LECTURE NOTES IN EMERGENCY AND DISASTER

NURSING
Mary C. Balintona, RN, MAN
DEFINITION OF TERMS

Disaster

 Any destructive events that disrupts the normal functioning of a community.

 Ecologic disruptions or emergencies of a severity and magnitude that result

in deaths, injuries, illness and property damage that cannot be effectively
managed using routine procedures or resources that require outside
assistance.

Types of Disaster

1. Natural- cause by natural or environmental forces. It includes

earthquakes, floods, tornadoes, hurricanes, volcanic eruptions, etc.

2. Man Made/Human Generated

- The principal direct causes are identifiable human actions,

deliberate or otherwise.

- It has three broad categories: complex emergencies, technologic

emergencies, disasters that are cause by natural hazards but occur
in natural settlements.

- Complex emergencies: involve situations where populations suffer

significant casualties as a result of war, civil strife, or other political
conflict.

- Technologic emergencies: large number of people, property,

community infrastructure, and economic welfare are directly and
adversely affected by major industrial accident, unplanned release
of nuclear energy and fires or explosions from hazardous
substances such as fuel, chemicals, or nuclear materials.

Medical Disaster

- Is a catastrophic event that results in casualties that overwhelm the health

care resources in that community.

Disaster Planning

- Addresses the problems posed by various potential vents, ranging in scale,

from mass casualty incidents.

Types of Disaster Planning

1. Agent specific approach

LECTURE NOTES IN EMERGENCY AND DISASTER
NURSING
Mary C. Balintona, RN, MAN
 It’s a planning type that focuses on the preparedness on most likely
threats to occur based on their geographic location.

2. All hazards approach

 Is a conceptual model for disaster preparedness that incorporates

disaster management components that are consistent across all major
types of disaster events to maximize resources, expenditures and
planning efforts.

Crisis/crisis management

 Administrative measures that identify, acquire, and plan the use of

resources need to acquire and plan the use of resources need to
anticipate, prevent, and or resolve a threat to public health and safety.

Triage

 Is a process which places the right patient in the right place at the
right time to receive the right level of care.

 The word triage is derived from the French word trier, which means “to
sort out or choose.”

DISASTER MANAGEMENT AND PLANNING

Disaster Planning

 Requires the cooperative efforts of the hospital, community agencies and

local government.

 Cunny describes three types of advanced planning activities

i. Strategic Planning

 These are planning activities that focus on preparing the

organization for any type of threat. This is commonly referred to as
the all hazards approach.

ii. Contingency Planning

 These are planning activities related to a site-specific threat that

may occur at any time. An example of this is in the hospital setting
LECTURE NOTES IN EMERGENCY AND DISASTER
NURSING
Mary C. Balintona, RN, MAN
would be planning activities from a facility that is in close proximity
to a nuclear power plant or an airport.

iii. Forward Planning

 These are planning activities pt a known imminent disaster; for

example, a pending snowstorm, hurricane or major rock concert.

Internal vs External Disaster

Internal Disaster

o Occurs when there is an event within the facility that poses a threat to
disrupt the environment of care. (e.g., related to physical plants, loss of
utilities or fire).

External Disaster

o Becomes a problem for a facility when the consequences of the event that
creates a demand for services that tax or exceed the usual available
resources (e.g., arrival of large number of trauma patients of a chemical
spill).

Combined Internal and External Disaster

o Classified as

i. Level 1- if the organization, agency or community is able to contain the

event and respond immediately.

ii. Level 2- if the disaster requires assistance from external sources, but
these can be obtained from nearby agencies.

iii. Level 3- if the disaster is of a magnitude that exceeds the capacity of the
local community or region and requires assistance form national level.

Disaster Management Programs

o is composed of five phases

i. Preparedness/Risk Assessment
LECTURE NOTES IN EMERGENCY AND DISASTER
NURSING
Mary C. Balintona, RN, MAN
o Evaluates the facility’s vulnerability or propensity for disasters. Issues
to consider include weather patterns, geographic locations,
expectations related to public events and gatherings, age, condition,
and location of the facility.

ii. Mitigation

o Steps that are taken to lessen the impact of as disaster should one
occur and can be considered as prevention measures.

o Examples are installing and maintaining backup generators to mitigate

the effects of power failure or cross training staff to perform tasks to
maintain services during staffing crisis that is due to weather
emergency.

iii. Recovery

o Once the incident is over, the organization and staffs need to

recover. Invariably, services have been disrupted and it takes time
to return to routine.

iv. Evaluation

 Often this phase of disaster planning and response receives the

least attention. After a disaster, employees of the community are
anxious to return to usual operations. It is essential that a formal
evaluation be done to determine what went well and what problems
were identified.

Phases of Disaster Management

1. Risk Assessment

 The disaster manager needs to consider what type of disasters is

most likely to be encountered by the organization.

 All types of events need to be considered including deliberate

human-caused, technological and natural events.

 The disaster manager needs to perform also a risk assessment in

the area of staffing. Depending on the nature and extent of the
disaster and the demographics of the workforce, there may be
variation in the employees’ ability and or willingness to report to
work.

2. Mitigation

 Lessens the severity and impact of the disaster through appropriate

planning and practice. The best ways to mitigate the results of a
disaster are to perform a thorough hazard vulnerability risk
LECTURE NOTES IN EMERGENCY AND DISASTER
NURSING
Mary C. Balintona, RN, MAN
assessment and be sure that your plan includes provisions for each
of the likely events.

Essential Elements for Hospital Disaster Management

1. An appropriate infrastructure to support the disaster response which includes

maintaining services for preexisting patients as well as the new arrivals.

2. An appropriately trained staff who are competent to perform their disaster

response functional roles and able and willing to report to work during any
sort of disaster.

3. A clearly defined, executable, practiced emergency response plan.

4. A strong foundation of preexisting relationships with partnering organizations

and agencies that can be called on to provide mutual aid and support when
needed.

Hospital Incident Command System (HICS)

- Is an emergency management system that is comprised of specific disaster

response functional role positions within a hierarchical organization chart.

Key Features of Incident Command and HICS

i. Predictable, responsibility oriented chain of command.

o There is one incident commander. This individual has overall

responsibility for the management of the incident and the employees
know who report to them and to whom they report.

ii. Use of common nomenclature

o All agencies utilizing ICS use the same titles and functional roles for
the command staff positions.

iii. Modular, flexible organization

o Only those portions of the system that are needed for the response are
activated.

iv. Unified command structure

o This allows all agencies involved in the response to coordinate efforts

by establishing a unified set of incident objectives and strategies.
LECTURE NOTES IN EMERGENCY AND DISASTER
NURSING
Mary C. Balintona, RN, MAN
v. Incident Action Plan (IAP)

o This is a plan that is developed when multiple agencies are involved in

the disaster response.

vi. Facility Action Plan (FAP)

o A FAP describes the purpose, goals and objectives for the hospital’s
response.

vii. Unity of Command

o Each person reports to only one individual.

viii. Manageable span of control

o Each manager controls a defined amount of resources, which is limited

to what can realistically be managed.

ix. Use of JAS (Job Action Sheets)

o JAS define for the staff what their defined functional role is during
emergency and sister response.

TRIAGE

1. Daily Triage

 Triage perform by nurse in the emergency room. It is a routine triage.

 The goal is to identify the sickest patients in order to assess and

provide treatment to them first, before providing treatment to others
who are less ill.

2. Incident Triage

 Occurs when the emergency department is stressed by a large number

of patients but is still able to provide care to all victims utilizing
existing agency resources.

3. Disaster Triage

 Is employed when local emergency services are overwhelmed to the

point that immediate care cannot be provided everyone who needs it.

 During disaster triage, patients are usually sorted into

i. Critical- are those that are life threatening but likely to be

amenable to rapid intervention that does not require an
inordinate amount of resources (e.g., upper airway obstruction).
LECTURE NOTES IN EMERGENCY AND DISASTER
NURSING
Mary C. Balintona, RN, MAN
ii. Urgent- those conditions that are serious and if not treated in a
timely manner are likely to deteriorate to become critical (e.g.,
compound fracture of a long bone).

iii. Minor- the care required can be provided in a low tech tribute
setting and a delay in treatment would unlikely constitute to a
significant deterioration in the victims condition.

iv. Catastrophic- conditions that have either a very grave prognosis

or would require an amount of resources that are so large they
would divert care from others with a much better prognosis
(e.g., cardiac arrest).

4. Tactical Triage

 Is similar to disaster triage, only military mission objectives rather than

traditional civilian guidelines drive the triage and transport decisions.

5. Special Conditions Triage

 Is used when patients present from incidents such as radiation,

biological or chemical contamination.

6. Triage during an epidemic

 Usually use during mass casualty trauma situations (e.g., bioterrorism).

I. In-Hospital Triage Systems

 Utilize a triage system that has between three and five categories.

 The three main categories are

i. Emergent- signifies a condition that requires treatment

immediately within 15mins.-30mins. (e.g., cardiac arrest, airway
obstruction).

ii. Urgent- utilized for serious illness or injury that must be

attended to but a wait of up to 2 hours would not add to the
morbidity and mortality of the patient.

iii. Non-urgent- is any condition that can wait for more than 2
hours to be seen without the likelihood of deterioration.

II. Disaster Triage System

 Simple Triage and Rapid Treatment System (START) for adults

LECTURE NOTES IN EMERGENCY AND DISASTER
NURSING
Mary C. Balintona, RN, MAN
 JumpSTART system (for triaging pediatric patients)

 Start/Save (when the triage process must be over an extended

period of time)

1. Simple Triage and Rapid Treatment System (START) for adults

 A common algorithm that is used with adult pre-hospital triage.

 Developed by Newport Beach California, Fire and Marine Department

and Hoag Hospital.

 It is based on the person’s ability to respond verbally and ambulate

and their respirations, perfusion, and mental status (RPM). The system
works as follows

i. All patients who can walk (walking wounded) are categorized as

Delayed (Green) and are asked to move away from the incident
area to a specific location.

ii. The next group of patients is assessed quickly (30-60 seconds

per patient) by evaluating RPM: respiration, perfusion and
mental status.

2. JumpSTART

 Created to meet the unique needs of assessing children less than 8

years of age.

 Should be used if t5he victim looks like a child and START should be
sued whenever the victim looks like a young adult or older.

 The JumpSTART Pediatric MCI Triage Tool is the first objective tool
developed specifically for the triage of children in the
multicasualty/disaster setting.

 The objective of JumpSTART are

i. To optimize the primary triage of injured children in the MCI

setting

ii. To enhance the effectiveness of resources allocation for all MCI

victims

iii. To reduce the emotional burden on triage personnel who may

have to make rapid life or death decision about injured children
in chaotic circumstances.
LECTURE NOTES IN EMERGENCY AND DISASTER
NURSING
Mary C. Balintona, RN, MAN
3. START/SAVE Triage for Catastrophic Disasters

 The SAVE Triage was developed to direct limited resources to the

subgroup of patients expected to benefit most from their use.

 The SAVE assesses survivability of patients with various injuries and on

the basis of relationship between expected benefits and resources
consumed.

 Two types of area location in START Triage

i. Expectant area- would require the use of significant medical

resources.

ii. Treatment area- would use few resources and would have a
reasonable chance of survival.

III. Disaster Triage for Chemical and Hazardous Material Disasters

 Triage for chemical incidents will occur in several places

i. In the field

o Hot Zone- this is the area immediately adjacent to the

location of the incident.

o Warm Zone- this is the distance of at least 300 feet from

the outer perimeter of the hot zone and is upwind and
uphill from the contaminated area.

o Cold Zone- this area is adjacent (and uphill and upwind)

to the warm zone and is where decontaminated victims
enter.

ii. In the hospital setting

o Warm Zone- this is an area that is adjacent to the

hospital (usually the emergency department), which has
a source of water.

o Clean Zone- this is the treatment area inside of the

emergency department or hospital where newly arriving
patients and victims are sent after having been triaged
and decontaminated.
LECTURE NOTES IN EMERGENCY AND DISASTER
NURSING
Mary C. Balintona, RN, MAN

NATURAL DISASTERS

Cyclones

 Are large scale storm characterized by low pressure in the center

surrounded by circular wind motion.

Drought

 Is often seen as a result of too little rain and is often synonymous with
famine. Drought often triggers a crisis in arid and semi arid areas, because
rain is sparse and irregular.

Earthquake

 Considered to be the most destructive and frightening of all forces of

nature, is a sudden, rapid shaking of the earth caused by the breaking and
shifting of rock beneath the Earth’s surface.

 The Ritcher scale, used as an indication of the force of an earthquake,

measures the magnitude and intensity of energy released by the quake.

Tsunamis

 Series of waves usually generated by large earthquakes under or near the

ocean occur when a body of water is rapidly displaced on a massive scale.

 Submarine landslides and volcanic eruptions beneath the sea or on small

islands can also be responsible for tsunami but their effects are usually
limited to smaller areas.

The following events may signal a tsunami

1. A recent submarine earthquake

2. The sea appears to be boiling, as large quantities of gas rises to the surface
of the water.

3. The water is hot, smells of rotten eggs, or stings the skin.

4. There is an audible thunder or booming sound followed by a roaring or

whistling sound.

5. The water may recede a great distance from the coast.

6. Red light might be visible near the horizon and, as the wave approaches, the
top of the wave may glow red.
LECTURE NOTES IN EMERGENCY AND DISASTER
NURSING
Mary C. Balintona, RN, MAN

ENVIRONMENTAL EMERGENCIES and DISASTERS

Environmental emergencies

 Is a sudden threat to the public health or to the well being of the environment
arising from the release or potential release of oil, radioactive materials or
hazardous chemicals into the land, air or water.

 These emergencies may occur from transportation accidents, events at

chemical facilities or other facilities using or manufacturing chemicals or as a
result of natural or manmade disaster events.

Environmental disasters

 Is defined as an environmental emergency or ecologic disruption of a severity

and magnitude resulting in deaths, injuries, illness and/or property damage
that cannot be effectively managed by the application of routine procedures
or resources and that result in a need for additional assistance.

 Measures that are implemented during environmental disasters:

1. The immediate removal of the hazard from the environment.

2. Decontamination of exposed individuals.

3. The restoration of services to meet the immediate physiological needs of

the affected people.

4. The prevention of further illness or injury as a result of exposure to the

hazard.

Environmental Hazards

1. Chemical Spills

o Intentional or accidental leakage or spill of certain chemical substances

into the environment that can have devastating consequences on
human health.

2. Oil spills

o The leakage of oil in the bodies of water surrounding a land area.

BIO-CHEMICAL WARFARE AND TERRORISM

LECTURE NOTES IN EMERGENCY AND DISASTER
NURSING
Mary C. Balintona, RN, MAN
Biochemical terrorism

o According to Bruce Hoffman, it is the deliberate creation and exploitation of

fear through violence or the threat of violence in the pursuit of political
change.

o The use of chemical or biological agents as the main element of a terrorist

attack or threat.

Chemical Agents

o Are those chemical compounds synthesized artificially and include the many
toxic chemicals that may be available to terrorists.

o Chemical weapons utilize the toxic nature of selected substances to cause

death or injury. These chemical warfare agents may cause injury via the
respiratory route, through the skin by ingestion.

Biological Agents

o Are those pathogens used deliberately to infect persons as well as toxins

normally derived from plants or animals. In biological warfare, infectious
agents can infect through respiratory and ingestion routes.

Chemical Terrorism

Delivery of Chemical Agents

o Is optimized by producing contaminated areas with high concentrations of a

toxic compound. Chemical compounds that are gaseous at room
temperature or are extremely volatile do not need much engineering to
deliver.

o For a terrorist who is intent on causing chemical casualties, acquiring

“higher end” agents such as military nerve compounds might be too
difficult r unnecessary.

o Some of the chemical agents used are

a) Nerve agents (e.g., sarin)

b) Tissue (blood) agents (e.g., cyanide)

c) Lung irritants (e.g., chlorine gas)

d) Vesicants (i.e., blister agents such as mustard or lewsite)

LECTURE NOTES IN EMERGENCY AND DISASTER
NURSING
Mary C. Balintona, RN, MAN
e) Psychoincapacitants (e.g., BZ, LSD)

f) Pesticides

Nerve Agents

o Include the chemical tabun, sarin, soman, and VX. These toxic
organophosphate compounds all operate on the same basic principle-they
inhibit acetylcholinesterase.

Tissue (Blood) Agents

o Includes cyanide in its various forms. Ultimately cyanide blocks the enzyme
cytochrome oxidase, shutting down the energy transport (ATP) system.

Lung Irritants

o Attack the respiratory system causing tightness in the airways, hypoxia, and
in more severe cases, pulmonary edema.

o Vesicants

- the so-called vesicants or blister agents such as mustard gas and lewisite,
have less utility for terrorist.

o Psychoincapacitants

- The psychotropic compounds such as the belladonna drug BZ (3-quinuclidinyl

benzilate) or the hallucinogen LSD have been considered by militaries for use
in combat and for sabotage. Their performance on the battlefield, however,
has largely been considered unpredictable and impractical.

o Pesticides

- Refers to a group of agents used to kill a number of different “pests,” such as

weeds, insects, ticks, rats, and so forth.

Bioterrorism

o The act of biological terrorism (bioterrorism) involves the deliberate use of

microbial pathogens or toxins. Unlike a chemical incident, the effects from
bioterrorism may not be fully known until many hours or days after the event.

o The following are the agents used in bioterrorism

- Bacterial agents

- Viral agents

- Toxins (derived from plant or animals)

LECTURE NOTES IN EMERGENCY AND DISASTER
NURSING
Mary C. Balintona, RN, MAN
- Parasites

PHILIPPINE DISASTER COORDINATING COUNCIL AND THE PHILIPPINE

NATIONAL RED CROSS