NUR 113: DISASTER NURSING

STUDENT ACTIVITY SHEET BS NURSING / FOURTH YEAR

Session # 18

LESSON TITLE: Preparing for Terrorism: Chemical Materials:

Weapons
LEARNING OUTCOMES: Book, pen and notebook

Upon completion of this lesson, the nursing student can:

1. Identify causes chemical disasters. References:

2. Identify the factors associated with chemical disasters
3. Determine the emergency nursing interventions for
patients who were exposed to chemical agents.
4. Describe the managements for person who were
exposed to chemical agents
Veenema, T.G. (2019) Disaster Nursing and
Emergency Preparedness for Chemical,
Biological, and Radiological Terrorism and other
Hazards 4th Edition

LESSON PREVIEW/REVIEW (5 minutes)

Instruction: What are the classifications of biological agents.

MAIN LESSON (40 minutes)

Chemical Agents of Concern

Chemical agents vary widely and are categorized by their structure and/or physical effect on victims. Scientists often
categorize hazardous chemicals by the type of chemical or by the effects a chemical would have on people exposed to it.

The categories/types used by the CDC are as follows:

• Biotoxins
• Blister agents/vesicants
• Blood agents
• Caustics (acids)
• Choking/lung/pulmonary agents
• Incapacitating agents
• Long-acting anticoagulants
• Metals
• Nerve agents
• Organic solvents
• Riot control agents/tear gas
• Toxic alcohols
• Vomiting agents

Chem-Agent Effects and Treatment

Health Effects:
• Disorientation
• Dizziness
• Nausea
• Blindness

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 • Serious injury
• Immobilization
• Death

Mitigation
1. Minimize exposure:
• Avoid chemical cloud
• Cover face to filter breathing
2. Get medical attention:
• Skin decontamination
• Antidote

Types of Chemical Agents

Chemicals may be either persistent or non-persistent. Persistent chemicals do not evaporate or break down quickly, and
may take days to weeks to become harmless. The rate of their evaporation or breakdown depends on environmental
conditions including temperature, wind, humidity, and surface type. Release of persistent chemicals may require isolation
of the contaminated area until decontamination is complete, and may thereby cause a longer-term disruption. In contrast,
non-persistent chemicals dissipate quickly, and thus represent only a short-term hazard after they are completely
released. Non-persistent chemicals are typically gases and liquids that evaporate quickly. Most of the common industrial
chemicals carried in bulk in the transportation system are non-persistent.

Persistent chemicals
• remain on surfaces without evaporating or breaking down for more than 24 hours
• can remain for days to weeks
Non-persistent chemicals
• quickly evaporate and break down
• carried in bulk on commercial carriers

1. Nerve Agents – disrupt nervous system, causes paralysis, fatal quickly

2. Blister Agents – destroy skin and tissues, cause blindness, may be fatal
3. Choking Agents – lung fills with fluid, cause choking, quick or delayed fatality
4. Blood Agents – interferes with oxygen at the cellular level, fatal quickly
5. Riot-Control Agents – skin and breathing irritations, rarely fatal

Exposure Pathways
This table shows the more common exposure pathways through which people may be be affected by chemical agents. All
types of chemical agents can cause significant symptoms by inhalation, whereas only nerve agents are likely to be
effective through ingestion. Skin contact is the most common pathway for harm from blister agents, but nerve, choking,
and riot-control agents can also cause skin or eye irritations. These exposure pathways point out that emergency workers
need not only respiratory protection, but full body cover suits for protection from the effects of many of these chemical
agents.

++ Typical path + Possible path -- Unlikely path

Pathway
Chemical Agent
Skin or Eye
Inhalation Ingestion
Contact

Nerve ++ + ++

Blister + -- ++

Choking ++ -- +

Blood ++ -- --

Riot-Control ++ -- ++

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Chem-Agent Dose

100% Lethal Air Dose Quantity

Chemical Agent
Domed Stadium Movie Theater Boeing 747-400

Nerve 13 Gallons 2 ½ Cups 1.3 ounces

Blister 338 Gallons 4 Gallons 1 Quart

Choking 780 Gallons 9 Gallons 2.3 Quarts

Blood 520 Gallons 6 Gallons 1.5 Quarts

Riot-Control 1820 Gallons 21 Gallons 5.3 Quarts

This table shows how much of a chemical agent it would take to deliver a lethal dose to people in a domed stadium, a
movie theater, and occupants of a Boeing 747. Nerve agents are the most lethal type of chemical and require the
smallest quantities, followed by blister and blood agents. Notice that hundreds of gallons are needed to reach lethal
doses in a domed stadium, which would be far more difficult to transport unnoticed than the few quarts that would be
needed on an airplane.

Chem-Agent Detection
Chemical threat agents can often be seen, smelled, tasted, or felt. In addition, numerous instruments and even simple
paper tests can be used to detect and identify chemical threats. In a chemical attack, agents are typically dispersed as a
vapor, liquid drops, or a solid aerosol of small particles, all of which may be inhaled and also come into contact with the
skin and eyes. Although many chemical agents have readily available antidotes, some do not have an antidote, and
treatment options are limited.

• Some can be seen

• Some can be smelled
• Some can be tasted
• Most can be felt (e.g. burning sensation, choking)
• All can be detected by appropriate instruments

Chem-Agent Response
• Call in hazmat team
• Identify chemical agent
• Isolate and contain affected area
• Evacuate and shelter-in-place public
• Provide needed medical treatment
• Cleanup contaminated area

CHEMICAL AGENTS

NERVE AGENTS
• Are among the most potent and most deadly of the chemical weapons
• Rapidly lethal and hazardous by any route of exposure
• Lethal in tiny amounts by disrupting the operations of the nervous system
Clinical presentations: (Develop within a matter of minutes after exposure)
• Gasping
• Miosis
• Copious secretions
• Sweating
• Generalized twitching

Cholinergic toxidrome (muscarinic signs and symptoms):

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 DUMBBELSS
• Diarrhea
• Urination
• Miosis
• Bradycardia
• Bronchorhea
• Emesis
• Lacrimation
• Salivation
• Sweating

Nicotinic signs and symptoms:

• Muscle fasciculations
• Tremors
• Weakness

Duration / Mortality:
• Recovery may take several months
• Permanent damage to CNS is possible

Mild inhalation exposure:

Rapid onset of miosis, blurry vision, runny nose, chest tightness, dyspnea, and possible wheezing

Severe inhalation exposure:

Sudden coma, seizures, flaccid paralysis with apnea, miosis, diarrhea, and a victim who is “wet” (lacrimation, salivation,
urination, sweating, copious upper and lower respiratory secretions).

Mild dermal exposure:

Sweating and muscle fasciculations localized to the area of exposure, nausea, vomiting, diarrhea, and possible miosis

Severe dermal exposure:

Sudden coma, seizures, flaccid paralysis with apnea, miosis, diarrhea, a victim who is “wet”

Treatment
• Decontamination
• Endotracheal intubation
• Suctioning
• Prophylactic anticonvulsants
• Anticholinergics (antagonize muscarinic effects)
• Oximes (reactivate the inihibited acetylcholinesterase and reverse paralysis)
• Atropine and pralidoxime

BLOOD AGENTS
• Primary route: inhalation
• Causes red blood cell lysis

Symptoms: weakness, shortness of breath, possible loss of consciousness, respiratory failure, paralysis, death
Long-term effects: kidney damage and neuropathy
Agent Appearance Odor
Arsine Colorless Mild garlic or fishy
Carbon monoxide Colorless Odorless
Cyanides Colorless, pale-blue Bitter almond

Signs and Symptoms:

Low concentration of cyanide, victims will have 10-15 seconds of:
• Gasping
• Tachypnea

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 • Tachycardia
• Flushing
• Sweating
• Headache
• Agitation confusion

High concentration of cyanide:

• Bradycardia
• Apnea
• Seizures
• Coma
• Death

Arsine:
• Burning sensation in the chest followed by chest pain
• Nausea and vomiting
• Headache
• Malaise
• Weakness
• Dizziness
• Abdominal pain
• Dyspnea
• Bloody urine
• Jaundice

Treatment
• Cyanide antidote kit:
o amyl nitrate
o sodium nitrate
o sodium thiosulfate (binds with cyanide and is excreted into the urine)
• Circulatory and respiratory support
• Monitor serum electrolytes, BUN, creatinine

The basic emergency response to a chemical threat attack involves immediate response by a trained Hazmat team,
equipped with appropriate protective gear and measurement instrumentation. It is of paramount importance to identify the
chemical agents involved while isolating and containing the affected area. Public protection is afforded by either
evacuation or sheltering depending on the specific circumstances of chemical type, amount, topography, public location
and weather conditions. With the chemical agents identified, appropriate medical treatment can be provided and the right
type of cleanup can commence. Cleanup may include the application of neutralizing chemicals.

CHECK FOR UNDERSTANDING (10 minutes)

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
You are given 10 minutes for this activity:

Multiple Choice
1. The nurse should plan to assess soldiers who might have been exposed to nerve gas agents for which
symptoms?
a. Nausea and vomiting
b. Convulsion and loss of consciousness
c. Diarrhea
d. Constipation
ANSWER: ________
RATIO:____________________________________________________________________________________
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 2. A nurse is responding to a biochemical incident, to protect the nurse from exposure to these chemicals, the nurse
must:
a. Handwash
b. Wear mask
c. Wear appropriate PPE
d. Call for emergency backup
ANSWER: ________
RATIO:____________________________________________________________________________________
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__________________________________________________________________________________________

3. The best room to use for shelter during a chemical accident or attack is a room with many windows and doors that
can be used as possible escape routes.
a. True
b. False
ANSWER: ________
RATIO:____________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

4. Chemical agents that destroy skin and tissues, cause blindness, may be fatal
a. Blood agents
b. Blister agents
c. Nerve agents
d. Choking agents
ANSWER: ________
RATIO:____________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

5. You work in a large convention center. Approximately 500 people have been attending an all -day computer
software conference. By mid- afternoon, however, more than a hundred attendees have developed complaints of
disorientation, dizziness, and nausea. Some have even left to go to the hospital. What is the most likely causing
these symptoms?
a. Radiation agents
b. Biological agent
c. Chemical agents
d. None of the above
ANSWER: ________
RATIO:____________________________________________________________________________________
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RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.
1. ANSWER: ________
RATIO:_______________________________________________________________________________________
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2. ANSWER: ________
RATIO:_______________________________________________________________________________________
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3. ANSWER: ________
RATIO:_______________________________________________________________________________________
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4. ANSWER: ________

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 RATIO:_______________________________________________________________________________________
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5. ANSWER: ________
RATIO:_______________________________________________________________________________________
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LESSON WRAP-UP (5 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Activity: Minute Paper

1) What was the most useful or the most meaningful thing you have learned this session?
_________________________________________________________________________________________________
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2) What question(s) do you have as we end this session?
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