 as a result of
disastrous diseases like meningitis, cholera e.t.c.
 Therefore, as floods continue to submerge communities, displacing thousands
of Nigerians and destroying property worth millions of naira; as erosion
continues to destroy lands and buildings in parts of the South- East, bombs
continue to explode across the nation, especially in the North, killing hundreds of
innocent souls, and kidnapping as well as cattle rustling remain alarming, the
agencies concerned with emergency and disaster management, e.g. the National
Emergency Management Agency (NEMA) are faced with the onerous task
(burden) of coordinating disaster mitigation, reduction and management.
 The total absence of disaster management and response initiative in the county
is worst at the level of the local council because most of these 774 local
government area councils have become dysfunctional because of the
undemocratic tendencies of state governors that have largely failed to respect
section 7 of the constitution by ensuring that democratic structures are
institutionalized at the grass root level.
 Nigeria must go back to the drawing board, design and implement effective
disaster management agenda and ensure that at every level from the local
council to the Federal, effective disaster management and rescue infrastructure
are put to work.
 Therefore, there is an urgent need for national emergency agencies/departments
across Nigeria and Africa to develop a robust emergency preparedness and
response plan.
 Every hospital should have a disaster management committee with flexible
disaster management plan to respond to these catastrophes.
Health Effects of Disasters

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The health effects of disasters may be extensive and broad in their distribution across
populations. However, Disasters affect the health status of a community in the
following ways:
1. Disasters may cause premature deaths, illnesses, and injuries in the affected
community, generally exceeding the capacity of the local health care system.
2. Disasters may destroy the local health care infrastructure. Disruption of routine
health care services and prevention initiatives may lead to long-term
consequences in health outcomes in terms of increased morbidity and mortality.
3. Disasters may create environmental imbalances, increasing the risk of
communicable diseases and environmental hazards.
4. Disasters may affect the psychological, emotional, and social well-being of the
population in the affected community. Depending on the specific nature of the
disaster, responses may range from fear, anxiety, and depression to widespread
panic and terror.
5. Disasters may cause shortages of food and cause severe nutritional deficiencies.
6. Disasters may cause large population movements (refugees) creating a burden
on other health care systems and communities. Displaced populations and their
host communities are at increased risk for communicable diseases and the
health consequences of crowded living conditions.
Nurses Roles in Disasters
“Disaster preparedness, including risk assessment and multi-disciplinary management
strategies at all system levels, is critical to the delivery of effective responses to the
short, medium, and long-term health needs of a disaster-stricken population.”
(International Council of Nurses, 2006), It is important for Nurses to remember that
nursing care in a disaster focuses on essential care from a perspective of what is best
for all patients.
However, the role of a nurse during a disaster varies, depending on the needs and
intensity of the disaster event:
1. Determine magnitude of the event
2. Define health needs of the affected groups
3. Establish priorities and objectives
4. Identify actual and potential public health problems
5. Determine resources needed to respond to the needs identified
6. Collaborate with other professional disciplines, governmental and non-
governmental agencies

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 7. Maintain a unified chain of command
8. A nurse may during a disaster provide temporary shelter, care in a temporary
housing area or bereavement, support and assist in identification of deceased
loved ones.
9. The nurse may participate in counseling other staff members and lots more.
10. In the care of Disaster victims, The nurse must constantly be aware of:
 Language difficulties that increase fears and frustration
 Hygiene or diet
 Specific places or times for prayer
 Rituals about handling the dead
 A timing for funeral services
 Specific religious practices related to medical treatment
UNIT II: EMERGENCIES AND LIFE-THREATENING SITUATIONS

 Emergency conditions are those life threatening conditions which are most often
sudden and at the same time require immediate medical or surgical interventions.

 Such conditions include; Heart Attack/ stroke/CVA, Extreme difficulty in

breathing, Severe bleeding or severe cuts, Broken bone (Fractures), Poisoning,
Acute abdominal pain, Severe allergic reactions, Minor Burns and lacerations,
Acute GIT bleeding, Comas, Head injuries/ TBI, Acute gastroenteritis, Seizures,
Vaginal bleeding, Spinal cord injuries, Asthma/ COPD, Respiratory Failures,
Chocking, Drowning, Smoke inhalation, Nasal bleeding, Gunshots injuries, Bites
e.g. snake bite, Hypertensive Emergency, Urine retention etc.
Causes of Emergencies and Life-Threatening Conditions
Emergencies are results of one or more of the following hazardous events;

 Fire

 Explosion

 Accident (Car, plane, Train, Motorcycle, bicycle, and tricycle).

 Chemical, Biological, Nuclear

 Collapse (Building), Burial, Drowning

 Natural disaster (Flood, Storm, Earthquake). Depending on the size and the
impact on life and health of the population.

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 UNIT III: MANAGEMENT OF EMERGENCIES USING BASIC LIFE-SAVING &SUPPORT
AIDS

What is Basic Life-Saving Support?

 Basic life support is the maintenance of an airway and the support of breathing
and the circulation without using equipment other than a simple airway device or
protective shield
 During BLS, rescuers provide and maintain oxygen supplies to victims by using
chest compressions to maintain blood circulation and ventilations to maintain
oxygen levels.
Key steps in BLS include:
 Check for responsiveness, and activate emergency medical services (EMS).
 Quickly check for normal breathing
 If the patient is not breathing normally, provide chest compressions to
temporarily take over the function of the heart and circulate blood
 Open the airway, and provide ventilations to deliver air to the lungs
What is a Triage System?
 The word triage is derived from the French word trier, which means, “to sort out
or choose.” The Baron Dominique Jean Larrey, who was the Chief Surgeon for
Napoleon, is credited with organizing the first triage system.
 “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).
 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
resources (Auf der Heide, 2000).
Concept of Triage
 Triage has been defined as the sorting of patients to determine the priority of
their health care needs and the proper site for treatment.
 In Emergency department, patients are not attended to on the basis of "First
come first serve" but on the basis of severity of their conditions. In a simple term

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 triage refers to a system where by causalities or patients are sorted according to
the seriousness of their injuries.
 Triage is also practiced during disaster management such as fire outbreak,
flooding, earthquake, terrorisms, bomb last, collapsed building, etc. In this case,
the triage officer rapidly assess those injured and immediately tagged with
appreciate colour code.
 However, in a disaster when health care providers are faced with a large number
of casualties, the fundamental principles guiding resource allocation is to do the
greatest good for the greatest number of people. Decisions are based on the
likelihood of survival and consumption of available resources. Therefore, this
same patient and others with conditions associated with high mortality rate
would be assigned a low triage priority in a disaster situation, even if the person
is conscious. Although this may sound uncaring from an ethical stand point the
expenditure of limited resources on people with low chance of survival and denial
of those resources to others with serious but treatable conditions cannot be
justified.

Why do we need a Disaster Triage?

1. Inadequate resource to meet immediate needs
2. Infrastructure limitations
3. Inadequate hazard preparation
4. Limited transport capabilities
5. Multiple agencies responding
6. Hospital Resources Overwhelmed
Goals of Triage
The main goal of Triage is to get the Right patient to the Right place at the Right time for
the Right reason to receive the Right treatment
Aims/Purpose/Objectives of Triage
1. In pre hospital settings is to ensure that patients who need immediate medical
care and transportation to the appropriate hospital are first attended to.
2. In the hospital settings, it helps to identify who requires immediate Care.
3. Is to also ensure, judicious use of human and material resources for the
appropriate patients.
4. To recognize futility (hopeless conditions)

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Principles of Triage: The main principles of triage are:
1. Every patient should receive and triaged by appropriate skilled health-care
professionals.
2. Triage is a clinic-managerial decision and must involve collaborative planning.
3. The triage process should not cause a delay in the delivery of effective clinical
care.
Types of Triage
There are two types of triage: (1) Simple triage and (2) Advanced triage
1. Simple Triage
 Simple triage is used in a scene of mass casualty, in order to sort patients
into those who need critical attention and immediate transport to the
hospital and those with less serious injuries.
 This step can be started before transportation becomes available.
 The categorization of patients based on the severity of their injuries can
be aided with the use of printed triage tags or colored flagging.
Simple Triage separates the injured into four groups:
1. 0 – The deceased who are beyond help
2. 1 – The injured who can be helped by immediate transportation
3. 2 – The injured whose transport can be delayed
4. 3 – Those with minor injuries, who need help less urgently
2. Advanced Triage
 In advanced triage, triage team leader may decide that some seriously
injured people should not receive advanced care because they are unlikely
to survive.
 Advanced care will be used on patients with less severe injuries. Because
treatment is intentionally withheld from patients with certain injuries,
advanced triage has an ethical implication.
 It is used to divert scarce resources away from patients with little chance
of survival in order to increase the chances of survival of others who are
more likely to survive.
Principles of Advanced Triage
“Do the greatest good for the greatest number”

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  Preservation of life takes precedence over preservation of limbs.

 Immediate threats to life should be considered first e.g. Hemorrhage.

Note that; If borderline decisions are encountered, always triage to the most urgent
priority. Example: If unsure whether the patient is green or yellow, the patient should be
tagged yellow
Triage Reminder: as a triage officer you should remember that;
1. You DO NOT decide who lives or dies
2. The sooner you start Triage the sooner the medical care process starts
3. Triage is an ongoing process that is repeated many times
4. If you forget any of the above rules, go back to rule number 1.
Triage Categories
 Triage categories separate patients according to severity of injury.
 A special colour coded tagging system is used during a Mass Casualty Incident
(MCI) so that the triage category is immediately obvious.
 Emergency department use various triage systems depending on the hospital
settings or policy or country, but the basic and widely used triage system is the
four (4) categories namely:
1. Emergent (Red Code):
 Signifies Immediate and life threatening injuries or illness requiring
immediate intervention
 This casualty needs immediate medical attention and has to be
transported as soon as possible.
 Cases under this category include: Airway obstruction or poor
breathing, Open chest or abdominal injuries, severe head injury or
coma, Cardiac arrest, acute heart failure etc.
2. Urgent (Yellow Code)
 Is a triage code signifying serious injury or illness that is not
immediate life threatening.
 The casualty in this category needs medical attention and has to be
transported as soon as practically possible.
 However, if care is not provided for a long period of time they may
suffer irreversible damages

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  Examples includes: Major or multiple lacerations including
fractures, Moderate or severe bruises, Drug overdose or suspected
poisoning, Spinal cord injuries, and Intestinal obstruction.
3. Non urgent (Green Code)
 Is a triage category signifying walking wounded or episodic and
minor injury or illness in which treatment may be delayed several
hours’
 This casualty requires medical attention after red yellow classified
victims have been treated. Example; soft tissue injuries, minor
fracture or dislocations, nail puncture, sprain and strain, etc.
4. Expectant (Blue or Black Code):
 This category is used for those causalities and patients who has No
or small chances of survival or are obviously dead
 No transport, only observation and if possible administration of
analgesics. They should be covered and separated from those
patients/ causalities that are alive
TABLE 1: Advanced Triage Categories

CLASS I (EMERGENT) RED IMMEDIATE

– Victims with serious injuries that are life threatening but has a high probability of
survival if they received immediate care.
– They require immediate surgery or other life-saving intervention, and have first priority
for surgical teams or transport to advanced facilities; they “cannot wait” but are likely to
survive with immediate treatment.
“Critical; life threatening—compromised airway, shock, hemorrhage”
CLASS II (URGENT) YELLOW DELAYED
– Victims who are seriously injured and whose life is not immediately threatened; and
can delay transport and treatment for 2 hours.
– Their condition is stable for the moment but requires watching by trained persons and
frequent re-triage, will need hospital care (and would receive immediate priority care
under “normal” circumstances).
“Major illness or injury;—open fracture, chest wound”
CLASS III (NON-URGENT) GREEN MINIMAL
– “Walking wounded,” the casualty requires medical attention when all higher priority
patients have been evacuated, and may not require monitoring.
– Patients/victims whose care and transport may be delayed 2 hours or more.
“minor injuries; walking wounded—closed fracture, sprain, strain”
CLASS IV (EXPECTANT) BLACK EXPECTANT
They are so severely injured that they will die of their injuries, possibly in hours or days
(large-body burns, severe trauma, lethal radiation dose), or in life-threatening medical
crisis that they are unlikely to survive given the care available (cardiac arrest, septic

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 shock, severe head or chest wounds);
They should be taken to a holding area and given painkillers as required to reduce
suffering.
“Dead or expected to die—massive head injury, extensive full-thickness burns”

TABLE 2: Using Rpm to Classify Patients

CATEGORY (COLOR) RPM INDICATORS

Critical (RED) R = Respiratory rate> 30;
P = Capillary refill> 2 seconds;
M = Doesn’t obey commands
Urgent (YELLOW) R< 30
P< 2 seconds
M = Obeys commands
Expectant: dead or dying (BLACK) R = not breathing

National Triage Scale

Table 3: Triage Scale

National triage scale Colour Time

Immediate resuscitation Red Immediately

Every urgent Orange Within 5-10mns

Urgent Yellow Within 1hr

Standard Green Within 2hrs

Non urgent Blue Within 4hrs

Advantages of Triage
1. Helps to bring order and organization to a chaotic scene.
2. It identifies and provides care to those who are in greatest need
3. Helps make the difficult decisions easier
4. Assure that resources are used in the most effective manner
5. May take some of the emotional burden away from those doing triage
ASSESSMENT IN EMERGENCY MANAGEMENT
 The first step in any emergency response is to assess the extent and impact of

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 the damage caused by the disaster or emergency situations (the needs) and the
capacity of the affected population to meet its immediate survival needs (degree
of vulnerability).
 Rapidly assess any danger to the patient and yourself from hazards such as gas,
electricity, fire, or traffic because there is no sense in having two patients.
 Establish whether the patient is responsive by gently shaking his or her shoulders
and asking loudly “Are you all right?” Be careful not to aggravate any existing
injury, particularly of the cervical spine
 Poorly conducted assessment is likely to lead to poor planning decisions and
inadequate response. This often has consequences beyond the emergency
phase and can affect recovery efforts too.
CROWD MANAGEMENT
 Dealing with traffic and crowds in emergency and disaster situations can be
challenging and dangerous
 Basic Incidence Command System(ICS) structure is established by person who
arrives first on scene
 Maintain personal safety by:
 Wearing correct attire and PPE e.g. gloves, mask etc.
 Behaving appropriately
 Recognizing personal limits
 Asking for assistance or relief
 Backing away from dangerous situations
 The triage officer rapidly assesses those injuries at the crowded disaster scene
and Patient are immediately tagged and transported or given life saving
interventions.
 Staff should control all entrances to the acute care facility so that incoming
patients are directed to the triage area first.
 The triage should be outside the entry or just at the door of E.D. This allows all
patients including those arriving by medical transport and those who walk in to
be triaged and treated.
ABCDEF OF RESUSCITATION
The ABCDEF approach is the use of the Airway, Breathing, Circulation, and Disability,
Exposure (ABCDE) approach to assess and treat the patient in critical situations.

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 Figure 3 ABCDE of Resuscitation

Airway (A)
 Establishing and maintaining an airway is the single most useful maneuver that
the rescuer can perform.
 Loosen tight clothing around the patient’s neck.
 Extend, but do not hyperextend, the neck, thus lifting the tongue off the posterior
wall of the pharynx. This is best achieved by placing your hand on the patient’s
upper forehead and exerting pressure to tilt the head.
 Remove any obvious obstruction from the mouth; leave well fitting dentures in
place. Place two fingertips under the point of the chin to lift it forwards. This will
often allow breathing to restart.
 Look, listen, and feel for breathing: look for chest movement, listen close to the
mouth for breath sounds, and feel for air with your cheek. Look, listen, and feel
for 10 seconds before deciding that breathing is absent.
Breathing (B)
 If breathing is absent, send a bystander to telephone for an ambulance.
 If you are on your own, go yourself.
 The exception to this rule is when the patient is a child or the cause of the
patient’s collapse is near drowning, drug or alcohol intoxication, trauma, or
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 choking. Under these circumstances it is likely that you are dealing with a primary
respiratory arrest and appropriate resuscitation should be given for about one
minute before seeking help.
 Return to the patient and maintain an airway by tilting the head and lifting the
chin. Pinch the nose closed with the fingers of your hand on the forehead.
 Take a breath, seal your lips firmly around those of the patient, and breathe out
until you see the patient’s chest clearly rising.
 It is important for each full breath to last about two seconds.
 Lift your head away, watching the patient’s chest fall, and take another breath of
air.
 The chest should rise as you blow in and fall when you take your mouth away.
Each breath should expand the patient’s chest visibly but not cause over-inflation
as this will allow air to enter the oesophagus and stomach.
 Subsequent gastric distension causes not only vomiting but also passive
regurgitation into the lungs, which often goes undetected.
 If the patient is still not breathing after two rescue breaths (or after five attempts
at ventilation, even if unsuccessful), check for signs of a circulation.
 Look and listen for any movement, breathing (other than an occasional gasp), or
coughing.
 Take no more than 10 seconds to make your check.

Circulation (C)
 If there are no signs of a circulation (cardiac arrest) it is unlikely that the patient
will recover as a result of CPR alone, so defibrillation and other advanced life
support are urgently required.
 Ensure that the patient is on his or her back and lying on a firm, flat surface, then
start chest compressions.
 The correct place to compress is in the centre of the lower half of the sternum.
To find this, and to ensure that the risk of damaging intra-abdominal organs is
minimised, feel along the rib margin until you come to the xiphisternum.

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  Place your middle finger on the xiphisternum and your index finger on the bony
sternum above, then slide the heel of your other hand down to these fingers and
leave it there.
 Remove your first hand and place it on top of the second. Press down firmly,
keeping your arms straight and elbows locked. In an adult compress about 4-5
cm, keeping the pressure firm, controlled, and applied vertically.
 Try to spend about the same amount of time in the compressed phase as in the
released phase and aim for a rate of 100 compressions /min (a little less than
two compressions per second).
 After every 15 compressions tilt the head, lift the chin, and give two rescue
breaths.
 Return your hands immediately to the sternum and give 15 further compressions,
continuing compressions and rescue breaths in a ratio of 15: 2If two trained
rescuers are present one should assume responsibility for rescue breaths and
the other for chest compression.
 The compression rate should remain at 100/min, but there should be a pause
after every 15 compressions that is just long enough to allow two rescue breaths
to be given, lasting two seconds each.
 Provided the patient’s airway is maintained it is not necessary to wait for
exhalation before resuming chest compressions
Disability (D)
 Common causes of unconsciousness include profound hypoxia, hypercapnia,
cerebral hypo-perfusion, or the recent administration of sedatives or analgesic
drugs.
 Examine the pupils (size, equality and reaction to light).
 Make a rapid initial assessment of the patient’s conscious level using the AVPU
method: Alert, responds to Vocal stimuli, responds to Painful stimuli or
Unresponsive to all stimuli.
 Determine neurologic disability by assessing neurologic function using the
Glasgow Coma Scale
 Measure the blood glucose to exclude hypoglycaemia using a rapid finger-prick
bedside testing method.
 Nurse unconscious patients in the lateral position if their airway is not protected.
Exposure (E)
 To examine the patient properly full exposure of the body may be necessary.

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  Respect the patient’s dignity and minimise heat loss.
ARTIFICIAL RESPIRATION
What is Artificial Respiration?

 Artificial Respiration is referred to as forced introduction of air in to the lungs of

someone who has stopped breathing (respiratory arrest) or whose breathing is
inadequate.

 In emergency first aid, artificial respiration can be given mouth-to-mouth or

mouth-to-nose to prevent brain damage due to oxygen deprivation, or using
ventilator.

 A delay in breathing for more than 6 minutes can cause death

 Cardiac compression may be necessary if poor respiration has led to cessation

of heartbeat.
Method
 Lay the person on his or her back
 Give chest compressions
 Tilt head slightly
 Breathe into the person’s mouth
 Continue until EMS personnel arrive
MECHANICAL VENTILATION
 Mechanical ventilation is a life support treatment in which a machine (ventilator)
is used to takeover or assist breathing
 Mechanical ventilation may be required for a variety of reasons, including the
need to control the patient’s respirations during surgery or during treatment of
severe head injury, to oxygenate the blood when the patient’s ventilatory efforts
are inadequate, and to rest the respiratory muscles.
Goals of Mechanical Ventilation
1. Relieve respiratory distress
2. Decrease work of breathing
3. Improve pulmonary gas exchange
4. Reverse respiratory muscle fatigue
5. Permit lung healing

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 6. Avoid complications

Figure 4 Mechanical Ventilation

Indications for Mechanical Ventilation
The major indication for mechanical ventilation is acute respiratory failure, of which
there are two basic causes:

1. Ventilatory (Hypercapnic respiratory failure)

 Reduced respiratory drive

 Chest wall abnormalities

 Respiratory muscle fatigue

2. Inefficient Gas Exchange (Hypoxic respiratory failure)

 Intrapulmonary shunt

 Ventilation-perfusion mismatch
CARDIOPULMONARY RESUSCITATION (CPR)
What is CPR?

 CPR is an emergency first-aid procedure that is used to maintain respiration and

blood circulation in a person, whose breathing and heartbeats have suddenly
stopped, (one or more vital functions failed).

 It is the administration of life-saving measures to a person who is not breathing

or has suffered a cardiac arrest, and has no a detectable pulse or heartbeat

 The goal of CPR is not to restart the heart but to provide critical blood flow to the
heart and brain and to keep oxygenated blood circulating.

 CPR delays damage to vital organs such as the brain and improves the chances
of successful defibrillation.

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  First, mouth-to-mouth respiration is given

 If this fails to restart breathing, repeated chest compressions, using the heel of
the hands are applied to the lower breast bone until trained help arrives.

 Both measures are used to restore blood circulation to the brain.

 Brain damage is likely to occur if the brain is starved of oxygen for more than 3-6
minutes.
MEDICAL EVACUATION
Medical evacuation is referred to as important steps taken to co-ordinate the prompt
rescue and treatment of those seriously injured or ill in remote and/or difficult to access
locations, and also to communicate the situation to interested persons back at base /
home.
Key points to remember for any evacuation plan:
 Time is critical

 Keep it simple

 Be thorough – always ask yourself “what if?”

 Think robust – it must work!

Medical Facilities for Evacuation

 The end point of any medical evacuation must be to a suitable medical facility,
typically a hospital or clinic.
 Not only should the facility be as close to your location as possible (or at least
easy / quick to access), be available 24/7, but should also be able to provide a
suitable range of emergency medical treatment. This could include specialist
equipment.
Means of Evacuation (Transport)
 You need to know the best means of transport and their response times.
 Transport options could include aircraft, vehicles, boats or even canoes or
animals.
 You need to be realistic about their availability, their reliability and any limitations
on their use e.g. operate at night, in bad weather, can they reach you or will you
need to get to them? Remember, at some point, any casualty will need to be

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 carried – do you have a stretcher? And do you have enough people for this carry?
Evacuation Key Contacts / Communication Options
 Communication is central to any evacuation plan: Ideally, you should have at
least 2 or 3, means of communication with the outside world and/or your
transport / medical facilities e.g. mobile phones, short-wave radios, mobiles,
walkie-talkies etc.
 Know their limiting factors (e.g. range, battery life, charging options, reception,
etc); ensure they work, and that you know how to use them, and know which ones
to use in an emergency
Emergency Evacuation Procedure
 P1- Life-threatening injury / illness: - emergency evacuation to medical provider
by quickest means available
 P2- Non-life threatening injury / illness: – casualty treated and stabilised on
location and evacuated to medical provider using non-emergency services.
 P3- Non-life threatening injury / illness: Can be treated on location, without need
for evacuation.
NB.Nb. P2 & P3 cases may become P1 should the condition of casualty change
Road Traffic Accident/Injuries
 In case of road traffic accident, the immediate step is to call a well-equipped
ambulance
 If the victim is breathing, then he can be placed on his back.
 If there is any visible bleeding, the area should be covered and pressed firmly.
 The victim shouldn’t be given water or forced to sit.
 Don’t move the victim by holding his hands and legs.
 Specific care should be taken to ensure that patient’s neck doesn’t move.
 In case of any visible fracture/ deformity, the area should be supported with a
hard plate or board under the affected part and immobilized using a cloth or tape.
 If the victim is not breathing, then a Cardiopulmonary resuscitation (CPR) is
required. You can start CPR if you are trained in it.
 Ensure that the ambulance is on its way.
 Once the ambulance arrives, the patient should be lifted upon stretcher or stiff
board. The lesser the movement; the lesser are the chances of worsening the
injuries.

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  The ambulance team assesses the patient and commences appropriate
resuscitative measures en-route.
 The Emergency Room is alerted at once to await the arrival of the injured patient.

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