DISASTER

A disaster is any natural or human-made incident that causes disruption, destruction and
devastation, requiring external assistance e.g. earth quake, industrial accidents, oil spills, forest –
fires, terrorist activities etc.
A disaster obviously hurts those affected. It also spares many in the affected areas, yet those
spared may be indirectly affected. The village tailors businesses suffer when a flood, or civil
disorders spares their premises but destroys their customers’ crops. And such indirect effects
extend beyond the affected areas, which is linked to huge damage area through commerce. These
indirect effects are adverse but not often and considering the effects of flooding, which are
economic, environmental, and human, from a health care stand point, disaster event type and
timing predict subsequent injuries and illness.

CLASSIFICATION OF DISASTERS

The United Nation categorized disaster into two (2)

1) Natural and
2) Human – made disaster

Natural Disaster

These are disasters that occur naturally not brought about by the activities of human
beings, eg. Hurricanes, Avalanches, Tornadoes, Earthquake, Drought, Pandemics and Epidemics,
Floods (Flash), Lightening – Induced forest fire, Tsunamis, Thunderstorms and Lightening,
Extreme heat or cold Mudslide etc.

Human – made disaster

These are hazard or disasters that are due to the activities of human beings eg. Crime,
Conventional Warfare, Hazardous Material incident, Transportation accident, Pollution,
Structural collapse, Air Plane crash, Explosions/Bombings, Water Supply contamination, Arson,
Terrorism (Chemical, biological, radiological and Nuclear explosives)

CLASSIFICATION BASED ON ONSET

Quick - onset (Immediate) e.g. Tsunamis, earthquake

Slow- onset e.g. famine, draught

TYPES OF DISASTER

Natural disaster- Earthquake, tsunamis, volcanic eruption flood draught human epidemics and
pandemics
Technological disaster - Air accident, road accident, computer network failure, economic
failure.

Intentional, civil and political hazards – Terrorism, religious terrorism, narco terrorism, cyber
terrorism, civil unrest

REQUIREMENT FOR DISASTER MANAGEMENT

Identifying, understanding and preparing for risks are vital parts of community disaster plan.

Communities should have a current and comprehensive disaster plan tailored to its needs and
circumstances.

Each communities plan will vary from the next because of its uniqueness, geographical setting
and infrastructures.

In developing a plan, community disaster managers should be aware of all threats to lives and
properties.

A strong disaster plan will recognize potential risks and allocate the necessary resources to
minimize damage or threat.

The plan should focus first on human safety.

DISASTER MANAGEMENT CYCLE

Disaster Management is based upon four distinct but not mutually exclusive components,
1) Prevention (Mitigation),
2) Preparedness,
3) Response and
4) Recovery
Nurses and other health practitioners have unique skills for all aspects of disaster to include
assessment, priority setting, collaboration, and addressing of both preventive and acute care
needs. In addition, public health nurse have a skill set that serves their community well in
disaster to include health education and disease screening, mass clinic expertise, an ability to
provide essential public health services, community resources referral and liaison work,
population advocacy, psychological first aid, public health triangle and rapid assessment.
Figure 1 Graphic presentation of the four phases of emergency management.

Response
Preparedness Recovery

Mitigation

Prevention or Mitigations

All – hazard prevention is an emergency management term for reducing risks to people
and property from natural hazards before they occur, mitigation efforts attempts to prevent
hazards from developing into disaster. The mitigation phase differs from the other phases
because it focuses on long – term measures for reducing or eliminating risk.

TYPES OF MITIGATION

Structured Mitigation:

This is a deliberate risk reduction effort designed through the construction or

modification of the physical environment through the application of engineered solution such as:
Relocation, Resistant construction, Building code, Detection system, Treatment systems,
Physical environment modification, Structure modification, and construction of community
shelters etc.

Non – Structured Mitigation:

This is a process or a measure that reduces risk through modification in human believe or
natural process without requiring the use of engineered structures, such as; communities
awareness and education programs, behavioral modification, regulatory measures, emergency
response capacity and capabilities, environmental control (forest and vegetation management,
hill side drainage etc.) and risk transfer.

IMPEDIMENTS TO MITIGATION

- Cost Implication Obstacle:

 Relocating to safer areas as a group
Community – training programs
Good analysis and a system to convey information about risk
Risk of permanent migration.

- Political Will Obstacle:

Poor implementation of building practices and code

Poor supervision during construction
Poor spending on prevention than relief

- Socio – Cultural Obstacle

The poor often live in dangerous areas and slums and often at risks of disaster.
Poor value for life (life priceless)

PREPAREDNESS

Preparedness is a continuous cycle of planning, organizing, training, equipping,

exercising, evaluation and the improvement of activities to ensure effective coordination and the
enhancement of capabilities to prevent, protect against, respond to, recover from, and mitigate
the effect of natural disaster, acts of terrorism and other man-made disaster.
In the preparedness phase, emergency managers develop plans of action to manage and
counter their risk and take action to build the necessary capabilities needed to implement
common preparedness measures such as:

-Communication plan with easily understandable terminologies and methods

-Proper maintenance and training of emergency services, which include human resources, such
as community emergency response teams.

-Development and exercise of emergency population warning methods combined with

emergency shelters and evacuation plans.

-Stocking inventory, and maintain disaster supplies and equipment.

-Develop organization of trained volunteers among civilian populations. Professional emergency

workers are rapidly overwhelmed in mass emergencies; trained, organized, responsible
volunteers are extremely valuable.

TYPES OF PREPAREDNESS

Personal Preparedness

Disasters by their nature require nurse to respond quickly. Public health nurse without
plans in place to address their own needs, to include family and pets, will be unable to fully
participate in their disaster obligations at work or in volunteer efforts. Disaster kits should be
made for the home, workplace, and car for a prompt responds. Emergency supplies that nurses
should have ready are:

- Identification badge and driver license

- Identification of licensure and certification (e.g. RN, First Aid etc.)

- Pocket – size reference books (e.g. Nurses protocols and intervention standards)

- Blood pressure cuff (adult and child) and stethoscope

- Gloves, mask, other personal protective equipment (PPF) for general care

- First aids kits with month –to- month CPR barrier

- Radio with batteries and all phone chargers

- Cash, credit card

- Important papers

- Sun protection

- Sturdy shoes with socks

- Medical identification of allergies, blood type

- Medication for self

- Weather appropriate clothing

- Toiletries

- Watch, cell phone, PDA with pre-entered emergency numbers

- Flash light, extra batteries

- Record – keeping materials to include pencil/pen

- Map of areas etc.

Professional Preparedness

The step is based on the assumption that the primary responsibility of disaster manager’s
revolves round government as it usually over power individual capacities. Therefore, every state
needs a qualified workforce of public health nurses and practitioner. For solutions to every day,
public health problems, include natural disaster and the threat of terrorism. Public health nurses
in turn need dedicated resourceful and visionary leaders .the chief public health nurse officers at
the state level developed and maintain a strong public health nursing workforce. Disaster
management in the community is about population health.
The core public health function, are assignment, policy development and assurance. the mission
of a public health nurse and its core function are essential service and does not change in
disaster, neither does the practice of public health nursing, the public health nurse must be
prepared to advocate for the community in terms of a focused on population based practice. The
number of public health nurses available to get the job done is small compared with those with
generic or other specialty. Also disaster and emergencies produced conditions that demand an
aggregate or total care approach, increasing the need for public health nursing involvement in the
community during disaster and catastrophes. The importance of being adequately trained and
properly associated with an official responds organization to serve in disaster cannot be over
stated. In disaster, many untrained rushed in to help, the spontaneous volunteers overload, create
added burden on an already tensed situation to include role conflict, a lot of anger, frustration,
and helplessness.
The steps to be embarked by government to ensure adequate preparedness are:
❖ Planning (hazard identification, Budgeting, Strategies etc.)

❖ Organization (Institutions and structures, statutory authority)

❖ Equipment (Personal protective equipment/PPE, communication equipment, special

search and rescue equipment e.g. Fire, seal water, search dogs/detection tools, vehicles
etc.).

❖ Training: Capacity buildings, professional disaster managers, emergency medicine, fire

suppression, policing /security, debris (refuse management), military academy, police
academy, fire institutions, red cross/ICRS etc.

❖ Exercise: Practice/simulations, drills, table top exercise / computer simulations,

functional exercises, full-scale exercise etc.

Community Preparedness

The public health security and bioterrorism preparedness and response Act 2002 adverse
the need to enhance public health and health care readiness and community health care
infrastructures. The community readiness is necessitate due to government’s limited resources
that can always over stretched in disaster management hence the need for public to be prepared
to provide their own response needs. It is therefore a step taken to empower ordinary citizens to
help themselves, their families, their neighbors, or people that are unknown to them. Community
preparedness require the involvement of variety of stakeholders including first and foremost the
general public as well as all levels of government, public health agencies, hospitals, first
responders, emergency management, health care providers within the community, schools and
university, the private sector, and business and non-governmental organization such as red cross
association. etc.
Mutual aid agreement established relationships between partners prior to disaster at the local,
state, regional and international levels and ensure seamless services.
Emergency management is responsible for developing and coordinating emergency plan within
their defined area whether local, state, federal. The national emergency management agency is a
coordinating entity responsible for creating a comprehensive, all hazard plan that incorporate
scenarios that illustrate plausible major incident that may affect their community-plans
incorporates all level of disaster management which include, prevention mitigation preparedness
recovery and response effort. Agencies personal who work closely with their communities and
community partners provide opportunities to train, exercise, evaluate and update the plan.
Good disaster preparedness planning involves simplicity and realism with back-up contingencies
because, plans never exactly fit the disaster as it occurs and all plans need implementation
viability, no matter which key members are present at the time. The community must have an
adequate warning system and an evacuation plan that includes measures to remove those
individuals from areas of danger who hesitate to leave.
The community can prepared by the formation of emergency vanguards and volunteer
associations, trained on search and rescue skills, fire suppression – skills, first aid skills, behavior
modification, equipping the community with detection devices/sensors, alarm systems at homes,
in schools, at work, in public spaces etc.

RESPONSE

The first level of disaster response occurs at the local level, with the mobilization of respondents
such as fire department, law enforcement, public health and emergency service. If, the disaster
overwhelms or stretched local resource, the country or state emergency management agency will
coordinates activities
Through, an emergency operation centers. When state resources, capacities are overwhelmed and
state governors, may request for assistance under a presidential or emergency declaration. If the
event is considered and incident of national significance, appropriate response personal and
resources are provided

Responses, is a process that involves taking all necessary actions that will reduce or eliminate the
impact of disaster that have occurred or are currently happening, in order to prevent further
death, suffering, financial loss or a combination of two or three of them.
In most cases the first response are the disaster survivors within the community, depending on
the type of the disaster, we can then have the local law enforcement agencies, fire suppression
agencies, emergencies medical personnel, the military etc. Their role is to search, rescue and
attend to those injured, suppress fires, secure and police disaster affected areas and begin the
process of relief activities.

Role of public Health nurse in disaster responds.

The role of the public health nurse during a disaster depends a great deal on the nurse experience,
professional role in a community disaster plans and prior disaster knowledge to include personal
readiness. public health nurses bring leadership, policy, planning and practice expert to disaster
preparedness and response .public health nursing roles in disaster are generally consistent with
the scope of public health nursing practice but the nurse provide that practice in chaotic surge
there is ongoing demand for flexibility in disaster especially during response.

TYPES OF RESPONSE

Pre - Disaster Action:

Depending on the disaster the following are some of the pre-disaster action that can be taken
- Warning and evacuation

- Pre-positioning of resources and supplies

- Last – minute mitigation and preparedness measures.

Post – Disaster Actions
- Process of responses.

- Organized search and rescue First aid medical attention/treatment.

- Evacuation of disaster survivors to safe destination.

- Disaster Assessment (situation/damage assessment, need assessment)

- Emergency health care facilities

- Sanitation (Collective and disposals of human waste/waste water/garbage, fatality

management e.g. search and recovery of corpse and their burials, preservations).

- Safety and security

- Resumption of critical infrastructure (Transportation, communication, electricity and

water systems, public health etc.)

- Emergency social services (Social therapies, Reunifications, Counseling services etc.)

- Coordination (Donations management, volunteer management – incident command

system.)

RECOVERY

This involves all those activities designed to return disaster survivors or victims to their
“normal way of life,” This starts when the emergency responses are officially declared to have
come to an end. It is simply the process through which disaster consequences such as
environmental damage, destruction of property and infrastructure, disruption of social and
economy systems, and other physical and psychological health consequences are rebuilt,
reconstructed, repaired and returned to their functional conditions as well as reducing the risk of
similar catastrophe in the future.

GOAL OF RECOVERY ACTIONS

The goal of recovery actions is to correct the following damages:

- Interrupted educational opportunities (damage to schools, loss or injury of

teachers and students).

- Damaged or destroyed transportation infrastructure

- Environmental damage and pollutions

- Homeless cause by housing and property losses

- Economic losses (Losses of factories, employees, inventories, customers etc.)

- Loss of sources of revenue to government due to loss of tax base

- Hunger and starvation due to shortage of food supply and inflation

- Loss of religious facilities and cultural heritage.

RECOVERY ACTIVITIES

- Assessment of damage and needs

- Provision of long-term shelter

- Removal and disposal of debris

- Rehabilitation of infrastructure

- Repair of damaged structure

- New constructions

- Re-imbursement of property losses

- Restoration of economic or Business activities and creation of employment opportunities

- Social rehabilitation programs

- Rehabilitation of the injured

- Reassessment of hazard risks

COMPONENTS OF RECOVERY

Data (Information from damage assessment)

Planning (Define recovery goals, budget for resource requirements, map out strategies for goals
attainments) and Coordination of the following:

Donations

Environmental, Transportation, Building, Floodplain, chambers of Commerce Officers,

Ministries of finance, works, water resources, budget and economy planning, health etc.

Financing

Equipment and supplies, government rebuilding public facilities and infrastructure, private sector
i.e. individuals, factories and industries will lead rebuilding private houses and business or may
be in form of partnership between government and private sector or NGO

Insurance or Risk Transfer

Government emergency relief funds, full – blown credits (local or international banks, World
Bank, IMF, ADB etc.)

ACTORS OF DISASTER MANAGEMENT

There are many actors or agencies that are involved in disaster management ranging from
government department, service providers, aid agencies, local institution, humanitarian and
development, private sector, insurance and financial industries, local and foreign individuals,
groups and associates.

INTERNATIONAL ASSOCIATION OF EMERGENCY MANAGERS

The international Associations of emergency managers (IAEM) is a non-

Profit educational organization dedicated to promoting the goals of lives protecting property
during emergencies and disasters. The mission of IAEM is to serve its members by providing
information, networking and professional opportunities and to educate the emergency
management profession. It currently has seven councils around the world. Asia, Canada, Europe
etc.

RED CROSS AND RED CRESCENT

National Red Cross/ Red Crescent societies often have a pivotal role in responding to
emergency. Additionally, the international Federation of Red Cross and Red Crescent societies
may deploy assessment teams to the affected country if requested by national Red Cross or Red
Crescent society. After having assessed the needs emergency response units may be deployed to
the affected country or region.

UNITED NATIONS

Within the United Nation system responsibility of emergency response rests with the Resident
Coordinator within the affected country. However, in practice international response will be
coordinated, if requested by the affected country’s government, by the UN office for the
coordination of Humanitarian Affairs (UN - OCHA) by deploying a UN Disaster Assessment
and coordination (UNDAC) team.

NATIONAL EMERGENCY MANAGEMENT AGENCY

NEMA, Co-ordinate resource toward effective disaster prevention, preparedness, mitigation and
response in Nigeria. It acts in the following areas “Coordination, disaster Risk Reduction, search
and rescue, policy and strategy, geographic information system, Advocacy, education,
administration, finance and logistics, relief and rehabilitation, planning research and forecasting.

DISASTER CARE

INTRODUCTION

Emergency care nursing is concerned with human responses to life – threatening

problems, such as trauma, major surgery, or complication of illness. The human response can be
a physiological or psychological phenomenon. The focus of the emergency care nurse involves
prevention as well as care.
A disaster is a sudden event in which local emergency medical services, hospitals and
community resources are overwhelmed by the demands placed on them. Disaster can be caused
by fire, weather, (e.g. earth quake, hurricane, floods, tornado), explosions, terrorist activity,
radiation or chemical spills, epidemic outbreak and human error (e.g. plane crash, multicar crash)
disaster planning and management response have long been considered a primary responsibility
of trauma system. However, each disaster is unique, placing tremendous strain on communities
to minimize mortality, injury and destruction of property.

ELEMENTS AND PRINCIPLES OF EMERGENCY AND DISASTER CARE

The oxford dictionary defines principles as a fundamental truth for basis of reasoning. Principles
guide people decisions and doctrines of policies and procedure developed by organization, and
laws and doctrines of political entities. if there is not a clear understanding and statement of
principles, then there cannot be a consistent, cohesive embracing disaster management strategy,
or effective communication between different organization. Within the field of emergency and
disaster management, there are a plethora of principles which are described in various books and
organization website. These principles purport to provide a guide and enduring basis for how the
practice of disaster management is pursed. Yet, a perusal of the various set of principles reveals
little convergence. Disaster management fundamentally deals with a responds to human misery
and losses of people livelihoods and assets, while disaster risk management is concerned with
mitigating or preventing such losses. Emergency management higher education project agreed
on eight principles that will be used to guide the development of a doctrine of emergency
management which are as follows:

- Comprehensive

Emergency managers consider and take into account all hazards, all phase, all stakeholders and
all impacts relevant to disaster.

- Progressive

Emergency managers anticipate future disaster and take prevention and preparatory measures to
build disaster – resistant and disaster – resilient communities.

- Risk – Driven

Emergency managers use sound risk management principles (Hazard identification, risk
analysis and impact analysis) in assigning priorities and resources.

- Integrated

Emergency managers ensure unity of effort among all levels of government and all elements of
a community.

- Collaborative

Emergency managers create and sustain broad and sincere relationships among
individuals and organization to encourage trust, advocate a team atmosphere, build consensus,
and facilitate communication among the team

- Coordinated

Emergency managers synchronize the activities of all relevant stakeholders to achieve a

common purpose.

- Flexible

Emergency managers use creative and innovative approaches in solving disaster

challenges.
- Professional

Emergency managers value a science and knowledge – based approach; based on

education, training, experience, ethical practice, public stewardship and continuous
improvement.

ROLE OF NURSES DURING DISASTERS

Nursing Role as First Responder

Although valued for their expertise in community assessment, case findings and referring,
prevention, health education, and surveillance, there may be times when the nurse is the first to
arrive on the scene. In this situation, it is important to remember that life threatening problems
take priority, once rescue workers begin to arrive at the scene, plans for triage should begin
immediately.

Nursing Role in Epidemiology and Ongoing Surveillance

Health care providers and public health officers are the first line of defense. A comprehensive
public health response to outbreaks of illness consist of time components, these include,
detecting the outbreak, determining the case, identifying factors that place people at risk,
implementing measures to control the outbreak and informing the medical and public
communities about treatment, health consequences, and preventive measure surveillance reports
indicate the continuity, status of the affected population and the effectiveness of ongoing relief
efforts. Surveillance continues into the recovery phase of a disaster.

Nurse Roles in Disaster Response

The role of the public health nurse during a disaster depends a great deal on the nurse’s
experience, professional role in a community disaster plan and prior disaster knowledge to
include personal readiness, public health nurses bring leadership, policy, planning, and practice
expertise to disaster preparedness and response. Public health nursing roles in disaster are
generally consistent with the scope of public health nursing practice, but the nurse provides such
practice in chaotic surge.

Nurses Role in Disaster Communication

Nurses working as members of an assessment team need to return accurate information to relief
managers to facilitate rapid rescue and recovery. A part of that communication is involved with
the rapid and ongoing needs assessment. Lack of or inaccurate information regarding the scope
of the disaster and its initial effects can contribute to a mismatched supply of resources. Times of
crisis or great uncertainty call for great skills in communication. The community needs accurate
information transmitted in a timely manner. Health care personnel are the best sources for
essential health information that is technical in nature.

Nurses Role in Sheltering

Generally, population shelters are often the responsibility of the local Red Cross. In massive
disasters, however, mega shelters with the capability to house thousands may be initiated in
partnership with local, regional or state government for the masses needing temporary shelter.
This responsibility includes the plan for structure, operations, management, and staffing of mass
care sites. Each person arriving at a shelter is assessed by a nurse to determine the type of facility
that is appropriate. Nurses in shelter functions are involved in providing assessment and referral,
health care needs (e.g. prescription, glasses, and medication) first aid and appropriate dietary
adjustment, keeping client records, ensuring emergency communication and providing a safe
environment.

Nursing Role in Psychological Support

Acute and chronic illness can become worse by the prolonged effects of disaster. The
psychological stress of cleanup and moving can course feelings of severe hopelessness,
depression, and grief in the disillusionment phase. Although the majority of individuals will
eventual recover from disaster, mental distress may persist for months to come. Especially at risk
of the members of vulnerable populations who continue to live in chronic adversity. Referrals to
mental health professionals should continue throughout the recovery phase and as long as the
+need exists. The role of the nurse in case finding and referrals remains critical during this phase.

PSYCHOLOGICAL IMPACT ON DISASTER WORKERS

Disaster relief work can be rewarding because it provides an opportunity to have a profound and
positive impact on the lives of those who may be experiencing their greatest time of need.
However, the work can also be challenging and stressful, during an assignment responders may
be exposed to chaotic environments, long hours, rapidly changing information and directions,
long wait time before setting on work, noisy environment, and living quarters that are less than
ideal.
Nurses who work with survivors of disaster may be at risk of vicarious traumatization, this
occurs in response to listening to survivors stories of the traumatic event. The degree of workers
stress depends on the nature of the disaster, their role in the disaster, individual stamina, and
other environmental factors, which include noise, inadequate works space, physical danger, and
stimulus overload, especially exposure to death trauma. Other sources of stress may emerge
when the workers do not think that they are doing enough to help, from the overall change in
living patterns.

SYMPTOMS OF PSYCHOLOGICAL STRESS

Symptoms that may signal a need for stress management assistance include the following: being
reluctant or refusing to leave the scene until the work is finished; denying needed rest and
recovery time, feelings of overriding stress and fatigue, engaging in unnecessary risk – tasking
activities, difficulty communication through remembering instructions, making decisions, or
concentrating, engaging in unnecessary argument and refusing to follow order. Physical
symptoms such as tremors, headaches, nausea, and colds or flu-like symptoms can also occur etc.

MANAGEMENT STRATEGIES

There are some common strategies that will help individuals returning from the incident, which
are rest and recovery time, focusing on accomplishments, using calming strategies such as
recreation techniques or working on hobbies and concentrating on self – care to include healthy
food and drink, exercise and sleep.

PUBLIC HEALTH IMPACT OF DISASTER

Mortality and Morbidity

Disasters cause deaths, injuries illnesses, may overwhelm medical resources and health
services

Health Care Infrastructure

Disaster may destroy – hospitals, disrupt routine health services and road destruction which
prevent health activities. Consequently increase morbidity and preventive death and decrease
quality of life.

Environment and Population

It may increase potential for communicable disease, exacerbate environmental hazards.

Consequently increase morbidity and preventive death and decrease quality of life.

Psychological and Social Behavior

It may course generalized panic and paralyzing trauma. Disaster may also provoke increase in
depression and neurosis, it could lead to post – traumatic stress disorder (PSTD) at epidemic
level.

Food Supply

Disaster may disrupt food supply, leading to food shortages and specific micronutrient
deficiencies. It could provoke severe nutritional consequences including famine and starvation.

Population Displacement

It could lead to spontaneous or organized movement, Increase morbidity and mortality,

Precipitation of epidemic of communicable disease in both displaced and host communities,
Crowding of population, leading to refugee and host population injuries and violence.
MANAGEMENT OF EMERGENCY USING BASIC LIFE – SAVING AND SUPPORT AIDS

TRIAGE SYSTEM

Triage system are methods by which people who are in need of medical attention can be
categorized based on their injuries to evaluate who is greatest need of attention. This system can
be used quickly and effectively to assess an emergency situation, especially one in which those
in need of help outnumber those to give the help. Once triage system are utilized, then people
can receive assistance based on individual need, which can ensure that medical help is given to
those who are in greatest need. Triage system are categorize into urgent and unstable (Red band),
urgent and stable (Yellow band), working stable (Green band) deceased (Black band).

TYPES OF TRIAGE SYSTEM

Most system categorizes triage into simple and advance triage system.

Simple Triage System

Simple triage system is used in those who are injured or in need of medical assistance and
are categorized based on their need for treatment. Simple triage system utilized four basic
categories in which injured people or those in need of medical assistance be categorized.

- Deceased (Black Band)

These category is utilized for those who has stopped breathing and do not respond to
initial efforts to reopen their airways.
- Immediate (Red Band)
Are those in need of medical assistance immediately, or they may die due to the injuries
they have sustained.

- Delayed (Yellow Band)

These are those who injuries require attention, though not necessarily immediate
attention.

- Minor (Green Band)

Are client who sustained only light injuries that may not require medical attention.

ADVANCED TRIAGE SYSTEM

Advanced triage system utilize the same basic categories as simple triage system, while
also including a category for those who are alive but who will not survive their injuries even with
treatment. Advanced system is subject to hospital policy.
APPLICATION OF TRIAGE

-Mass casualty situation is used to decide who is most urgently in need of transportation
to a hospital for care and who injuries are severe and must wait for medical attention.
-Crowded emergency rooms and walk – in clinic to determine which patient should be
seen and treated immediately. Triage may be used to prioritize the use of a space or equipment,
such as operating rooms, in a crowded medical facility.

COMMUNITY ASSESSMENT

The traditional model of community assessment presents the foundation for the rapid community
assessment process. The acute need of population in disaster turns the community assessment
into rapid appraisal of a sector or regions of population social system, and geographical factors.
Elements of a rapid need assessment include, determining the magnitude of the incident, defining
the specific health needs of the affected population, establishing priorities and objectives for
action, identifying existing and potential public health problems, evaluating the capacity of the
local response including resources, and logistics, and determining the external resource needs for
priority action, disaster assessment priorities relate to the type of disaster, sudden – impact
disaster such as tornadoes and earthquakes involve ongoing hazards, injuries and death, shelter
requirements and clean water. Gradual – onset disasters such as famines produce concerns with
mortality rates, nutritional status, immunization status and environmental health.

CROWD MANAGEMENT

As the task force sought information on crowds and public safety, it becomes increasingly clear
that the primary factor in assuring a safe and comfortable environment for large crowds is the
planning for their management. Crowd management must take into account all elements of an
event especially the type of events, characteristics of the facility size and demands of the crowd,
methods of entrance, communication, crowd control, and queuing. As in all management, it must
include planning, organizing, staffing, directing and evaluating. Particularly critical to crowd
management is defining the roles of parties involve in an event, the quality of the advance
intelligence, and the effectiveness of the planning process.
SEARCH AND RESCUE.

Fig. 2 FIELD ORGANISATION

Administrative Unit Information Unit

Security Post Search and Rescue

Site

Source: Centre for Disaster Risk Management and Development Studies, Ahmadu Bello
University, Zaria

Administrative Unit

This unit is responsible for the following information

- Exact location of disaster
- Definition of the event
- Estimation of casualties
- Approach routes
- Declaration of event manager

Security Post

The security post is responsible for:

- Security of victims and rescue team
- Notification of location, type, size routes and others

Information Unit

The information unit is responsible for information gathering on

- Estimation of the event
- Ambulance assignment, such as movement in and out of disaster site
- Mission Assignment etc.

SEARCH AND RESCUE SITE

- Consideration for mechanism of rescue (Franco – German or Anglo – America model)

Table 1 Search and Rescue Model

Model Franco – German Model Anglo – America Model

Stay and Play Scoop and run
No- of Patient More treated on scene Less treated on scene
Provider of care Medical doctors, nurses and Paramedics with medical
other paramedics oversight
Main motive Brings the hospital to the Brings patient to the hospital
patient
Destination for transported Direct transports to hospital Direct transport to emergency
patient wards department
Overarching organization EMS is part of public health EMS is part of public safety
organization organization

DROWNING

Drowning death shows a bi modal age distribution. Toddlers less than three years of age and
adolescent males age 15 to 19 represent the peaks in incidence. Male victims lead females in
nearly all age groups, and male drowning death rate is approximately five time that of females.
Such discrepancy has been attributed to frequency of alcohol and drug use among male victims
of adolescent and adult age.
Near – drowning has been assigned to those patients who experience an immersion or
submersion event in a liquid medium of sufficient severity to require medical attention and
services at least temporarily, the initial post rescue period – usually 24 hours.
Secondary drowning is a term applied to initially asymptomatic survivors, usually children, who
later develop respiratory distress from minutes to days after a near – drowning episode as a
delayed complication of the event.

MECHANISM OF INJURY

The terminal event of a drowning episode or a near drowning incident, the final common
pathological denomination is reduce oxygen delivery at the tissue level. A deficit of oxygen at
the tissue level is the final common pathway of drowning deaths and immersion injuries.
Conventional depictions of drowning episodes frequently feature a failing swimmer thrashing
about repeatedly breaking the surface while calling out for help.
Breath – holding follows fatigue and loss of swimming ability and concomitantly, large amounts
of water may be surrounded while the victim struggles to maintain buoyancy. Further attempts at
breathing subsequently introduce fluid and particularly material into the air passages. Aspiration
interrupts oxygenation and hypoxia/anoxia develops, although most drowning victims are
thought to aspirate up to 22ml/kg of fluid.

RESCUE

The extraction of a victim from water is the initial measure toward the hopeful return to
pre-injury functioning. For pool and open water body immersion, reaching the victim and
assessing respirations must be accomplished swiftly. After cessation of breathing, hypoxia
develops rapidly as body tissue oxygen supply is quickly depleted. Rescue aims to prevent
irreversible CNS hypoxia which is – the pivotal point of intervention that determines normal
versus impaired recovery.
During water rescue situation, discovery of non-breathing victims should direct emergency
treatment initially is ABCs even before transport out of the water begins. Opening the airway and
providing rescue breaths using standard CPR techniques should be the initial intervention for an
apneic victim.

MEDICATION

- 100% supplemental oxygen

- Manage hypothermia
- Use of bronchodilators
- Diuretic administration
- In many cases, endotracheal intubation and positive pressure ventilation with possible –
end expiratory pressure (PEEP) are the most important interventions.
- Antibiotic prophylaxis.
 MANAGEMENT OF MULTIPLE – INJURED PATIENT

INTRODUCTION

A multiple – injured patient is a patient that has sustained significant injury to two or
more systems or organs within the same system.
Trauma is the leading cause of death in patient more than 45 years. And responsible for 60% of
deaths in 15 – 24 years old and the third leading cause of death in all ages.

TRIMODAL PATTERN OF MORTALITY

⮚ The first peak (Immediate deaths)

- Constitute 50% of the mortality
- Occur within minutes of injury
- Are related to laceration of brain, brainstem, spinal cord, heart and great vessels.
⮚ The second peak (early deaths)
- Constitute 30% of the mortality
- Occur within the first few hours after injury
- Causes include major internal hemorrhages in the CNS, thorax and abdomen
⮚ The third peak (Late deaths)
- Constitute 20% of the mortality
- Occur within days or weeks after injury
- Due to infection

PATTERN OF INJURY

- External trauma
- Head injury
- Abdominal trauma
- Chest trauma
- Internal injury

CAUSES OF INJURIES

- Road traffic accident

- Industrial accident
- Domestic accident
- Fall from height
- Sport injuries
- Social violence and conflicts
- Airplane or train crashes
- Natural disaster
- Warfare injuries/Terrorism

PRINCIPLES OF MANAGEMENT
Injury management requires a coordinated team response, with rapid assessment, resuscitation
and the development of an investigation and management plan.

LEVELS OF CARE

Pre – Hospital Care

The goals is to ensure the safety of patients and team members at the scene, liaise with
other emergency personnel to coordinate the rescue and extract the casualty safely and swiftly
with due protection of the spine. And ensure that the ABCDE of resuscitation is adopted in
monitoring of the patients.

ABCDE of Resuscitation

- Airway
- Breathing
- Circulation
- Disability
- Exposure

Evacuation or Transportation

- Stabilize fractures
- Ensure the safe transfer of the patient to appropriate hospital
- Alert the appropriate specialist or activate the trauma team prior to arrival.
- “Scoop and run” or stay and play approach may be adopted, depending on the
prevailing circumstance of the rescue scene
- Ensure adequate communication prior to transfer
- Transport modality to include, land air, sea
- And ensure the credibility of ambulance

The Hospital Phase

The trauma team is mobilized to the accident and emergency departments. This team
usually comprises
- The team leader (usually an A&E consultant/Advance nurse practitioner)
- A & E Medical staff
- A & E Staff Nurse
- Anesthetists
- Surgeon
- Orthopedic surgeon and Orthopedic nurse
Primary Survey and Resuscitation

The aim is to identify life – threatening conditions and simultaneously manage them. And
ensure that universal precautions are observed when dealing with trauma patient

Airway and cervical spine control

if the air way is not patent

- Remove foreign bodies/dislodged teeth
- Use suction for blood and vomitus
- Chin lift and jaw turns without moving the head.
- Consider Oropharyngeal air way
If no improvement, attempt endotracheal intubation and if not possible a needle or surgical
cricothyroidotomy should be done.

Breathing and Ventilation

- Look for chess wall movement

- Feel for tracheal position
-Do percussion and auscultation of the chest
- Identify and treat open or tension pnenmothorax
- Identify fail chest and massive haemothorax

Circulation and control of hemorrhage

- Pulse quality
- Skin perfusion and neck vein distension are assessed
- Two wide bore cannula (size 16G) are inserted for IVF
- Blood sample is taken for urgent cross – matching, biochemistry and hematology test.
- Control of external hemorrhage.

- Disability (Neurological assessment)

Assess conscious level
A - Alert (GCS 14 & 15)
V - Responds to voice (GCS 12)
P - Responds to painful stimulus
U - Unresponsive (GCS 8 & <)

Exposure

The patient is fully undressed in a warm environment to avoid hypothermia and

monitoring is establish with
- Pulse rate
 - Pulse oximeter
- Urine output
- Frequent blood pressure monitoring.

WOUND MANAGEMENT

INTRODUCTION

They goal of wound care, is to facilitate haemostasis, decrease tissue loss, promotes wound
healing, and minimize scar formation. The chapter will discuss the mechanism of injury, wound
evaluation and its classification.

MECHANISM OF INJURY

Wounds are caused by three different types of forces, sheer, compressive and tensile force.

Sheer force

This injuries result from sharp objects with the following characteristics
- Low energy
- Minimal cell damage
- Result in straight edges, little contamination
- Heals with a good result

Compressive Force

Injuries from compressive force are usually from blunt objects impacting the skin at a
right angle. Which are characterized by
- Results in stellate or complex laceration
- Ragged or shredded edges
- More prone to infection

Tensile force

Result from blunt objects impacting the skin at an oblique angle, usually such injuries are
characterized by the following:
- Results in triangular wound
- Sometimes produces flap
- More prone to infection

EVALUATION OF WOUND

Evaluate for airways, breathing and circulation first.

- Ensure hemostasis by saline gauze dressing, compressive and pressure packing
- Remove obstruction by removing rings, clothing and other jewelry.
- History of the wound. By noting the symptoms, types of forces, contamination, potential
for foreign body, tetanus status, allergies, medications, comorbidities and previous scar
formation,
- Location of the wound, its size, shape, margins, depth, alignment with skin lines, neuro
function, vascular function and underlying structures of the body.

WOUND CLASSIFICATION

Contusion and Haematomas

Contusion (Bruise or ecchymosis) is the consequence of injury causing bleeding in

subcutaneous or deeper tissue while leaving the skin basically intact. Haematomas is a large
tender swelling or deformity. The blood usually clots and become, firm, warm and red, later
about 10 days it begins to liquefy and becomes fluctuant.

Abrasions

Loss of superficial part of the skin from injury. These result from blunt injury applied
tangentially. Abrasions are often ingrained with dirt, with the risk of infection and in the longer
term, unwanted and insightful tattooing. They are common with bicycle or motorcycle accident
and skate board accident.

Puncture wounds

Are mostly, sharp object wounds to hollow organs and the mostly result from injury with
sharp objects, although a blunt object with sufficient force will also penetrate the skin.

Incised wounds

This type of wound is caused by sharp injury e.g. knives or broken glass. They are
characterized by clean – cut edges. These typically include wounds which are deeper than they
are wide

Lacerations

The skin is turn, resulting in irregular wound edges, unlike most incised wounds, tissues
adjacent to laceration wound edges are also injured by crushing and will exhibit evidence of
bruising. Very complete laceration and those involving nerves or other structures should be
referred to an expert.

LOCAL WOUND CARE

Minimize the pain of injection

 - Use sodium bicarbonate mixed with the anesthetic agents
- Use smallest needle possible
- Inject needle through open wound edge and skin that has already been anesthetized.

Maintain hemostasis
- Direct pressure
- Pressure packing
- Epinephrine
- Gelfoam
- Cautery (heat)
- Use a tourniquet

Foreign Body Removal

- Visual inspection
- Glass, Metal, Gravel fragment, organic substance, Plastic are detected by imaging.

Irrigation:
- Local anesthesia prior to irrigation
- Do not soak the wound
- Use normal saline
- Large syringe (60ml)
- Do not use iodine, chlorhexidine peroxide or detergents
Debridement
- Remove foreign matter, devitalized tissue, dark tissue
- Creates sharp wound edges
- Excision with elliptical shape
- Respect skin lines

Antibiotics

- Infections occur in 3 – 5% of traumatic wounds seen in emergency department

- Factors that increase risk are heavily contaminated wound, immunocompromised
patients, and diabetics, human and animal bites.
- Most important prevention is adequate irrigation and debridement
- Dog, human and cat bites used Augmentin
- Puncture wounds use ciprofloxacin

TETANUS PROPHYLAXIS

Tetanus is a very serious disease but completely preventable by active immunization. Protection
should be universal, especially if the childhood immunization programs are followed. However,
all patients with wounds should be assessed for their tetanus status and managed on their merits.

TETANUS – PRONE WOUNDS

- Compounds Fractures
- Penetrating injuries
- Foreign bodies
- Extensive crushing
- Delayed debridement
- Severe burns
- Pyogenic infection

IMMUNIZATION OF PATIENT

The need for tetanus immunization after injury depends upon a patient’s tetanus status.
Wounds at risk include those contaminated with dirt, faces, manure, soil, saliva or other foreign
materials, puncture wounds, wounds from missiles, crushes and burns.
Consider primary immunization of adults, tetanus toxoid (Single or combined with
diphtheria, if primary childhood course not given) then it is given as two doses 6 weeks apart
with a third doses 6 months later. Booster doses of tetanus toxoid are given every 5 – 6 years or
at the time of major injury occurring 5 years after previous dose.
If patient has received a full dose course of tetanus vaccines, do not give further vaccines.
Only consider human anti-tetanus immunoglobulin 250 – 500 units Intramuscular only if the risk
is especially high (e.g. wound contaminated with stable manure).
When patient had complete initial course, booster up to date but not yet complete,
vaccine is not required, but, if the patient initial course is incomplete or booster not up to date,
give a reinforcing dose of combined tetanus/diphtheria vaccine and refer to the general
practitioner for further doses as required to complete the schedule.
And for tetanus – prone wounds, also give one dose of HATI at different site. The dose of
HATI is 250 units Intramuscular for most tetanus prone wounds. But give 500units if > 24 hours
have elapse since injury or if there is heavy contamination or following burns.

WOUND CLOSURE

- Primary closure
- Secondary closure
- Tertiary closure

TYPES OF SUTURE MATERIAL

- Absorbable: e.g.
- Chromic gut
- Vicryl
- PDS II
- Non – Absorbable: e.g.
- Nylon
- Prolene
- Dermalon
TYPES OF SUTURE TECHNIQUES

- Simple interrupted
Use on majority of wounds, even each stitch is independent
- Simple continuous
Useful in pediatrics, its rapid and easy to removed, it provides effective homeostasis and
distribute tension evenly along the length.
- Horizontal material
Useful for single – layer closure of lacerations under tension
- Vertical materials
Useful for overlapping skin edges

PRINCIPLES OF FLUIDS AND ELECTROLYTES:

INTRODUCTION

This chapter provides a review of fluid compartment, composition of fluid and electrolyte
requirement in the body.
⮚ Total body water:
42, 000ml (60% of body weight)
- Intracellular: 28, 000ml (40% of body weight)
- Extracellular: 14,000ml (20% of body weight)
- Interstitial: 10,500ml (15% of body weight in a 70 Kg man)
⮚ Total blood volume
- Total blood volume: 5600ml (8% of body weight in a 70 Kg man)
- Red blood cells mass
Man: 20 – 36ml (1.15 – 1.21 L/M2)
Woman: 19 – 31 m2/Kg (0.95 – 1.0L/m2)
⮚ Water Balance
The minimum obligate water requirement to maintain homeostasis (if temperature and
renal – concentrating ability are normal and solute (Urea, salt) excretion is minimal) is about
800mL/d, which would yield 500mL of urine.
- Normal intake
2500 ml/d
Oral Liquids 1500ml
Oral solids 700ml
Metabolic (endogenous) – 300ml
- Normal output
- 1400 – 2300ml/d
- urine: 800 – 1500ml
- stool: 250ml
- insensible loss: 600 – 900ml (lungs and skin)
COMPOSITION OF PARENTAL FLUIDS

Parental fluids are generally classified according to molecular weight and oncotic pressure.
Colloids have a molecular weight > 800 and have high oncotic pressure
Crystalloids have a molecular weight < 800 and have low oncotic pressure.

Colloids

- Natural
- Albumin
- Blood products (e.g. RBCs, single – donor plasma)
- Plasma protein fraction
- Synthetic colloids
- Dextran
- Hetastarch (Hespan)

Crystalloids

- Normal saline
- 5% detrose saline
Ringer lactate
- 5% dextrose water.

ELECTROLYTE REQUIREMENT

- Sodium as (NaCl)
- 80 – 120mEq/d (children, 3-4 mEq/kg/24h)
- Chloride
- 80 – 120mEq/d as NaCl
- Potassium
- 50 – 100 mEq/d (Children, 2-3 mEq/kg/24h)

In the absence of hypokalemia and with normal renal function, most of this potassium K is
excreted in the urine, of the total amount of potassium K, 98% is intercellular, and 2% is
extracellular. If the serum K level is normal, about 4.5 mEq/L, the total extracellular pool K + =
4.5 × 142 = 63mEp. Potassium K is easily interchanged between intracellular and extracellular
stores under the condition such as acidemia or alkalemia. Potassium K demands increase with
diverse raw building of new body tissues.
One of the most difficult tasks to master is choosing appropriate intravenous therapy for a
patient. The patient underlying illness, vital signs, serum electrolyte, and a lot of other variables
must be considered.
Burns patients, use the parkland or the rules of nines formula and Lund and Browder chart for
electrolyte replacement.

PARKLAND FORMULA
Total fluid required during the first 24 hours = (% body burn) × (body weight in Kg) × 4 ml, will
give the amount of flow to be replaced in a patient.

TYPES OF RESPONDS TO FLUIDS AND TRANSFUSION

- Stable – when fluids and blood are usually transfused the patient’s condition becomes
stable, and then continue to investigate for further complications.
- Transient responders – this category of patients have an initial improvement but
subsequent deterioration. In this case, early surgical intervention is required after limited
investigation of the victim.
-No response to volume resuscitation, therefore an immediate surgical intervention is
required after minimal investigation.

VENTILLATORY ASSISTANCE

Essential intervention for all patients include, maintaining an adequate airway, and
ensuring adequate breathing (ventilation) and oxygenation. Artificial respiration,
cardiopulmonary resuscitation, tracheotomy, advance cardiovascular support, external
defibrillator are also discussed.

ARTIFICIAL RESPIRATION

Oxygen is administered to treat or prevent hypoxemia. Oxygen may be supplied by

various sources such as piped into wall devices, oxygen tanks, or oxygen concentrators. The
amount of oxygen administered to the patient is described as the fractions of inspired oxygen.
Oxygen delivery devices are classified into two general categories low – flow systems (nasal
cannula, simple face mask, partial – rebreathe mask, and non – rebreathe mask.) and high – flow
systems (air – entrainment or venture mask and high – flow nasal cannula).

The purpose of mechanical ventilation is to support the respiratory system until the
underlying cause of respiratory failure can be corrected. It is indicated in patient with respiratory
failure, who is unable to maintained adequate gas exchange, abnormal breathing patterns,
complaint of dyspnea.

POSITIVE – PRESSURE VENTILATION

In the critical care setting, most patients are treated with positive – pressure ventilation.
This method uses positive pressure to force air into the lungs via artificial airway.

NON INVASIVE POSITIVE – PRESSURE VENTILATION (NPPR)

It involves the delivery of mechanical ventilation without tracheostomy tube, it provides

ventilation via face mask, that covers the nose, mouth or both or a nasal mask or pillow or a full
mask NPPR is indicated in cardiogenic pulmonary edema, early hypoxemic and obstructive sleep
apnea.
HIGH FREQUENCY OSCILLATORY VENTILATION

High frequency oscillatory ventilation delivers sub – physiological tidal volumes at

extremely fast rates. (300 to 420 breathe per minute) it is indicated in patient with non –
compliant lungs and hypoxemia where conventional ventilation results in high airway pressures.

COMPLICATION OF MECHANICAL VENTILATION

Numerous complications are associated with intubation and mechanical ventilation.

These include, damage to the oral or nasal mucus, Larynx geal and tracheal injury, trauma,
infection, oxygen toxicity psychosocial hazards, vocal cord injury, ventilator – associated
pneumonia etc.

CARDIOPULMONARY RESUSCITATION

The goal of basic line support is to support or restore effective circulation, oxygenation,
and ventilation with return of spontaneous circulation. CPR must be initiated immediately in the
event of an arrest to improve the patients’ chance of survival.
CPR recommend a change in the Basic Life Support sequence from A – B – C (air way,
breathing, circulation) to C – A – B (chest compressions, airway, breathing).

TRACHOTOMY

A tracheostomy tube provides an airway directly into the anterior portion of the neck.
Tracheostomy tubes are indicated for long – term mechanical ventilation, long – term secretion
management, protecting the air way from aspiration when cough and gag reflexes are impaired.
Tracheostomy tubes come in a variety of sizes and styles, and are primarily made of plastic.
They consist of cuffed versus uncufted tracheostomy tubes, single – versus double – cannula
tracheostomy tubes, fenestrated tracheostomy tube and speaking tracheostomy tube.

ADVANCE CARDIAC LIFE SUPPORT

Cardiac or respiratory emergency, the tools of management are the Basic Life Support
survey followed by the Advance Cardiac Life Support survey. The BLS survey focuses on early
CPR and early defibrillation. The ABCDs of ACLS are the same as for BLS which is air ways,
breathing, and compressions or circulations. “D” refers to differential diagnosis or searching,
finding and treating reversible causes.

AIRWAY
 Airway management involves re - assessment of original techniques established in BLS.
Endotracheal intubation provides definite airway management and should be performed if
needed by properly trained personnel during the resuscitation effort.

BREATHING

Breathing assessment determines whether the ventilator effort is causing the chest to rise.

CIRCULATION

Circulation initially focuses on chest compressions, attachment of electrodes and leads to

the monitor – defibrillation, rhythm identification, IV and or intraosseous access, and
administration of medication.

DIFFERENTIAL DIAGNOSIS

Differential diagnosis involves searching for, finding, and treating reversible causes of
the cardiopulmonary arrest, cardiac dysrhythmia that result in cardiac arrest have many possible
causes.

DEFIBRILLATION

Defibrillation is the delivery of an electrical current to the heart through the use of a
defibrillator. The current can be delivered through the chest wall by the use of external paddles
or adhesive electrodes pads.

AUTOMATED EXTERNAL DEFIBRILLATION

The AED is considered an integral part of emergency cardiac care. It is used to achieve
early defibrillation. It should be used only when a patient is in cardiac arrest (unresponsive,
absent or abnormal breathing and no pulse) confirmation that the patient is in cardiac arrest must
be obtained before attaching the AED

CARE OF THE PATIENT AFTER RESUSCITATION

A systematic post – cardiac arrest care after return of spontaneous circulation can
improve patient survival with good quality of life. Post resuscitation goals include optimizing
cardiopulmonary function and tissue perfusion, transporting the patient to an appropriate critical
care unit capable of providing post – cardiac arrest care, and identifying treating the precipitating
causes of the arrest to help prevent another arrest. Emotional support is an important aspect of
care after an arrest. Fear of death or of a recurrence of the arrest is common.