Learning Objectives
By the end of this section, you will be able to:
- Recognize types of traumas often seen in the emergency department
- Discuss forms of abuse often seen in the emergency department
- Identify psychiatric emergencies often seen in the emergency department
- Explain substance use disorders often seen in the emergency department
Many different types of traumas are seen daily in the emergency department. It is important for nurses to understand that not all traumas are treated the same way. Nurses must work within the interdisciplinary team to provide timely, competent care for each unique situation. Most emergency departments throughout the United States are staffed with a wide range of specialists that are able to treat any situation that might be encountered.
Types of Traumas
Before arriving at the hospital, emergency medical services (EMS) call ahead to inform the ED staff about the patient’s initial condition and any life-threatening injuries. The ED nurse then works with the health-care team to anticipate the patient’s needs by setting up any equipment, gathering supplies, and preparing the patient’s room. After the patient arrives at the hospital, the nurse performs the initial assessment. At this point, EMS gives a more in-depth hand-off report. The gold standard for report hand-off involves using the ISBAR method (Dalky et.al., 2020).
Clinical Safety and Procedures (QSEN)
QSEN Competency: Maintaining Quality and Safety During an Emergency
Disclaimer: Always follow the health-care facility’s policy for triaging during an emergency.
Definition: Maintain safety and quality care to patients during an emergent response.
Knowledge: The nurse will assess and triage patients using the ABCDE triage method and appropriately prioritize care, escalating care to the appropriate facility when necessary.
Skill: Demonstrate effective triage strategies. The nurse will:
- Utilize the ABCDE triage method when assessing trauma patients.
- Escalate patient care to the appropriate level of care during the trauma event.
- Stabilize the patient before transport.
- Complete a secondary survey of the patient after they have been stabilized.
- Utilize the SBAR communication tool during handoff.
Attitude: The nurse will adhere to the ABCDE triage method and use the SBAR handoff tool for effective communication when transferring care.
(QSEN Institute, n.d.)
After the patient is stabilized, the nurse performs a secondary, more comprehensive assessment. If additional diagnostic testing is indicated, it is performed at this stage as well. If the current facility lacks the specialized care needed by the patient, they will be transferred to another facility to meet the identified needs. Some specialty facilities include burn units, stroke centers, or mother-baby care. Many kinds of trauma come through the emergency room, regardless of whether it is a small rural facility or a big metropolitan emergency room.
Crush Injuries
Emergency department nurses often encounter patients with crush injuries resulting from motor vehicle accidents or other catastrophic events. A crush injury occurs from prolonged pressure to an area of the body. Many crush injuries result in the loss of a limb or even patient death. Nurses must understand the potential health complications that can develop and recognize any cues of early and/or late deterioration. While these injuries most often occur with a traumatic event, they can also result from prolonged immobilization or anesthesia. Pressure sustained can block the return of the blood to the affected body area causing swelling and damage to muscle tissue and nerves. The muscles then release myoglobin into the bloodstream, along with other cellular components like potassium, magnesium, phosphates, and other chemicals, which can accumulate in toxic levels in the bloodstream. Crush injuries often result in life-threatening diagnoses like compartment syndrome, rhabdomyolysis, and other serious health conditions (Usuda et al., 2023).
Upon initial assessment, the nurse should assess the patient’s skin color, especially the area distal to where the crush injury occurred. The nurse should observe the skin for signs of cyanosis and palpate pulses distal to the area of injury. If pulses are not palpable, the nurse can use a Doppler ultrasound to locate the patient’s pulse. The nurse should also check the patient’s capillary refill time, which should ideally be less than three seconds. In addition, the nurse should ask the patient to move the affected body area, if possible, and ask the patient what they feel when the nurse applies sensation to the affected area (Long et al., 2023).
Nurses should perform neurovascular checks frequently on patients with crush injuries. If there are any notable deviations, this may indicate a worsening of the patient’s condition. The nurse must immediately notify the health-care provider.
Rhabdomyolysis
One potential complication of crush injuries is rhabdomyolysis, the breakdown of skeletal muscle tissue that is often the result of sustained pressure or crushing of the muscles. Nurses will assess for early symptoms of this condition, which include pain, muscle weakness, and tea- or dark red–colored urine (myoglobinuria). The hallmark sign of rhabdomyolysis is significantly elevated CPK levels in the blood. Late symptoms include confusion, malaise, vomiting, and fever (Stanley et al., 2023). If any symptoms of rhabdomyolysis begin to develop, the nurse must alert the health-care provider immediately. In addition, nurses must continuously monitor the patient’s diagnostic labs, such as CPK, CRP, and ESR.
Compartment Syndrome
Compartment syndrome leads to sustained pressure within a muscle compartment. Pressure increases within the muscle compartments to the point that circulation and oxygenation are restricted, and this results in muscle anoxia and necrosis. Permanent functions could be lost if this condition persists for longer than six hours (Torlincasi et al., 2023). The frequency of acute compartment syndrome is estimated to be 7.3 per 100,000 in males and 0.7 per 100,000 in females, with the majority of cases occurring after a crushing trauma (Torlincasi et al., 2023). Diligent and frequent assessment of the patient’s neurovascular system, ideally every 30 minutes, can reduce the occurrence of compartment syndrome. Neurovascular assessment includes checking the patient’s circulation, ability to move extremities, and loss of sensation.
Nursing Care for Crush Injuries
Crush injuries can result in severe complications, such as cardiac arrhythmia, compartment syndrome, internal hemorrhaging, and rhabdomyolysis. Fluid and electrolyte imbalances (e.g., hyperkalemia, hypocalcemia, hypovolemia) are common with crush injuries. It is vital that the nurse recognizes that rapid fluid resuscitation is key to improved outcomes. Recognizing cues for decline in status, prioritizing care, and taking swift action are the keys to providing competent, quality patient care. Nurses will need to perform frequent focused assessments such as the following (Long et al., 2023):
- Neurovascular checks that involve looking for cues, such as severe pain, pallor, decreased or absent pulses, numbness or tingling, and decreased sensation
- Monitor diagnostics, such as CPK, EKG, and urine samples, that involve looking for signs of improved vascularization in the affected area
- Monitoring of intake and output levels to check for balances or shifts
Read the Electronic Health Record
Caring for the Patient with a Crush Injury
A nurse is caring for a patient admitted to the surgical intensive care unit after receiving an open reduction and fixation of the right femur (ORIF) following a car accident. Review the patient’s electronic medical record and answer the questions that follow.
Nurse’s note (0247):- Patient brought to SICU from OR following ORIF of right lower leg after being ejected from car, un-restrained.
- BP: 88/62
- O2 saturation: 95 percent, sedated and ventilated
- HR: 110
- Temp: 99.5°F
- RR: 16
- Gen/Neuro: Sedated, multiple ecchymotic areas on face, right lower leg, and chest
- CV/Pulm: S1S2, RRR, tachycardic, lungs diminished throughout
- Skin: Cool to touch
Poisoning
In 2021, more than two million calls to Poison Control were made in the United States (NCPC, 2023). This translates to approximately one call of reported exposure every fifteen minutes. In the emergency department, nurses are required to stay up to date on current poisoning protocols, as well as be responsible for understanding diagnostic testing related to poisoning, which refers to exposure to substances, drugs, or chemicals. They will also need to implement medical therapies to reverse poisoning, while providing appropriate nursing care and preventing further complications.
Specifically, accidental poisoning occurs when a person unintentionally exposes themselves to a substance that is harmful, while intentional poisoning can be caused by a person purposely exposing themselves to toxic substances or another person intending harm. Poisoning can occur through inhalation, ingestion, or absorption through the skin. It can happen through any form of a substance, whether a solid, liquid, or gas. Many chemicals around the household, such as fertilizers and cleaning supplies, can cause poisoning. Poisoning can also occur at the workplace. A common non-drug poisoning is from carbon monoxide, a poisonous gas that is inhaled (Centers for Disease Control and Prevention [CDC], 2018a).
The provider will order diagnostic testing as soon as possible if they suspect or confirm poisoning. Typically, this involves the nurse collecting bloodwork, such as CBC, CMP, ABGs, LFTs, and serum blood levels. Toxicology screening and urine samples may also be ordered to identify the substance. When a patient enters the emergency department with suspected or confirmed poisoning, the nurse is obligated to notify Poison Control (Mukherji et al., 2023).
Link to Learning
Poison Control is a valuable resource that nurses can use. It has a national number, 1-800-222-1222, that enables callers to speak with a representative that can provide guidance about conditions to watch for and even offer treatment recommendations for patients with acute poisoning. Explore Poison Control for additional information.
Depending on the poisoning substance and mechanism of action, different reversal agents or antidotes can be administered. For most poisonings, activated charcoal. For opioid overdoses, naloxone is administered, and for benzodiazepines, flumazenil. N-acetylcysteine (NAC) is another common reversal agent, and it is used for salicylate or acetaminophen poisoning (Chacko & Peter, 2019). Nurses can utilize Poison Control as a resource for information about the correct reversal agents to choose. Additional medical therapies include fluid resuscitation, the administering of anti-epileptic medications, and the facilitating of other supportive measures, such as inducing vomiting.
Nurses use the ABCDE triage assessment for assessing patients with potential or confirmed poisoning. Depending on the severity of the poisoning and the status of the patient, mechanical ventilation, supplemental oxygen, and/or medical sedation may be necessary. The patient should be placed on cardiac monitoring. Frequent assessment of the patient’s vital signs is also needed to recognize hypotension, hypertension, bradycardia, or tachycardia. Fluid resuscitation will be dependent on the patient’s condition. The nurse assesses the patient’s neurological status and may administer anti-epileptic medications, if they are prescribed, to prevent or control seizure activity (Chandran & Krishna, 2019). Depending on the substance, nurses should ensure the use of proper personal protective equipment (PPE) to protect against potential cross-contamination.
Link to Learning
The CDC published a resource for PPE use that includes types of PPE as well as proper use and disposal.
Nurses should also monitor bloodwork for electrolyte imbalances and administer appropriate electrolytes, as ordered. If the patient is hyperthermic, the nurse can apply a cooling blanket and administer antipyretics, as indicated. The nurse should administer any antidotes or reversal agents to the patient and provide frequent updates to the Poison Control Center. In addition, the nurse may employ elimination techniques, which include urine alkalinization, hemodialysis, or continuous renal replacement therapy as outlined in Chapter 20 Genitourinary and Reproductive Systems (Chandran & Krishna, 2019). Nurses will also provide supportive care for the patient and family.
Abuse
Abuse, neglect, and maltreatment can happen to anyone, anytime, and at any age. Often, the emergency department is the place of discovery. It is important for an ED nurse to be able to recognize cues of abuse and be prepared to take action for appropriate reporting and education on available resources. The nurse must understand the different types of abuse that can occur and the appropriate nursing interventions for each type. Nurses are legal mandatory reporters of abuse (Einboden et al., 2019). Every practicing nurse should follow their state and federal guidelines on reporting abuse.
The term maltreatment refers to the poor quality of care an individual receives. Neglect and abuse are types of maltreatment. The term abuse means harming another person physically, sexually, or emotionally. The term neglect means failing to supply a person with basic needs, such as food, shelter, or clothing. This can also pertain to emotional needs or failure to seek medical treatment. There are different types of abuse that can occur, such as a child, elder, sexual, and domestic partner abuse. Abuse can be emotional, physical, neglect, substance, and others.
Child Abuse
Nurses must be able to recognize potential cues of child abuse. Abuse should be suspected when there are unexplained injuries or injuries that do not match the described situation. For example, a spiral fracture of a child’s wrist may indicate they were forcefully grabbed. A child may also exhibit aggressive or disruptive behavior, or alternatively, be withdrawn or emotionless. Upon discharge, an abused child may express fear of returning to the home with the abuser (Einboden et al., 2019). A nurse should recognize injuries on both sides of the head or around both eyes, unexplained bruising, bite marks, limping, or burn marks, as these can potentially indicate abuse. In the case of neglect, the victim may appear unkempt and have clothing or shoes that are beyond normal wear and tear. They may also show signs of malnutrition or have developmental delays (Adigun et al., 2023). Nurses should immediately report suspicions of abuse through the proper channels, like state departments and health-care organization protocols.
Older-Adult Abuse
Older-adult abuse is maltreatment of a person who is over sixty years old. The term older-adult abuse encompasses neglect, physical, financial, sexual, or psychological abuse (CDC, 2021). Signs of abuse can include the person who provides care showing frustration or hostility. They can even have a lack of awareness about the older person’s care. The older adult may be disengaged, fearful, and have a different account of events than the caregiver. There may be a lack of adherence with medications and treatments or multiple visits to the emergency department. Sometimes there are unexplained or frequent injuries or a lack of proper medical attention (Rosen et al., 2018).
Sexual Abuse
Signs of sexual abuse in children can present as nonspecific medical complaints or symptoms (e.g., incontinence), or the signs may be more obvious (e.g., genital bruising and bleeding). Children may exhibit inappropriate sexual behavior or language that is not age-appropriate, or have personality changes (Adigun et al., 2023). Signs of sexual abuse in older adults may look a little different. They may have recently received a diagnosis of a sexually transmitted disease. Physical examination may reveal genital or rectal bruising or redness (Rosen et al., 2018). If abuse is reported, a SANE nurse (discussed further in Forensic Nursing) examines these patients.
Domestic Partner Abuse
Domestic partner abuse is also called intimate partner abuse. In cases of physical abuse, the patient often will cover injuries by wearing clothing over the injury sites. They may have wounds or burns on their hands and forearms (Huecker, 2023). Some victims of abuse exhibit psychological symptoms, such as fear or poor self-esteem (Rosen et al., 2018). Others may have anxiety or depression or present with chest pain, complaints of painful intercourse, or even nonspecific symptoms. The nurse should attempt to talk to the patient privately and provide safety. If violence or assault is suspected, ask for a forensic nurse to participate in the care of the patient.
Nursing Responsibilities for Abuse
If abuse is suspected, a comprehensive history and assessment are required. This should be conducted away from the abuser if possible. The nurse should document the patient’s general posture, demeanor, affect, and mental status. During the physical examination, the nurse should look for signs of poor hygiene, previous trauma, current injuries, or pressure injuries. Potential signs of injuries sustained from abuse include burn marks, broken jaw bones or teeth, lacerations, or bruising. If a genital assessment needs to be performed for suspected sexual assault, ensure a chaperone is present and recruit a specialized SANE nurse. Nurses should initiate a referral for a social worker to ensure the provision of proper follow-up care. The nurse should document findings thoroughly, and notify the appropriate authority of the potential abuse (Adigun et al., 2023).
Psychiatric Emergencies
A psychiatric emergency occurs when a patient’s behavior is or can become harmful to themselves or others. These incidents are sometimes referred to as mental health crises. There are different types of psychiatric emergencies; examples include suicide attempts, acute psychosis, intoxication, and delirium episodes. Consequently, some psychiatric emergencies are induced by the treatment plan for the patient’s condition or diagnosis. Serotonin syndrome and neuroleptic malignant syndrome can result from to high levels of the prescribed psychiatric medication (Maktabi et al., 2024). The nurse should be knowledgeable about different types of psychiatric emergencies and be familiar with interventions for each.
When a patient is at risk for harming themselves or others, the provider will order a psychiatric hold, also called involuntary hold. A psychiatric hold is when a patient is involuntarily admitted to a health-care facility under law. These types of mandates do not require patient consent and are usually 72 hours in length (Morris, 2020). Each state has its own laws regarding psychiatric hold guidelines.
When assessing a patient with a psychiatric emergency, there are several factors the nurse must consider. First, the nurse must make safety a priority for themselves, the patient, and the other members of the health-care team. The nurse should remove any unnecessary items from the patient’s surroundings and have the patient change into a gown, if possible. Please note that some patients may require sedation before they are able to be assessed. If the patient is having a medical emergency in addition to psychiatric emergency, the nurse should follow the ABCDE triage assessment method when performing the initial assessment. The nurse should ensure that the patient is medically stable before proceeding to the neurological assessment. The nurse should then check the reaction time of the patient’s pupils and assess the patient’s mental status. As part of the neurological assessment, the nurse should verify the patient’s orientation to person, place, and time, and check their reasoning, memory, and attention (Newman, 2020). All assessment details should be thoroughly documented in the patient’s chart.
In addition, the nurse should use evidence-based suicide and violence risk screening tools to evaluate the patient. The nurse should document a thorough health history, including any past violent behaviors or acts. If unsure of the patient’s psychiatric status or if there are any concerns, the nurse should always request an order for referral for a psychiatric evaluation.
In some cases, a urine drug screen is ordered, so the nurse should anticipate completing this as soon as possible (Stellpflug et al., 2020). Not all psychiatric emergencies are caused by substances or mental health conditions. Organic causes, such as encephalopathy, electrolyte imbalance, or infection, can also cause psychiatric symptoms. In these cases, the nurse should anticipate additional bloodwork and diagnostic tests to discover the primary cause.
Safety is the nurse’s top priority when caring for a patient with a psychiatric emergency. When speaking with the patient, the nurse should set clear boundaries and permit choices when possible. The nurse should utilize de-escalation techniques, and only use restraints as a last resort with a provider’s order. If restraints are required, the nurse must follow all legal and institutional guidelines, and the patient should be continuously monitored.
Substance Abuse
According to the Centers for Disease Control and Prevention, in 2016, around one in five emergency department visits was associated with misuse of prescription drugs or alcohol. Additionally, in 2021, it was reported over 100,000 drug overdose deaths occurred in the United States (CDC, 2022a). Considering these alarming statistics, nurses in the emergency department will encounter many substance abuse cases over the course of their careers. It is critical for nurses to know the different types of substance abuse, intoxication, and withdrawal symptoms. Nurses must also be able to perform rapid nursing assessments and implement appropriate interventions while caring for patients with substance abuse disorders. According to the 2021 Substance Abuse and Mental Health Services Administer (SAMHSA) report, the most common drug-related emergency department visits were caused by the use of opioids, alcohol, methamphetamine, cocaine, and marijuana (Substance Abuse and Mental Health Services Administer, 2022).
High-Risk Intoxication and Withdrawal
It is critical that ED nurses recognize cues of high-risk intoxication, potential overdose, and withdrawal. Opioid and heroin abuse cause respiratory and nervous system depression and can potentially lead to patient death if not reversed. Patients abusing these drugs often present as lethargic, dysphoric, and unable to answer questions. Their respirations may be shallow, and their respiratory rate is low. Because opioids release histamine, urticaria is another common finding. The same drugs can also have opposite neuropsychiatric effects, like agitation and violent behaviors in some patients. Pupil dilation, hypotension, and seizure activity are also common signs (Schiller et al., 2023).
Patients will also present to the ED with symptoms of alcohol withdrawal. If a patient has long-term alcohol dependence, withdrawal symptoms will occur if the substance is abruptly stopped. Symptoms range from mild to severe, depending on the length of alcohol use and the average amount consumed. Mild symptoms include elevated blood pressure, anxiety, and hyperreflexes, while hallucinations and seizures are more moderate symptoms. The most severe stage of alcohol withdrawal is called delirium tremens, which entails seizures and hallucinations, along with tachycardia, hypertension, and hyperthermia (Newman et al., 2022).
Link to Learning
Nurses use the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) tool to assess symptoms of alcohol withdrawal in patients.
Nursing Responsibilities for Substance Abuse
When assessing patients with substance abuse disorders, it is important to obtain a thorough history, including what drug was taken and the time the patient last took the substance. If the patient is having trouble breathing or is unconscious, the nurse should follow the ABCDE triage assessment method to do an initial assessment of the patient’s respiratory, cardiovascular, and neurological systems. The nurse should then administer any reversal medications, if indicated, for the determined substance and follow the appropriate protocols. If the patient has an opioid overdose, administer naloxone to the patient (Schiller et al., 2023). If the patient is having alcohol withdrawal symptoms, use the Clinical Institute Withdrawal Assessment for Alcohol (CIWA) to assess the severity of symptoms. Alcohol withdrawal symptoms can become severe, and the nurse’s role is to prevent the worsening of these symptoms. Benzodiazepines, such as diazepam and lorazepam, are administered to alcohol withdrawal patients to control their symptoms and progression. The nurse should also prepare to administer medications such as phenytoin for seizures and chlordiazepoxide for withdrawal symptom prevention (Newman et al., 2022).
Interdisciplinary Plan of Care
Interdisciplinary Care for Patients with Alcohol Abuse Disorder
Nurses work with an interdisciplinary team and coordinate care for patients with alcohol abuse disorders. The following professionals may be part of the team:
- Neurologist: Patients with severe withdrawal symptoms, or delirium tremens, may have seizures and require referral to a neurologist.
- Pulmonologist and critical care intensivist: These providers may be necessary if withdrawal is so severe that the patient requires sedation and intubation to maintain their airway.
- Physical and occupational therapist: Once the patient is able to come off ventilator support, physical and occupational therapy will need to be ordered, ensuring the patient is able to complete the activities of daily living.
- Psychiatrist: Patients with alcohol use disorders often have underlying mental health conditions.
- Case manager: These professionals coordinate outpatient rehab facility care or other options once the patient is able to be discharged.
When caring for a patient with opiate withdrawal, nurses commonly utilize the Clinical Opiate Withdrawal Scale (COWS). This scale assigns points for a patient’s symptoms by each body system, with scores totaling five or more, indicating withdrawal symptoms are present (National Institute on Drug Abuse, 2015). Nurses must also manage the patient’s hydration status by administering IV fluids and electrolytes as ordered (Baandrup et al., 2017). They will also administer anti-emetic medications, such as promethazine, to control nausea and/or vomiting. To help with withdrawal from opioids, methadone or buprenorphine can be administered and dosage titrated. Because opioid use is linked to psychiatric disorders, the nurse should collaborate with the health-care provider and request a psychiatric referral for inpatient and outpatient services (Shah et al., 2023).
Link to Learning
The Clinical Opiate Withdrawal Scale (COWS) is a useful tool for assessing signs and symptoms of opiate withdrawal and monitoring these symptoms over time.