CEN: ED Safety, Disaster and Toxic Exposures

In depth

The one-page summary above is what the PDF prints. These sections go further.

Fire evacuation in the hospital

Hospitals are built so that patients can be protected without leaving the building: smoke compartments and fire doors isolate people from a fire. Evacuation plans therefore escalate in steps. Horizontal evacuation moves people from the threatened area to a non-threatened area, usually on the same floor, and should assure life safety in most situations; moving horizontally into an adjacent building is the secondary form. Vertical evacuation to another floor is used when staying in place is undesirable or unsafe, and a building-wide evacuation to the exterior, with the alternate care site plan and assembly areas, only when remaining inside is unsafe. Vertical and building-wide moves may have to use stairwells only, because elevators may be unsafe or nonfunctional.

• An ED with smoke in one hallway and a clear compartment beyond the doors: move the patients through the doors (closing them behind you is standard teaching; UCLA names the doors as isolating barriers) rather than out to the parking lot or down the stairs.
• Moving unstable stretcher patients outside or down stairs adds risk and delays care when a horizontal move would do.
• Care-related evacuation needs are reported to the person authorized to activate the hospital's internal emergency plan.

Active shooter in a health care facility

Federal guidance adapts run, hide, fight to health care. The priority is to reduce the number of people near the shooter, because fewer people in the hot zone means fewer targets. Running may mean leaving behind patients who cannot evacuate themselves, a life-and-death choice that staff should discuss before an incident. Hiding alone may not be enough; units away from the shooter lock down, and staff practice barricading doors without locks and stay ready to run if the shooter approaches. Announcements to patients and visitors use plain language. Ready.gov ranks fighting as a last resort, to be used only when running and hiding are impossible.

The response changes when law enforcement arrives. Ready.gov advises staying calm and following instructions, keeping hands visible and empty, going to designated areas to give information and get help, and evacuating in the direction officers indicate. The first officers in may not yet know who the attacker is, so a nurse holding trauma shears drops them, shows empty hands and obeys commands before raising the needs of a patient who cannot be moved. Plans should also cover facility hazards responders may not know (MRI, medical gases) and behavioral health support once the shooting stops.

Workplace violence, reporting and EMTALA

NIOSH defines workplace violence as an act or threat of violence, from verbal abuse to physical assault, directed at people at work, and sorts it into four types: criminal intent (Type I), patients, clients or families (Type II), co-workers (Type III) and personal relationships (Type IV). Violence by patients and families is Type II. Underreporting is the rule: prior studies suggest 30% or fewer nurses and physicians report what they experience. Barriers include the belief that violence is part of the job, lack of injury, perceived lack of management support, fear of retaliation, cumbersome reporting and confusion about what is reportable when the patient has psychosis, substance use, delirium or dementia.

In one ED project, education, a 1 to 2 minute reporting tool at the charge nurse desk (the formal online report took 15 to 20 minutes) and leadership follow-up of every report cut the share of staff who saw violence as part of the job from 55.8% to 24.2%. Reports went from none in 2012 to more than 50 in 2013, and leadership supported reporting to law enforcement. That article cites Minnesota statute 609.2231, which makes inflicting bodily harm on a health care provider in an ED a felony; penalties vary by state.

Culpability is the hard part with impaired patients. In a survey of ED staff and police officers, a dementia patient punching a nurse was called a reportable crime by only about a quarter to a third of each group, and staff and police disagreed about a delirious patient's threats. An internal incident report is still filed: it tracks risk and drives prevention whatever the patient's capacity. An alert, oriented patient who punches a nurse can be reported to police by the nurse herself; the penalty depends on state law. Reporting does not end the hospital's duties: under 42 CFR 489.24 any person who comes to the ED gets a medical screening examination and, if an emergency condition exists, stabilizing treatment or an appropriate transfer, regardless of ability to pay.

Chlorine and phosgene

Chlorine is only slightly soluble in water but reacts with moisture to form hypochlorous and hydrochloric acids, so it burns the eyes and upper airway at once and can reach the lower airways. People exposed only to the gas pose little risk of secondary contamination; clothing soaked with industrial-strength bleach can still release chlorine. For decontamination, remove and double-bag clothing, flush skin and hair with plain water for 2 to 3 minutes, then wash twice with mild soap, guarding against hypothermia in children and older adults. Irrigate the eyes for at least 15 minutes and check acuity. Give oxygen by mask for respiratory symptoms and aerosolized bronchodilators for bronchospasm (racemic epinephrine for a child with stridor); intubate for respiratory compromise. Pulmonary injury may progress for several hours. Admit patients with persistent shortness of breath, severe cough or chest tightness and observe them until symptom-free; patients with only minor burning or a slight cough may go home, most of them symptom-free within an hour.

Phosgene smells like new-mown hay or green corn at low levels, and smell is not a reliable warning. Early irritation can be mild, but pulmonary edema can follow an asymptomatic interval of 30 minutes to 48 hours, shorter after heavier exposures. The CDC advises monitoring exposed people for the full 48 hours, and ATSDR suggests considering hospitalization for all patients with suspected exposure. Edema, hilar enlargement and patchy infiltrates on the chest radiograph are late findings, 6 to 8 hours or more after exposure, so an early normal film settles nothing. Keep the patient warm and quiet, because any activity after exposure may increase the likelihood of death. There is no antidote: oxygen, bronchodilators for bronchospasm, and diuretics avoided because the edema is not from volume overload. Patients who are asymptomatic with normal examinations after 48 hours may be discharged, told to avoid vigorous activity for 1 to 2 days and to return with any symptoms.

Carbon monoxide: diagnosis, treatment and the home

Carbon monoxide is odorless, and its symptoms (headache, dizziness, weakness, nausea, vomiting, chest pain, confusion) are often called flu-like. Suspect it when several people from the same dwelling, especially a heated one, share nonspecific symptoms, when there is no fever, and with unexplained metabolic acidosis. Infants, older adults and people with heart disease, anemia or breathing problems are more likely to become ill. Common sources are furnaces, portable generators, charcoal grills, gas ranges and stoves, fireplaces, small engines and vehicles.

A standard two-wavelength pulse oximeter cannot tell carboxyhemoglobin from oxyhemoglobin, so diagnosis rests on co-oximetry. The CDC treats 2% in a nonsmoker or above 9% in a smoker as strongly supportive, but levels correlate poorly with severity, outcome or response to treatment, and they fall with time since exposure and with oxygen (half-life about 4.5 h on room air, 1.5 h on 100% oxygen, 20 minutes at 3 atmospheres). Give 100% oxygen until the patient is symptom-free, usually about 4 to 5 hours, with serial neurologic checks. Merck lists life-threatening cardiopulmonary complications, ongoing chest pain, altered consciousness, any loss of consciousness and COHb above 25% as reasons to consider hyperbaric oxygen, and pregnancy at lower levels; the CDC gives COHb above 25 to 30%, severe acidosis and neurologic or neuropsychiatric impairment. Severe poisoning can leave delayed neuropsychiatric effects days to weeks later.

Merck's advice when CO is suspected in a dwelling is to open windows, evacuate it and evaluate it for the source. A family is not discharged to a house nobody has checked. Teaching: battery or battery-backup CO alarms near every sleeping area, yearly service of heating systems and fuel-burning appliances, never a generator, grill or camp stove indoors or in a garage, generators more than 20 feet from windows, doors and vents, and never a running vehicle in an attached garage.

Smallpox recognition and response

Smallpox has an incubation of 7 to 19 days (usually 10 to 14) without symptoms or contagion, then a prodrome of about 4 days with fever of 38.3 to 40.5 °C. Lesions appear first in the mouth, then on the face and extremities, spreading to trunk, palms and soles (a centrifugal pattern), and develop uniformly: macules, papules, vesicles over 4 to 5 days, pustules over 1 to 2 more, crusts by about day 9, scabs off about 14 days after the rash began.

CDC's risk categories: high risk when all three major criteria are met (febrile prodrome 1 to 4 days before the rash, classic deep firm round lesions, same stage on any one body part), which calls for urgent infectious disease or dermatology consultation and is a public health emergency if confirmed as probable; moderate risk with the prodrome plus one other major criterion or four or more minor ones (urgent consultation and varicella testing); low risk without a prodrome. For a high-risk patient: airborne infection isolation room (a private room if none), out of waiting areas, airborne, contact and standard precautions with fitted N95, gown and gloves, a sheet over the rash and a mask on the patient if moved, and calls to infection control and the state or local health department. Precautions last until all scabs have crusted and separated (3 to 4 weeks); nonvaccinated staff do not provide care when immune staff are available, and postexposure vaccine within 4 days is protective.

Legionella and public health reporting

Legionella grows in warm water (25 to 40 °C supports the highest concentrations) and infects people who inhale mist from hot tubs, whirlpool baths, shower heads, misters, decorative fountains and cooling towers. It is not spread from person to person, so only standard precautions are used and a well spouse is not a risk to others. Symptoms usually start 2 to 14 days after exposure. Features beyond pneumonia include confusion, headache, diarrhea, relative bradycardia, hyponatremia, hypophosphatemia and raised liver enzymes.

Legionellosis is nationally notifiable. Surveillance identifies cases quickly, reveals links between them and decides when an outbreak investigation is needed; most recognized outbreaks are in health care and travel settings (hotels, resorts, cruise ships), and travel-associated cases are roughly 10 to 15% of those reported. Public health collects exposures for the 14 days before onset, including overnight travel. The urinary antigen detects only L. pneumophila serogroup 1 (65 to 90% of cases), so culture or molecular testing of sputum or lavage is sent with it, ideally before antibiotics without delaying them. Merck prefers a respiratory fluoroquinolone (levofloxacin or moxifloxacin) for 7 to 14 days, or azithromycin for 5 to 10 days.

Breath-hold blackout

Merck calls these dangerous underwater breath-holding behaviors: intentional hyperventilation, hypoxic training and static apnea, practiced mostly by healthy young men who swim well. Blowing off carbon dioxide before going under delays the normal urge to breathe, so while submerged hypoxia comes first, then loss of consciousness, then drowning. A swimmer rescued after this never felt the need to surface. Teaching: stop pre-dive hyperventilation and breath-hold games, and supervise them if they are practiced at all. Observation after the rescue follows the drowning guidance (see Hypothermia, Heat Stroke and Drowning): mild symptoms with clear lungs and normal oxygenation are observed 4 to 6 hours.

Packaging clothing as evidence

Water drives the reactions that degrade biological samples, so stained items are dried quickly (most within about 2 hours outside very humid climates) and kept in paper bags or envelopes, whose porosity lets drying continue; plastic is avoided. Each item gets its own paper container, never two stains in one, with clean paper between folds of a garment with several stains. Merck adds that clothing condition (damage, stains, adherent material) is recorded, that specimens are placed in individual packages that are labeled, dated, sealed and held until delivery, and that chain of custody means the evidence is in the possession of an identified person at all times, with each transfer signed for. Leaving a bag at the nurses' station breaks the chain. Timing, kits and storage belong to the Forensics, Abuse and Sexual Assault in the ED page and local protocol.

Exam pearls

• Smoke in one ED hallway, clear compartment next door: horizontal move, doors shut behind you.
• Police burst in during an active shooter event: empty, visible hands and follow commands.
• Pushed by a delirious patient, not hurt: still file the incident report.
• Punched by an alert patient: she may call police; his screening exam goes on (EMTALA).
• Phosgene with a normal film at 1 hour: admit, rest, observe 48 h.
• Chlorine with wheeze and SpO₂ 93%: clothes off, eyes 15 min, O₂, bronchodilator, observe until symptom-free.
• Whole family with headaches every morning in winter: CO; the house is checked before anyone goes home.
• Adult with a toxic prodrome and same-stage pustules on face, palms and soles: airborne plus contact, notify now.
• Legionella: standard precautions, report the case and the hotel; the well spouse is no risk to visitors.
• Blackout after hyperventilating underwater: low CO₂ delayed the urge to breathe.
• Damp evidence: air-dry, one paper bag per item, sealed and labeled.