EMERGENCY NURSE TEXTBOOK

Emergency nursing is the specialty of caring for people at the moment their health, or their sense of safety, has broken down without warning. The patient who walks through the doors of the emergency department (ED) may be a toddler who swallowed a button battery, a retired machinist whose chest pain began at the breakfast table, a teenager in a crisis that no one saw coming, or a person who has lived with an untreated illness for so long that the ED is the only door still open. You do not choose who arrives, you do not know what the next patient will need, and you are often asked to act before a complete history exists. Few other fields of nursing ask for such a wide base of knowledge, such quick reasoning, and such steady kindness in the same shift.

1. 1.1 What Defines Emergency Nursing
2. 1.2 Competencies and Core Knowledge of the Emergency Nurse
3. 1.3 Clinical Judgment Under Time Pressure
4. 1.4 Communication With Patients, Families, and Teams
5. 1.5 Documentation in a High-Acuity Setting
6. 1.6 Professional Resilience, Moral Distress, and Burnout
7. 1.7 Certification and Lifelong Learning

The role of the emergency nurse is carried out in a particular place, and that place shapes almost every decision made within it. The emergency department (ED) is not simply a collection of rooms with beds. It is a system designed, imperfectly, to receive an unpredictable stream of people, sort them by urgency, deliver diagnostic and therapeutic care at speed, and send each patient on to an appropriate destination. Its layout determines how far you walk to reach a deteriorating patient. Its processes determine how long a patient with chest pain waits for an electrocardiogram. Understanding the department as a system allows you to work with it and, when necessary, to recognize and speak up about the places where it fails.

1. 2.1 Layout and Care Areas of the Emergency Department
2. 2.2 Patient Flow From Arrival to Disposition
3. 2.3 Roles of the Emergency Care Team
4. 2.4 Crowding, Boarding, and Throughput
5. 2.5 Emergency Medical Services Handoff and Prehospital Care
6. 2.6 Equipment, Monitoring, and Point-of-Care Testing
7. 2.7 Infection Prevention and Isolation in the Emergency Department

Every patient who enters the emergency department (ED) passes through a decision that is made in minutes, often by a single nurse, with incomplete information and a line of people waiting. That decision, triage, determines how soon the patient is seen, where the patient is placed, and which resources are set in motion. When it is made well, the patient whose life is at risk is recognized at the door and the patient with a minor problem waits safely and is not forgotten. When it is made poorly, a patient with an evolving catastrophe may sit unrecognized in a waiting room while others with less urgent needs are taken first. Few tasks in nursing carry so much consequence for so little time.

1. 3.1 The Purpose and History of Triage
2. 3.2 The Five-Level Emergency Severity Index
3. 3.3 Rapid Visual Assessment and the Triage Interview
4. 3.4 Vital Signs and Danger Zone Parameters
5. 3.5 Resource Prediction and Acuity Assignment
6. 3.6 Reassessment, Re-Triage, and Undertriage Risks
7. 3.7 Triage of Special Presentations

Every clinical decision you make in the emergency department (ED) sits inside a framework of law, professional ethics, and safety systems, whether or not you are conscious of it at the moment. The patient who arrives without insurance, the intoxicated adult who wants to leave, the child whose injury does not match the story, the family demanding that everything be done for a dying relative, the handoff that omits one critical allergy: each is a clinical problem and a legal and ethical problem at once. This chapter examines the obligations that attach to every patient from the instant they present, and the habits that keep patients and staff from being harmed by the system meant to help them.

1. 4.1 Emergency Medical Treatment and Labor Act
2. 4.2 Consent, Capacity, and Refusal of Care
3. 4.3 Confidentiality and Privacy
4. 4.4 Mandatory Reporting and Abuse Recognition
5. 4.5 Ethical Dilemmas in Resuscitation and End-of-Life Care
6. 4.6 Patient Safety, Error Reduction, and Handoff Communication
7. 4.7 Workplace Violence and Staff Safety

When a critically ill or injured patient reaches you, the most dangerous mistake is not ignorance of a rare disease but loss of order. Dozens of stimuli compete for attention: a screaming relative, a dramatic wound, an alarming monitor, a paramedic's rapid report, a physician asking for access and a rhythm strip at once. The primary survey is the discipline that restores order. It is a rapid, systematic, prioritized assessment that finds and treats the threats most likely to kill the patient in the next minutes, in the sequence in which they kill: airway, breathing, circulation, disability, and exposure. Each letter is a physiologic requirement for life, addressed before the next, because a patient who cannot move air cannot benefit from a perfect blood pressure.

1. 5.1 The Structured Approach to the Critically Ill Patient
2. 5.2 Airway With Cervical Spine Consideration
3. 5.3 Breathing and Ventilation
4. 5.4 Circulation and Hemorrhage Control
5. 5.5 Disability and Neurologic Status
6. 5.6 Exposure and Environmental Control
7. 5.7 Adjuncts to the Primary Survey

The primary survey keeps the patient alive; the secondary survey and focused assessment work out what is actually wrong. Once the immediate threats to airway, breathing, circulation, neurologic function, and temperature have been found and treated, the pace changes. You can now ask questions, examine each region of the body, notice what does not fit, and begin the reasoning that connects symptoms to causes. A thorough history and careful physical examination still account for a large share of correct emergency diagnoses, and the tests that follow are chosen to confirm or exclude possibilities the bedside assessment has suggested.

1. 6.1 History Taking in the Emergency Setting
2. 6.2 Head-to-Toe Examination
3. 6.3 Focused Assessment by Chief Complaint
4. 6.4 Pain Assessment Across Populations
5. 6.5 Laboratory Testing and Interpretation
6. 6.6 Imaging Basics for the Emergency Nurse
7. 6.7 Bedside Ultrasound and Point-of-Care Findings

Every other intervention in emergency care depends on a patient who can move oxygen from the air into the blood and carry it to the tissues. No cardiac catheterization, antibiotic order, or trauma operation will help if the airway is lost in the first few minutes. The airway therefore occupies the first letter of the primary survey, and the emergency nurse is expected to recognize airway compromise before it becomes obvious, to open and support the airway with simple tools, to deliver oxygen in the right way for the right patient, and to function as an expert member of the team when a definitive airway must be secured. The previous chapters introduced triage and the ABCDE (airway, breathing, circulation, disability, exposure) sequence. This chapter takes the first two letters of that sequence as far as they can go, from a gentle jaw thrust to a scalpel incision through the neck.

1. 7.1 Airway Anatomy and Assessment of Difficulty
2. 7.2 Basic Airway Maneuvers and Adjuncts
3. 7.3 Oxygen Delivery Devices and High-Flow Therapy
4. 7.4 Noninvasive Ventilation
5. 7.5 Rapid Sequence Intubation and Medication Selection
6. 7.6 Post-Intubation Care and Ventilator Basics
7. 7.7 Surgical Airway and Failed Airway Management

Cardiac arrest is the most time-critical event an emergency nurse will ever face. The heart stops delivering blood, the brain loses its oxygen supply within seconds, and without circulation the injury becomes irreversible within minutes. Nothing else in emergency care is so unforgiving of delay or so dependent on the coordinated action of a team. The airway and oxygenation skills of the previous chapter are essential in arrest, but they are secondary to a set of priorities that is deliberately simple: recognize the arrest immediately, start high-quality chest compressions, defibrillate a shockable rhythm as soon as it is identified, and treat the reversible cause while keeping interruptions to a minimum.

1. 8.1 Pathophysiology of Cardiac Arrest
2. 8.2 High-Quality Cardiopulmonary Resuscitation
3. 8.3 Defibrillation and Shockable Rhythms
4. 8.4 Nonshockable Rhythms and Reversible Causes
5. 8.5 Resuscitation Medications and Vascular Access
6. 8.6 Post-Cardiac Arrest Care and Targeted Temperature Management
7. 8.7 Family Presence, Termination of Resuscitation, and Organ Donation

Shock is the state in which the circulation fails to deliver enough oxygen and nutrients to meet the metabolic needs of the tissues. It is a final common pathway reached by many routes, such as hemorrhage, a failing heart, overwhelming infection, a severe allergic reaction, or a blockage in the great vessels, and untreated it ends in organ failure and cardiac arrest. For the emergency nurse, shock is among the most common and most consequential diagnoses to recognize early, because the patient who is in shock may still be talking, may still have a blood pressure that looks acceptable, and may be only minutes from collapse.

1. 9.1 Perfusion, Oxygen Delivery, and the Physiology of Shock
2. 9.2 Hypovolemic and Hemorrhagic Shock
3. 9.3 Cardiogenic Shock
4. 9.4 Distributive Shock
5. 9.5 Obstructive Shock
6. 9.6 Fluids, Blood Products, and Vasopressors
7. 9.7 Monitoring Response and Escalating Care

Chest discomfort is among the most common reasons people come to an emergency department (ED), and its most dangerous cause, acute coronary syndrome (ACS), is among the most time-sensitive conditions you will ever manage. In the preceding chapters you built the foundation: recognizing the deteriorating patient, securing the airway and supporting breathing and circulation, and reading the monitor as a source of information rather than decoration. This chapter applies those skills to a disease in which minutes of delay translate directly into myocardium that dies and does not come back. The emergency nurse is therefore not a bystander to the cardiology consult but the person who first identifies the problem, obtains the electrocardiogram, starts the cascade of care, and keeps the patient alive through the dangerous first hours.

1. 10.1 Coronary Anatomy and the Pathophysiology of Plaque Rupture
2. 10.2 Recognizing Atypical Presentations
3. 10.3 The Twelve-Lead ECG in Acute Coronary Syndrome
4. 10.4 Cardiac Biomarkers
5. 10.5 ST-Elevation Myocardial Infarction and Reperfusion
6. 10.6 Non-ST-Elevation Acute Coronary Syndromes
7. 10.7 Complications and Mimics of Myocardial Infarction

The heart keeps its rhythm because a small group of specialized cells generates electrical impulses and a network of conducting fibers delivers them in a precise sequence. When that system fails, slows, speeds, or becomes disorganized, the consequence is not an abstract abnormality on a monitor but a change in how much blood the heart can deliver. A rate that is too slow starves the brain and kidneys, a rate that is too fast leaves the ventricle no time to fill, and a chaotic rhythm may produce no output at all. In the previous chapter you saw how an acute coronary syndrome (ACS) damages the myocardium and how often that damage is announced first by an electrical event. This chapter takes the rhythm itself as the subject and teaches the emergency nurse to recognize, interpret, and respond to the dysrhythmias, also called arrhythmias, that appear at the bedside every shift.

1. 11.1 Cardiac Conduction and a Systematic Approach to Rhythm Analysis
2. 11.2 Bradydysrhythmias and Heart Block
3. 11.3 Narrow-Complex Tachycardias
4. 11.4 Atrial Fibrillation and Flutter
5. 11.5 Wide-Complex Tachycardias
6. 11.6 Synchronized Cardioversion and Transcutaneous Pacing
7. 11.7 Electrolyte and Drug-Induced ECG Changes

The preceding chapters examined the heart as a victim of coronary occlusion and as a source of electrical disturbance. This chapter widens the view to the circulation as a whole, in which a pump that cannot keep pace, pressures that exceed what vessels can bear, and arteries that tear or balloon can each produce collapse within minutes. The conditions gathered here, acute decompensated heart failure, cardiogenic pulmonary edema, hypertensive emergency, aortic dissection, abdominal aortic aneurysm, syncope of cardiac origin, and pericardial disease with tamponade, differ in mechanism but share a clinical character. They often present with vague or misleading complaints, they deteriorate abruptly, and they punish both delay and the wrong treatment. A drug that is lifesaving in one can be lethal in another, and a blood pressure that is reassuring in one patient is a catastrophe in the next.

1. 12.1 Acute Decompensated Heart Failure
2. 12.2 Cardiogenic Pulmonary Edema Management
3. 12.3 Hypertensive Emergency
4. 12.4 Aortic Dissection
5. 12.5 Abdominal Aortic Aneurysm
6. 12.6 Syncope and Cardiac Causes
7. 12.7 Pericardial Disease and Cardiac Tamponade

Few emergency presentations announce themselves as quickly, or as honestly, as a patient who cannot breathe. The preceding chapters followed the circulation: the heart that fails as a pump, the rhythm that fails as a conductor, the vessels that fail as a closed system. This chapter turns to the other half of oxygen delivery, the lungs and the airways that feed them. A heart can beat perfectly and still deliver nothing useful if the blood passing through the lungs never meets oxygen, or if carbon dioxide cannot leave. The emergency nurse who understands gas exchange can read a breathing patient the way a cardiac nurse reads a monitor strip, seeing not just that something is wrong but which part of the system has failed and how fast the failure is progressing.

1. 13.1 Gas Exchange and Types of Respiratory Failure
2. 13.2 Assessing the Work of Breathing
3. 13.3 Acute Asthma and Status Asthmaticus
4. 13.4 Acute Exacerbation of Chronic Obstructive Pulmonary Disease
5. 13.5 Bronchodilators, Steroids, and Adjunct Therapies
6. 13.6 Interpreting Arterial and Venous Blood Gases
7. 13.7 Ventilatory Support in Obstructive Disease

The previous chapter concentrated on diseases that narrow the airways, where the lung is structurally intact but air cannot move freely. This chapter considers the opposite problem: the airways may be open, but the lung tissue, its blood supply, or the space around it has been compromised. Pneumonia fills alveoli with inflammatory fluid. Aspiration and inhalation injury damage the lung from within through contaminants and heat. A pulmonary embolism blocks the blood flow that gas exchange depends on. A pneumothorax or a large pleural effusion squeezes the lung from outside. Acute respiratory distress syndrome (ARDS) is a diffuse inflammatory injury that stiffens the lung and floods it with fluid. Foreign body obstruction and anaphylaxis can close the airway in minutes. Each produces dyspnea and hypoxemia, but each requires a different recognition pattern and response.

1. 14.1 Community-Acquired Pneumonia
2. 14.2 Aspiration and Inhalation Injury
3. 14.3 Pulmonary Embolism: Risk, Recognition, and Risk Stratification
4. 14.4 Anticoagulation and Thrombolysis
5. 14.5 Pneumothorax and Pleural Effusion
6. 14.6 Acute Respiratory Distress Syndrome
7. 14.7 Foreign Body Airway Obstruction and Anaphylaxis

Trauma is the leading cause of death among Americans from childhood through middle age, and it differs from the diseases discussed so far in one fundamental way: it arrives without warning, in a body that was healthy a moment earlier. The cardiac and respiratory emergencies of the previous chapters usually develop through a process the patient can describe. The injured patient arrives instead as the product of a transfer of energy, a collision, a fall, a blade, or a bullet, and the nurse must read that event in the body. This chapter opens the study of trauma by describing the organized system of care that surrounds the injured patient, the physics that explains why injuries occur, and the structured approach that allows a team to find and treat life threats in the order in which they kill.

1. 15.1 Trauma Systems and Verification Levels
2. 15.2 Kinematics and Mechanism of Injury
3. 15.3 Trauma Team Activation Criteria
4. 15.4 Trauma Resuscitation Priorities
5. 15.5 Hemorrhage Control and Massive Transfusion
6. 15.6 The Lethal Triad and Damage Control Resuscitation
7. 15.7 Tetanus, Antibiotics, and Trauma Documentation

The preceding chapters on the primary survey, hemorrhage control, and the systematic approach to the injured patient gave you a framework for finding and fixing what will kill a patient in minutes. This chapter turns to the part of the body that most often determines whether a patient who survives the first hour will ever return to the life they had before: the head, the spinal cord, and the face and neck. Brain and spinal cord regenerate poorly, so outcome is decided largely by what is prevented in the first hours.

1. 16.1 Traumatic Brain Injury Classification
2. 16.2 Intracranial Hemorrhage Patterns
3. 16.3 Intracranial Pressure and Herniation Syndromes
4. 16.4 Concussion Assessment
5. 16.5 Spinal Cord Injury and Spinal Motion Restriction
6. 16.6 Neurogenic Shock
7. 16.7 Facial, Eye, and Neck Injuries

The previous chapter followed injuries to the nervous system, where the central lesson was that secondary harm, produced by low oxygen and low perfusion, often exceeds the harm done at impact. The chest and abdomen teach the same lesson in a different register. Here the structures at risk are the ones that move air and blood: the lungs and airways, the heart and great vessels, and the solid organs and vascular bed of the abdomen and pelvis. Injuries to these regions are among the leading causes of preventable death after trauma, and they are preventable because most are treated with techniques an emergency nurse and team can perform in minutes: opening an airway, relieving trapped air, controlling bleeding, and moving a patient to the operating room without delay.

1. 17.1 Rib Fractures and Flail Chest
2. 17.2 Pneumothorax and Hemothorax
3. 17.3 Tension Pneumothorax and Needle and Finger Decompression
4. 17.4 Blunt Cardiac Injury and Great Vessel Injury
5. 17.5 Blunt Abdominal Trauma and Solid Organ Injury
6. 17.6 Penetrating Trauma
7. 17.7 Pelvic Fractures and Genitourinary Trauma

Of all the injuries that bring patients to the emergency department, those of the bones, joints, muscles, and skin are by far the most frequent. They are also the most likely to be underestimated. A fractured wrist or a gaping laceration is rarely a threat to life in the way a tension pneumothorax or an expanding intracranial hematoma is, so these patients may wait while sicker patients are treated. Yet the extremities contain the major arteries and nerves that supply the hands and feet, and a limb can be lost, or function permanently changed, by a missed compartment syndrome, an unrecognized vascular injury, an open fracture left uncovered, or a contaminated wound closed too early.

1. 18.1 Fracture Recognition and Immobilization
2. 18.2 Compartment Syndrome
3. 18.3 Open Fractures and Neurovascular Assessment
4. 18.4 Dislocations and Joint Injuries
5. 18.5 Amputations and Crush Injury
6. 18.6 Wound Assessment, Irrigation, and Closure
7. 18.7 Bites, Stings, and Foreign Bodies

The preceding chapters in this part of the book dealt with injury delivered by force: blunt impact, penetrating wounds, fractures, and the hemorrhage and shock that follow. This chapter turns to injury delivered by energy and environment. Heat, electricity, caustic chemicals, cold, water, and altitude all damage the body without any object ever striking it, and the damage follows physiologic rules of its own. A burn is not simply a skin wound; it is a systemic inflammatory insult that moves fluid out of the circulation, injures the airway, and can poison the blood. A patient with heat stroke has not merely been in the sun; the thermoregulatory system has failed and the brain is overheating. A patient pulled from cold water has a heart that may still be salvageable long after it appears to have stopped. Understanding these mechanisms is what allows you to prioritize correctly when the department receives a patient with mottled skin, a smoky smell, and no clear history.

1. 19.1 Burn Depth, Extent, and Severity
2. 19.2 Burn Resuscitation and Wound Care
3. 19.3 Inhalation Injury and Carbon Monoxide
4. 19.4 Electrical and Chemical Burns
5. 19.5 Heat Illness and Heat Stroke
6. 19.6 Hypothermia and Frostbite
7. 19.7 Drowning and Altitude Illness

The brain is the organ that gives every other emergency its meaning, and it is the organ least able to tolerate a bad few minutes. It makes up about two percent of body weight yet receives roughly a fifth of the cardiac output, stores almost no energy, and begins losing neurons within minutes of losing blood flow or glucose. Neurologic emergencies therefore share a harsh arithmetic: the longer the delay, the more tissue is lost, and much of that loss cannot be reversed. The emergency nurse is the first clinician to see most of these patients and often the first to recognize that a facial droop, a staring spell, or a change in behavior is the leading edge of a catastrophe.

1. 20.1 Cerebrovascular Anatomy and Stroke Syndromes
2. 20.2 Rapid Stroke Assessment and Scales
3. 20.3 Ischemic Stroke and Reperfusion Therapy
4. 20.4 Hemorrhagic Stroke
5. 20.5 Seizures and Status Epilepticus
6. 20.6 The Differential for Altered Mental Status
7. 20.7 Meningitis, Encephalitis, and Headache Emergencies

The preceding chapter ended with a recurring observation: a patient who arrives confused, weak, seizing, or unresponsive may have a brain that is structurally normal and chemically starved or poisoned. Glucose, hormones, electrolytes, and acid-base balance form the internal environment on which every cell depends, and the nervous system and heart signal first when that environment fails. Endocrine and metabolic emergencies are therefore among the most common causes of altered mental status, dysrhythmia, and collapse in the emergency department, and among the most treatable. The nurse who recognizes the pattern, obtains the key bedside measurements, and starts the correct therapy in the correct order can reverse conditions that would otherwise be fatal within hours.

1. 21.1 Hypoglycemia
2. 21.2 Diabetic Ketoacidosis
3. 21.3 Hyperosmolar Hyperglycemic State
4. 21.4 Thyroid Storm and Myxedema Coma
5. 21.5 Adrenal Crisis
6. 21.6 Sodium and Potassium Disorders
7. 21.7 Calcium, Magnesium, and Acid-Base Disturbances

The preceding chapters followed the body's most time-critical failures: the airway, the lungs, the heart, the brain, and the circulation. Those emergencies announce themselves with abnormal vital signs or obvious distress. The abdomen is different. It is a large cavity that holds the digestive tract, the liver, pancreas, spleen, kidneys, bladder, and reproductive organs, and it can hide a catastrophe behind a patient who looks only mildly uncomfortable. A ruptured appendix, ischemic bowel, bleeding ulcer, or twisted testicle may present with only pain and normal-looking vital signs in the first hour. This chapter teaches you to see through that deceptive calm.

1. 22.1 The Acute Abdomen
2. 22.2 Gastrointestinal Bleeding
3. 22.3 Bowel Obstruction, Appendicitis, and Perforation
4. 22.4 Pancreatitis and Biliary Emergencies
5. 22.5 Acute Kidney Injury and Rhabdomyolysis
6. 22.6 Urinary Tract Infection, Pyelonephritis, and Renal Colic
7. 22.7 Testicular and Other Genitourinary Emergencies

Chapter 22 ended with a recurring observation: the abdomen and the urinary tract are among the most common places where a localized infection escapes its boundaries and becomes a threat to the whole body. This chapter follows that escape. Sepsis is not an infection of a particular organ. It is the body's own dysregulated response to infection, a response that injures the patient's tissues and organs and can kill faster than the original microbe could. It is among the leading causes of death in hospitalized patients in the United States, and the emergency department (ED) is where most community-onset sepsis first meets a clinician. The emergency nurse is often the first person positioned to recognize it.

1. 23.1 The Host Response and the Pathophysiology of Sepsis
2. 23.2 Early Recognition and Screening Tools
3. 23.3 The Sepsis Bundle and Resuscitation
4. 23.4 Source Identification and Antimicrobial Therapy
5. 23.5 Septic Shock and Vasopressor Support
6. 23.6 Skin, Soft Tissue, and Necrotizing Infections
7. 23.7 Emerging and Communicable Disease Presentations

The previous chapter described the body's response to an invading organism. This chapter addresses a different kind of invasion: a chemical, drug, or toxin that enters the body by ingestion, inhalation, injection, or absorption and disturbs physiology in ways that can be rapidly fatal. Poisoning and overdose account for an enormous number of emergency department (ED) visits in the United States each year, from a toddler who swallowed a household product to an adult in a deliberate overdose, a worker exposed to a gas, and a person in the grip of alcohol withdrawal. The emergency nurse meets all of them, often with little history, an unreliable historian, and a clinical picture changing by the minute.

1. 24.1 The Toxicologic Assessment and Toxidromes
2. 24.2 Decontamination and Antidotes
3. 24.3 Acetaminophen and Salicylate Poisoning
4. 24.4 Opioid, Sedative, and Stimulant Overdose
5. 24.5 Alcohol Intoxication and Withdrawal
6. 24.6 Toxic Alcohols, Carbon Monoxide, and Cyanide
7. 24.7 Cardiovascular Drug Overdose and Poison Control Resources

The preceding chapters built a framework for the adult emergency patient: a systematic primary survey, a disciplined approach to airway, breathing, and circulation, and an understanding of how shock, trauma, and cardiac arrest unfold. Children enter the same department, but they are not small adults. Their airways are narrower, their hearts compensate differently, their bodies lose heat and fluid faster, and they cannot tell you what is wrong in an adult's words. A toddler who is quiet and still may be conserving the last of his energy rather than resting. An infant whose heart rate has quietly fallen may be on the edge of arrest rather than recovering. Reading these signals and acting early is the central work of pediatric emergency nursing.

1. 25.1 Anatomic and Physiologic Differences in Children
2. 25.2 The Pediatric Assessment Triangle and Vital Sign Norms
3. 25.3 Pediatric Respiratory Emergencies
4. 25.4 Pediatric Shock, Dehydration, and Sepsis
5. 25.5 Pediatric Resuscitation
6. 25.6 Fever, Seizures, and Neurologic Presentations
7. 25.7 Child Maltreatment and Family-Centered Care

The previous chapter showed how the youngest patients demand a different mental model from the adult. Pregnancy demands one too. A pregnant woman who arrives in the emergency department is two patients in one body, and her physiology is so altered that vital signs, laboratory values, imaging choices, drug selection, and even the technique of resuscitation change. A heart rate that would alarm you in a non-pregnant patient may be normal at term, while a blood pressure that looks reassuring may signal early preeclampsia. The best care of the fetus in nearly every emergency is excellent care of the mother, and that principle organizes this chapter.

1. 26.1 Physiologic Changes of Pregnancy
2. 26.2 Ectopic Pregnancy and First-Trimester Bleeding
3. 26.3 Hypertensive Disorders of Pregnancy and Eclampsia
4. 26.4 Third-Trimester Bleeding
5. 26.5 Emergency Childbirth and Neonatal Resuscitation
6. 26.6 Trauma and Cardiac Arrest in Pregnancy
7. 26.7 Gynecologic Emergencies and Sexual Assault Care

The preceding chapter examined patients whose physiology is temporarily rearranged by pregnancy. Older adults present a different and more permanent challenge. Aging is not a disease, but it steadily narrows the margin between health and crisis. Organs lose reserve, homeostatic responses slow, the immune system weakens, and the accumulation of chronic conditions and medications creates a body in which a small insult can cause a large and unexpected failure. In the United States, adults aged sixty-five and older make up a growing share of emergency department visits, arrive by ambulance more often, stay longer, and are more likely to be admitted.

1. 27.1 Physiologic Changes of Aging
2. 27.2 Atypical Presentations in Older Adults
3. 27.3 Falls and Geriatric Trauma
4. 27.4 Delirium, Dementia, and Cognitive Assessment
5. 27.5 Polypharmacy and Medication Safety
6. 27.6 Elder Abuse and Neglect
7. 27.7 Goals of Care and Palliative Approaches in the Emergency Department

The preceding chapters followed the body through its most dramatic failures: the airway that closes, the heart that stops, the injured patient who bleeds. Behavioral health emergencies look quieter at the bedside, yet they fill emergency department (ED) waiting rooms, hallway beds, and boarding areas in nearly every community in the United States. A person in psychiatric crisis may have no visible wound and a normal set of vital signs, and still be at the edge of a life-threatening act, whether directed toward self or toward others.

1. 28.1 Assessment of the Patient in Psychiatric Crisis
2. 28.2 Suicide Risk Screening and Safety Planning
3. 28.3 Agitation and De-escalation
4. 28.4 Chemical and Physical Restraint
5. 28.5 Psychosis, Mania, and Medical Mimics
6. 28.6 Intimate Partner Violence and Human Trafficking
7. 28.7 Forensic Evidence Preservation

Everything in the emergency department is built around the idea that resources are matched to the individual patient: the sickest person gets the most attention, and no one is left unseen. A disaster breaks that assumption. When a tornado, an earthquake, a chemical release, a transportation crash, or an act of violence sends dozens or hundreds of injured people toward a hospital in a short span of time, the number of patients exceeds the number of nurses, beds, ventilators, and operating rooms, and the ethical frame shifts from the greatest care for each patient to the greatest good for the greatest number.

1. 29.1 Disaster Cycles and Hospital Emergency Preparedness
2. 29.2 Mass Casualty Triage Systems
3. 29.3 Incident Command in the Emergency Department
4. 29.4 Chemical, Biological, Radiological, and Nuclear Threats
5. 29.5 Decontamination and Personal Protective Equipment
6. 29.6 Active Shooter and Blast Injuries
7. 29.7 Surge Capacity and Crisis Standards of Care

Most of this book has concerned the recognition and reversal of threats to life. Yet the large majority of emergency department (ED) patients arrive with something else uppermost in their minds: they hurt, they are frightened, and they want to know what will happen to them. Relieving pain, performing procedures with skill and kindness, teaching patients how to continue their recovery at home, and ensuring that each person moves safely to the right next place of care are not afterthoughts to resuscitation. They are the daily substance of emergency nursing and a measure of its quality. A patient with a fractured forearm who receives timely analgesia, a safely performed reduction under sedation, clear discharge teaching, and a dependable follow-up plan has been served as well as one whose airway was secured in a crisis.

1. 30.1 Pain Management Principles and Multimodal Analgesia
2. 30.2 Procedural Sedation and Monitoring
3. 30.3 Regional Anesthesia and Nerve Blocks
4. 30.4 Common Emergency Nursing Procedures
5. 30.5 Discharge Teaching and Return Precautions
6. 30.6 Admission, Transfer, and Interfacility Care
7. 30.7 Quality Improvement and Emergency Nursing Research