4-25-08

Kathy Batton

Nursing in Disasters
• Disasters and Nursing o A sudden and massive disruption in health care service because of hostile elements of any kind (natural and man-made) requiring survival resources be brought into action in the shortest possible time using the fewest resources Does not necessarily mean numerous injured or dead. It may be 5 critically injured MVA clients taken to a small community hospital.

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Disaster Types o Natural      o Tornadoes Hurricanes Earthquakes Blizzards Epidemics

Man-Made         Fires Explosions Nuclear accidents Bombings Biological Chemical Radiation War

Nurses Role in Disaster Triage o o Triage will be based on utilization of resources to treat the MOST people Good of the “whole” becomes more important than good of the individual

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Kathy Batton Potential outcomes/ survivability and available resources is the issue-not degree of injury Nurses will still be involved with assessment and basic treatment

Disaster Triage Categories o Immediate/ Priority 1/ Red Tagged   Life threatening injuries that are survivable with minimal interventions Examples: airway obstruction, sucking chest wounds, tension pneumothorax, hemothorax, open fractures of long bones, burns (2nd and 3rd degree as long as it is 15%-40% of the TBSA) This group can rapidly deteriorate without treatment and become black tagged

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Delayed/ Priority 2/ Yellow Tagged  Significant injuries that are survivable with medical care, but aren’t going to die immediately without care Examples: stable abdominal injuries, fractures that need reducing, eye injuries, soft tissue injuries, facial injuries without airway difficulties Can go from yellow to red as they get sicker

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Minimal/ Priority 3/ Green Tagged   Minor injuries, treatment can be delayed for hours or days without death Examples: sprains, cuts, fractures that don’t have to be reduced surgically, psych people

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Expectant/ Priority 4/ Black Tagged  Significant injuries, chances of survival are minimal even with immediate care or walking wounded Examples: nursing home patients who are DNR, unresponsive people with penetrating head wounds, major burns over 60% of body, fixed and dilated pupils, brain matter coming out of ears, this is also the walking wounded People that will be fine even if they don’t get medically treated. Usually the walking wounded are trying to care of the dying.

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After triage category decided the person is tagged and treated and / or transported, triage continues at each point of care.

Disaster Levels

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Kathy Batton Level I-local emergency response personnel and organizations can contain and effectively manage the disaster and its aftermath Level II-regional efforts and aide from surrounding communities are sufficient to manage the effects of the disaster Level III- local and regional assets are overwhelmed; state wide or federal assistance is required

Terrorism Recognition and Awareness o o o o o Be aware of an unusual increase in the number of people with fever of GI problems Unusual illness for time of year Cluster of client from a specific location Large number of rapidly fatal cases with death in 72 hours Increase in disease in otherwise healthy population

Levels of protection for health care workers o Level A- highest level of respiratory, skin, eye, mucus membrane protection  o o o Covered from head to toe, breathing apparatus, chemical resistant

Level B-same respiratory but less skin and eye protection, still wear chemical resistant suit Level C-air purified respirator, with filters that remove harmful substances and a chemical resistant coverall, gloves, boots, and splash hood Level D- what you would normally wear plus universal precautions

Weapons of Terror o Biological Weapons      Easily obtained Easily disseminated Significant morbidity and mortality Signs and symptoms similar to common diseases May be liquid, dry, applied to foods or water or vaporized

4-25-08  

Kathy Batton Vector may be animal, insect, or human or direct contact with agent itself. Types • Anthrax/Bacillus Anthracis o o o o o o o Most likely weapon to be used (has been used before) Naturally occurring in soil As an aerosol it is odorless and invisible and can travel for miles Causes hemorrhage, edema and necrosis Incubation period is 1-6 days Use standard precautions Skin contact  Signs and symptoms • • • edema with pruritis macule, papule formation resulting in ulceration with 1-3mm vesicles eschar (painless) develops and falls off in 1-2 weeks

Nursing care • • Treat symptoms Maybe antibiotics

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Ingestion  Signs and symptoms • • • • • Fever Nausea and vomiting Abdominal pain Bloody diarrhea (occ. Ascites) Massive diarrhea can result in volume depletion

4-25-08 • •  Can result in sepsis Frequently fatal due to sepsis

Kathy Batton

Nursing care • • • Assess for and maintain adequate fluid status Treat symptoms Assess for sepsis

Medications • • • Fluoroquinolones Tetracycline Penicillin

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Inhalation  Signs and symptoms • Mimics flu-in first stage o o o o • Headache, syncope Cough, dyspnea (no rhinorrhea or nasal congestion) Fever, chills Vomiting, weakness

After initial s/s brief recover period then 1-3 days o o o o Fever Severe respiratory distress, strider, hypoxia, cyanosis 50% have hemorrhagic mediastinitis on x-ray Diaphoresis

4-25-08 o o o o o  Nursing Care • • • • • Use standard precautions Hypotension Shock

Kathy Batton

May progress to meningitis with SA hemorrhage Death 24-35 hours Mortality rate near 100%

If antibiotics started within 24 hours after exposure death can usually be prevented Nurses must be vigilant in surveillance Penicillin, chloramphenicol, gentamicin or doxycycline For mass exposure and persons exposed but without s/s-doxycycline or ciprofloxacin for 60 days Cremation for the dead

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Smallpox/ Variola Major o o o o o o o DNA virus Highly contagious Lives 24 hours in cool temperatures 30% Mortality rate, morbidity rate extremely high Spread by direct contact and contact with clothing, linens, or by droplet Contact precautions and droplet precautions Incubation period   7-17 days Not contagious during this time

4-25-08   o Feel fine Contagious after patient develops fever

Kathy Batton

Prodrome Phase      Sometimes contagious Lasts 2-4 days Fever (high 101-104F) highest when rash starts Malaise, head and body aches Feel too sick to carry

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Rash phase    4 days Most contagious during rash phase Starts as small red spots on tongue and in mouth, these rupture and spreads virus into mouth and throat, rash then starts of face and spreads to arms and legs and then hands and feet Rash is everywhere in 24 hours As rash appears fever decreases they feel better 3rd day of rash is raised bumps 4th day bumps fill with thick opaque fluid and have depression in center (looks like a belly button and a major characteristic) Fever will rise again and stay high until scabs form over the bumps

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Pustular Rash Phase    Duration -5 days Bumps become pustules-raised, usually round and firm Crust and scabs form (duration about 5 days,) by end of the second week of the rash most of the sores have formed scabs

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Kathy Batton Once scabs are gone, patient is no longer contagious

Hemorrhagic smallpox o o o Same s/s as variola major except dusky erythema and petechiae to frank hemorrhage of the skin and mucus membranes Death usually within 5-6 days Nursing Care for both types of Smallpox    Protect yourself (contact and airborne precautions) Symptomatic care Assess for additional infection-if present administer antibiotics Vaccine administered up to 4 days after exposure-before the rash appears will help prevent and or decrease disease symptoms Chemotherapeutic agent-Cidofovir is being used experimentally in the lab Bodies should be cremated

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Infection control  Wear gloves, caps, gowns, and surgical masks

Tularemia o o o o o o o Also known as deerfly or rabbit fever Naturally found in small mammals and the insects that bite them Can survive for weeks at low temps in water, moist soil, hay, straw, or decaying animal carcasses Can be aerosolized for biological weapon use Mortality rate not high Can’t be spread from person to person S/S  Develop 3-5 days

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Kathy Batton May be mild illness or acute sepsis and rapid death Sudden fever, chills, headache, diarrhea, generalized aching, dry cough sore throat without adenopathy, then progressive weakness, pneumonia to chest pain, blood sputum and dyspnea If inhaled death due to pneumonitis, sepsis and shock

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Nursing care     For inhaled, treatment within 48 hours Treat symptomatically Streptomycin or gentamicin for 10-14 days For mass casualty, doxycline or cipro for 14 days

Botulism o o o o o o o o Produces a neurotoxin Exposure results in flaccid paralysis May be ingested or inhaled Spread via direct contact Not contagious via human to human Use standard precautions If skin contact use soap and water or bleach solution to clean S/S   GI-abdominal cramps, N&V, diarrhea Inhaled (manmade) • • • • Symmetric descending paralysis Diploplia Dysphagia, dry mouth, altered mental status death from airway obstruction and decreased tidal volume

4-25-08 • •  may or may not have fever usually responsive initially

Kathy Batton

Nursing care • Supportive care o o o o • Mechanical ventilation Fluids and nutrition Do not give aminoglycosides or clindamycin No isolation required

Antitoxin o Equine antitoxin given to decrease nerve damage-check allergies

Plague o o o o o o Necrosis and destroys the lymph nodes Pneumonic plague type most likely to be used in terrorism Will likely be aerosolized Pneumonic is contagious through human to human contact Transmitted via respiratory droplet contact s/s      severe bronchospasms chest pain dyspnea, cough hemoptysis 100% mortality if not treated within first 24 hours after exposure, even with treatment mortality is 50%

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Treatment  Symptomatic

4-25-08     o Chemical Weapons  Nerve Agents • Sarin Gas-heavier than area, settles in low areas o o o o Evaporates into a colorless, odorless, vapor Can be inhaled or absorbed

Kathy Batton Utilize barrier precautions with full face respirators Have client wear mask Streptomycin or gentamicin for 10-14 days After close contact give doxycycline for 7 days

Results in continuous stimulation of the nerve endings S/S start in ½ hour to 18 hours            Bilateral miosis Visual disturbances GI motility N&V, and diarrhea Substernal spasm Bradycardia AV block Bronchoconstriction Laryngeal spasm Seizures Death –really bad death

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Nursing Care  Decontamination at site with copious amounts of water or NS for 8-20 minutes Blot to dry

4-25-08     Maintain airway Suction PRN Decontamination at hospital

Kathy Batton

IV atropine 2-4 mg, Then 2 mg every 3-8 minutes for up to 24 hours or atropine 1-2 mg every hour until resolution Pralidoxime 1-2mg in NS IVPB over 15-30 minutes Diazepam (valium) or benzodiazepines for seizures

  • Cyanide o o o o

Affect cellular metabolism resulting in alterations of hemoglobin that leads to asphyxiation Has a bitter almond odor Can be ingested inhaled or absorbed through skin and mucus membranes Inhalation symptoms      Flushing Tachycardia Nonspecific neurologic symptoms Seizure Respiratory arrest

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Nursing Care       Intubate Ventilate Nitrate pearls-put in reservoir of ventilator Sodium nitrate-given IV 300mg over 2-4 minutes Sodium thiosulfate-given IV 12.5mg over 5 minutes Alternative treatment-vitamin B12

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Kathy Batton Chemical Vesicants (mustards, phosgene, lewisite-contains arsenic) o o o o Cause blistering and burning Minimal mortality but large morbidity Sulfa mustard smells like garlic Signs and Symptoms  Initially presents like a large superficial partial thickness burn in warm, moist areas Then pruritus painful burning and vesicle formation Possibly a purulent fibrinous discharge that may obstruct airway

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Nursing Care      Treated as a burn Decontaminate with soap and water Do not rub skin Irrigate eyes if exposed If respiratory exposure-intubate, ventilate, and prepare for bronchoscopy Observe all mustard exposures for 24 hours due to possible latent effects

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Chemical Pulmonary Agents (phosgene, chlorine) o o o o Destroy pulmonary membrane that separates alveolus from the capillary bed Capillary leaks result in fluid filled alveoli Phosgene smell like fresh-mown hay S/S   Pulmonary edema with SOB Hacking cough that progresses to frothy sputum

4-25-08 o Nursing Care     o Radiation Weapons  Types • Alpha o o • Beta o o • Gamma o o o • Penetrates Difficult to shield from Often accompanies alpha and beta emissions Moderately penetrates the skin Skin damage if prolonged exposure Low level Localized damage only Supportive Airway management Intubate ventilate

Kathy Batton

Measurement and Detection o o o o o o Rad-basic unit of measurement Rem-type of radiation and potential for damage Half life-time it takes to lose half of radioactivity Geiger counter-detects gamma and some beta radiation Personal dosimeters-worn by radiology personnel to detect exposure It is the dose rather than the source that determines if ARS will develop

4-25-08 • Radiation Exposure/ injury o o o o o Time-how long they were exposed Distance-how close they were to the source

Kathy Batton

Shielding-decreasing exposure by stopping at shield External Irradiation-when body itself exposed, all the way through the body, but the patient doesn’t become radioactive Contamination-body has been exposed to source of radiation, don’t touch someone who is contaminated-need to be decontaminated-need medical attention very quickly to prevent incorporation Incorporation – patient will have radiation that goes into the cells of their body-will kill off liver, kidneys, bone, and thyroid Nursing care should begin at the scene    Decontaminate without contamination of rescuers Assess presenting symptoms to determine triage Triage based on predicted survival • Probable-minimal or no initial s/s o • CBC, discharge with possible instructions to return for certain s/s

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Possible-N/V for 24-48 hrs o o Start supportive measures Probably go ahead and isolate them (reverse isolation)

Improbable-greater than 800 rad of total body penetrating irradiation-death o Shock, neurological symptoms

Decontamination • First decontamination then triage, should occur at the scene

4-25-08 • • • • • • • • • Disaster plan should be in effect

Kathy Batton

Immediately notify hospital radiation safety officer Survey for exposure Triage outside the hospital if possible to prevent facility contamination Cover floors Strict isolation Control waste Staff should wear dosimeter badges, and protective covering Decontamination should occur outside the hospital (shower, collection pool, tarp collection containers for belongings). Provide soap, towels, disposable paper gowns Then survey-decontaminate until free of contamination After survey indicates no external contamination victim can be sent into hospital Biologic samples should be taken If client has internal contamination or incorporation then catharsis and/ or gastric lavage with chelating agents Sample of urine feces, and vomitus may be surveyed to determine internal effects

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Acute Radiation Syndrome (ARS)  Severity determined by dose,, rate, total body exposure and penetrating type radiation Age, medical history, and genetics Cells that multiply rapidly are most affected

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4-25-08  o Hematopoietic system affected first

Kathy Batton

Outcome indicators  Lymphocyte count 48 hours after exposure-3001200=significant exposure 600 rad or more=GI symptoms=NV in 2 hours post exposure 1000 rad or more = CNS symptoms 600-1000 rad effects skin 5000 rad or more= necrosis in a few days to months Secondary injury may be present if exposure due to blast or burn-trauma increases mortality

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Phases of ARS  Prodromal phase • s/s 48-72 hours post exposure o • NV, decreased appetite, fatigue, high dose=fever, resp distress, excitability

Monitor lymphocyte count, provide fluids and electrolytes, if significant exposure isolate to prevent infection, bleeding precautions

Latent phase • • • • • • • Symptom free period Lasts up to 3 wks-less if significant exposure Decreasing lymphocytes, platelets, leukocytes, thrombocytes, and RBC’s Isolation as needed Frequent rest periods O2 PRN Bleeding precautions

4-25-08 •  Supportive measures

Kathy Batton

Illness phase • • • • • Infections Fluid and electrolyte imbalances S/S =bleeding, shock, change in LOC Treat symptomatically Isolation precautions

Recovery phase or death • • • • Can take weeks or months to recover or die S/S=increasing ICP is ominous sign of impending death Supportive care ABC’s

www.thepodgame.com o Can become a disaster worker to see how well you manage your disasters

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