Ch. 73 Terrorism, Mass Casualty, and Disaster Nursing

larger amount of nerve agent

- systemic symptoms -effects begin anywhere from 30 min to 18 hours after exposure

anthrax

-Bacillus anthracis is a naturally occurring gram-positive, encapsulated rod that lives in soil in spore state around the world -bacterium sporulates when exposed to air and is infective only in the spore form -contact with infected animal products (raw meat) or inhalation of spores results in infection -cattle and herbivores are vaccinated against this to prevent transmission through meat -as an aerosol, it is odorless and invisible -it can travel a great distance before disseminating -site of release and site of infection can be miles apart

expectant

-Color: Black -Priority: 4 -injuries are extensive -chances of survival are unlikely even with definitive care -persons in this group should be separated from other casualties but not abandoned -comfort measures should be provided when possible

minimal

-Color: Green -Priority: 3 -injuries are minor -treatment can be delayed hours to days -individuals in this group should be moved away from the main triage area

Immediate

-Color: Red -Priority: 1 -injuries are life-threatening but survivable with minimal intervention -individuals in this group can progress rapidly to expectant if treatment is delayed

delayed

-Color: Yellow -Priority: 2 -injuries are significant and require medical care but can wait hours without threat to life or limb -individuals in this group receive treatment only after immediate casualties are treated

Regulatory Agencies and Preparedness

-Federal agencies -State and local response agencies -The Incident Command System -Hospital emergency preparedness plan

hospital emergency preparedness plans

-Health care facilities are required by The Joint Commission to create a plan for emergency preparedness and to practice this plan twice a year

EPA has divided protective clothing and respiratory protection into 4 categories

-Leval A-D

federal agencies

-National Health Security Strategy -Dept of Health and Human Services -Dept of Justice -Dept of Defense -Dept of Homeland Security

survival of radiation exposure

-Presenting signs and symptoms determine predicted survival -Probable survivors have no initial symptoms or only minimal symptoms. -Possible survivors present with nausea and vomiting that persists for 24 to 48 hours -Improbable survivors are acutely ill with nausea, vomiting, diarrhea, and shock. Neurologic symptoms suggest a lethal dose. Survival time is variable.

managing internal problems

-Red Cross has developed a basic survival/shelter resource kit -each facility must determine its supply lists based on its own needs assessment -EOP committee should determine the top 10 critical medications used during normal day-to-day operations and anticipate which other medications may be required in a disaster

disasters categorized by type based on anticipated use of resources and incident duration

-Type 1 and 2: National and State level -Type 3: State or Metropolitan Area level -Type 4: City, County, or Fire District level -Type 5: Local Village and Township level

biologic weapon

-a biologic agent that is used to spread disease among the general population or the military

chemical weapon

-a chemical agent that is used to cause disability and mortality in the general population or the military

security plans

-a coordinated security plan involving facility and community agencies is key to the control of a chaotic situation

plan for coordinated patient care

-a response is planned for organized pt care into and out of the facility, including transfers from within the hospital to other facilities

education plan for all of the above

-a strong education plan for all personnel regarding each step of the plan allows for improved readiness and additional input for fine-tuning

beta particles

-ability to moderately penetrate the skin to the layer in which skin cells are being produced -high-energy radiation -can cause skin damage if the skin is exposed for a prolonged period and can cause injury if beta particles penetrate skin

radiation decontamination

-access restriction -triage outside of hospital -floor covered to prevent tracking of contaminants -strict isolation precautions -air ducts and vents sealed -waste double-bagged and use of plastic-lined containers outside the facility -all radiation-contaminated waste must be disposed of in color-coded yellow and magenta canisters

Dept of Homeland Security

-activate teams such as the Urban Search and Rescue teams (FEMA) -designates a level of security threat that is intended to alert the country to credible threats of terrorism

Essential components of the emergency operations plan

-activation response -internal and external communication plan -plan for coordinated patient care -Security plans -Identification of external resources -plan for people management and traffic flow -data management strategy -Demobilization response -After-action report or corrective plan -plan for practice drills -Anticipated resources -Mass causality incident planning -education plan for all of the above

level C

-adequate for average pt exposure

exposure of radiation

-affected by time, distance, and shielding

types of radiation

-alpha particles -beta particles -gamma radiation

two most likely biologic weapons

-anthrax -smallpox

common responses to disaster

-anxiety -depression -impaired perfomance -interpersonal conflicts -posttraumatic stress disorder -somatization (fatigue, generaly malaise, headaches, GI disturbances, skin rash) -substance abuse

critical incident stress management

-approach to preventing and treating emotional trauma that can affect emergency responders as a consequence of their jobs and that can occur to anyone involved in a disaster -handled by teams that all branches of emergency services have

treatment of vesicants

-appropriate decontamination -scrubbing and use of hypochlorite solutions should be avoided b/c they increase penetration -once penetrated, it cannot be removed -copious irrigation for eye exposure -respiratory exposure: intubation and bronchoscopy to remove necrotic tissue -Treatment for lewisite exposure: dimercaprol IV or topically -sulfur mustard exposure- monitor for 24 hours for delayed effects

disaster response strategy should have

-appropriate physical assets and trained staff -increased security -stockpiles of equipment and medications -planning, drills, and training

chemical or biologic agents and radiation

-are silent killers and are generally colorless and odorless

considering ethical conflicts issues

-assisted suicide -confidentiality -consent -duty -futile therapy -rationing care -resuscitation

medications for nerve agents

-atropine 2-4 mg IV -followed by 2 mg every 3-8 minutes for up to 24 hours -or IV atropine 1-2 mg/ hr until clear signs of anticholinergic activity returns -can serve as antidote: pralidoxime -diazapam (Valium) or other benzos used to control seizures, decrease fasciculations, and alleviate apprehension and agitiation

b/c of increased business and pleasure travel

-biologic weapon could be released in one city and affect people in other cities thousands of miles away

types of explosive devices

-bomb -Molotov cocktaild -dirty bombs (radioactive source that spreads radiation after initial blast)

anthrax- inhalation: second stage

-brief recovery period -this stage occurs within 1-3 days -fever -respiratory distress -stridor -hypoxia -cyanosis -diaphoresis -hypotension -shock

radiologic weapon

-by-products of radiation contamination that are used to cause morbidity and mortality in the general population or the military

biologic weapon vector

-can be insect, animal, or person -or direct contact with weapon itself

acute radiation syndrome

-can occur after exposure to radiation -dose, rather than source, that determines if this develops -each body system is affected differently -systems with cells that rapidly reproduce are most commonly affected -hematopoietic system if the first affected and serves as indicator of the severity of radiation exposure

sequelae of contamination and incorporation

-can occur days to years later

alpha particles

-cannot penetrate skin -thin layer of paper or clothing is all that is necessary to protect skin -can enter body through inhalation, ingestion, or injection -only localized damage occurs -low-level radiation

vesicants

-cause blistering -result in burning, conjunctivitis, bronchitis, pneumonia, hematopoietic suppression, and death -used in WWI and Iran-Iraq conflict to disable opponents (liquid sulfur mustard) -main incapacitating agents, resulting in minimal death but large numbers of injuries

smallpox

-classified as a DNA virus -incubation period is 12 days -extremely contagious -spread by direct contact with clothing or linens, or by droplets from person to person only after fever has decreased and the rash phase has begun

internal and external communication plan

-communication is critical for all parties involved, including communication to and from the prehospital arena

dirty bomb

-conventional explosive (e.g. dynamite) that is packaged with radioactive material that scatters when the bomb is detonated -radiologic weapon, not nuclear

Office of Emergency Services

-coordinates disaster relief efforts at the state and local level -responsible for providing interagency coordination during an emergency

anthrax- inhalation: initial symptoms

-cough -headache -fever -vomiting -chills -weakness -mild chest discomfort -dyspnea -syncope -without rhinorrhea or nasal congestion

Demobilization response

-deactivation of the response is as important as activation -resources should not be unnecessarily exhausted -person who decides when the facility is resumes daily activities is clearly identified -any possible residual effects of disaster must be considered before this decision is made

treatment of nerve agents

-decontamination with copious amounts of soap and water or saline solution for 8-20 minutes -water is blotted off, not wiped off skin -bleach can also be used -airway maintained with frequent suctioning -plastic airway equipment should not be used b/c absorbs sarin

activation response

-defines where, how, and when the response is initiated

factors that influence a person's response to disaster

-degree and nature of the exposure to the disaster -loss of friends, family members, pets -existing coping strategies -available resources and support -personal meaning attached to the event -loss of home and valued possessions -extended exposure to danger -exposure to toxic contamination

National Health Security Strategy

-designed to protect the health of all citizens of the US in the even of any large-scale incident -prioritizing the use of limited resources and ensuring a rapid coordinated response by the entire affected community so that the maximum number of lives are saved, property preserved and protected, and basic health care needs are met in the aftermath of any incident that results in mass casualties

nuclear radiation exposure

-dirty bomb -nuclear weapons -nuclear reactor incidents -exposure to radioactive samples

managing media requests for information

-disaster plan should include a clearly defined process for managing media requests, including a designated spokesperson, the public information officer, a site for dissemination of information (away from pt care areas), and a regular schedule fro providing updates -EOP helps prevent the release of contradictory or inaccurate info -initial statements should focus on current efforts and what is being done to better understand the scope and impact of the situation -info on casualties should not be released -security should not allow media in pt care areas -media may be mobilized to notify population when disease containment is needed, location of shelters, necessity of quarantines

identifying pts and documenting pt info

-disaster tags, which are numbered and include triage priority, name, address, age, location, description of injuries, treatments or medications given -tag securely placed on pt and remain with pt at all times -tag number and pt's name is recorded in the disaster log

factors that affect outcome from a physical blast injury

-distance from blast -whether the blast space was enclosed -composition of the explosive -whether a building collapsed -efficiency of the medical resources available

s/s of blast lung

-dyspnea -hypoxia -tachypnea or apnea -cough -chest pain -hemodynamic instability

components of management plan

-education (preparedness) before an incident occurs about critical incident stress and coping strategies -field support (adequate rest, food, fluids, rotating workloads) during an incident -defusings, debriefings, demobilization, supportive services for family, and follow-up care after incident

biologic weapons are delivered by

-either liquid or dry state -applied to foods or water or vaporized for inhalation or direct contact

a very small drop of a nerve agent

-enough to result in sweating and twitching at the site of exposure

personal protective equipment (PPE)

-equipment beyond standard precautions -may include different levels of equipment to provide complete protection, depending on the nature of the suspected biologic, chemical, or radiologic agent

nurses can plan for ethical dilemmas by

-establishing a framework for evaluating ethical questions before they arise -identifying and exploring possible responses to difficult clinical situations -nurses may find it difficult not to provide care to dying or to withhold information to avoid spreading fear and panic

limiting exposure of chemical weapons

-evacuation is essential -removal of person's clothing -decontamination as close to the scene as possible and before transport of person who was exposed -soap and water are effective -staff must wear PPE and contain and dispose of runoff after decontamination

blast abdomen

-evidenced by abdominal hemorrhage and internal organ injury

external irradiation

-exposure occurs when all or part of the body is exposed to radiation that penetrates or passes completely through the body -person is not radioactive and does not require special isolation or decontamination measures -does not necessarily constitute a medical emergency

three types of radiation-induced injury

-external irradiation -contamination with radioactive materials -incorporation of radioactive materials into body cells, tissues, or organs

After-action report or corrective plan

-facilities often see increased volumes of pts 3 months or more after an incident -postincident response must include a critique and debriefing for all parties involved, immediately and again at a later date

Incident Command System

-federally mandated command structure that coordinates personnel, facilities, equipment, and communication in an emergency situation -center of operation for organization, planning, and transport of pts in the event of a specific local MCI -ensures any hazardous substances used during an MCI are identified promptly and that appropriate personal protection equipment is distributed -responsible for determining when an MCI has ended

anthrax- ingestion

-fever -n/v -abdominal pain -bloody diarrhea -occasionally acites -sepsis can occur

decontamination two steps

-first step is removal of pt's clothing and jewelry and then rinsing the pt with water -second step consists of a thorough soap-and-water wash and rinse

each pt exposed to radiation

-first surveyed with radiation survey meter for external contamination -directed to decontamination area as needed -decontaminated with soap and water -decontamination outside the ED -water runoff needs to be contained -Showering should be performed to not contaminate clean areas with runoff from the showering -second survey after decontamination -wounds irrigated and covered before decontamination

Anticipated resources

-food and water must be available for staff, families, and others who may be at the facility for an extended period

data management strategy

-for every aspect of the disaster -will save time at every step -backup system for documenting, tracking, and staffing is developed if the facility utilizes an EHR

blast injury

-from terrorism, but can also occur anywhere or anytime

level D

-generally not adequate for a pt who has been chemically, biologically, or radiologically contaminated

s/s of tympanic membrane rupture

-hearing loss -tinnitus -pain -dizziness -otorrhea

clinical manifestations of anthrax

-hemorrhage -edema -necrosis -incubation is 1-6 days

factors that determine if pt's exposure will result in ARS

-high dose (min 100 rad) -rate of radiation with total body exposure -penetrating-type radiation -age, medical hx, and genetics

s/s of smallpox: inital

-high fever -malaise -headache -backache -prostration

blood agents

-hydrogen cyanide and cyanogen chloride -have direct effect on cellular metabolism, resulting in asphyxiation through alteration in hemoglobin -cyanide release associated with odor of bitter almonds

initiating the emergency operation plan

-identifying pts and documenting pt info -triage -managing internal problems -communicating with media and family -nurse's role in disaster response plans -critical incident stress management

injuries can result from

-impact of the explosion -primary blast wave -shrapnel

plan for people management and traffic flow

-includes strategies to manage the pts, the public, the media, and personnel -specific areas are assigned and a designated person is delegated to manage each of these groups

Mass causality incident planning

-includes such issues as planning for mass fatalities and morgue readiness

clinical manifestations of blood agents

-ingested, inhaled or absorbed through skin and mucous membranes -respiratory muscle failure -respiratory arrest -cardiac arrest -death

clinical manifestations of vesicants

-initial: similar to large superficial to partial-thickness burns in warm, moist areas of body -stinging and erythema for 24 hours -followed by pruritus, painful burning, and small vesicle formation after 2-18 hours, can coalesce into large, fluid-filled bullae

neurological responses to nerve agents

-insomnia -forgetfulness -impaired judgment -depression -irritability

debriefing

-involves 2-3 hour process during which participants are asked about their emotional reactions to the incident, what symptoms they may be experiencing, and other psychological manifestations

Levels C and D

-levels most often used in hospitals

examples of vesicants

-lewisite -phosgene -nitrogen mustard -sulfur mustard

Metropolitan Medical Response Teams Systems

-local teams of health care providers who are located in cities considered possible terrorist targets -funded for specialty response to WMD

lethal dose of nerve agent results in

-loss of consciousness -seizures -copious secretions -fasciculations -flaccid muscles -apnea

s/s of small pox after 1-2 days

-maculopapular rash appears, evolving at the same rate -beginning on face, mouth, pharynx, and forearms -only then does it progress to the trunk and also becomes vesicular to pustular -large amount of virus in saliva and pustules

emergency operations plan

-main goal is protection of the community -should be integrated with local, state, and federal government plans and coordinated with private sector and volunteers -coordinated in advance, but flexible enough to adapt to any likely situation

management of TM rupture

-majority heal spontaneously -5% will require hearing aids -majority will suffer from mild high-frequency hearing loss

vaporization

-may be accomplished through spray or explosives loaded with the weapon

state and local agencies

-may be branches of federal agencies -American Red Cross, poison control centers, and other local volunteer organizations -Metropolitan Medical Response Teams Systems -Office of Emergency Services

chemical weapons

-may be used as agents in warfare or for terrorist purposes -overt agents in that the effects are more apparent and occur more quickly than those caused by biologic weapons

GI exposure of vesicants

-may cause n/v, leukopenia, and upper GI bleeding

persistence

-means that the chemical is less likely to vaporize and disperse -more volatile chemicals do not evaporate very quickly -most industrial chemicals (e.g. cyanide) are not very persistent -weaponized agents (e.g. mustard gas) are more likely than industrial chemicals to penetrate skin and mucous membranes and also cause secondary exposure

follow-up

-members of the CISM team contact the participants of a debriefing and schedule a follow-up meeting if necessary -people with ongoing stress reactions are referred to mental health specialists

variola major

-more common -results in higher fever -more extensive rash -30% fatality rate

respiratory effects of vesicants

-more serious and often cause of mortality -purulent fibrinous pseudomembrane discharge may cause obstruction of the airways -bacterial pneumonia may be cause of death within a week of pulmonary exposure

tympanic membrane rupture

-most frequent injury after a subjection to a pressure wave -TM is body's most sensitive organ to pressure -increased incidence when blast occurs in close proximity or in an enclosed space

protective equipment

-must be donned before contact with a pt who has been contaminated -under no circumstance should responders wear any PPE without proper training, practice, and fit testing of respirator masks

traige area

-must be outside the entry or just at the door of the ED -some pts may be reclassified based on current presentatio

local communities

-must be prepared to act in isolation and provide competent care for up to 5 days before the federal or other state resources may become available

nurse's role in disaster response plans

-nurses may be asked to perform duties outside their areas of expertise and may take on responsibilities normally held by physicians or advanced practice nurses -nurses should strive to maximize pt safety and be aware of state regulations related to nursing practice -exact role for nurse depends on the specific needs of the facility at the time -nonmedical personnel can provide services where possible -new setting and atypical roles for nurses arise - shelter, counselor

contamination

-occurs when the body is exposed to radioactive gases, liquids, or solids either externally or internally -if internal, the contaminant can be deposited within the body -immediate medical management to prevent incorporation

special population and blast-associated risks

-older adults susceptible to bone fractures and pre-existing conditions exacerbated by the explostion -pregnant pts are susceptible to placental shear forces that may result in abruptio placentae -pt with mobility disabilities may have difficulty extricating themselves from the site of the blast

management of inhaled anthrax

-optimization of oxygenation -correction of electrolyte imbalances -ventilatory and hemodynamic support -can progress to meningitis with subarachnoid hemorrhage -death results 24 to 36 hours after onset of severe respiratory distress -mortality rate approaches 100%

s/s of internal abdominal injury

-pain -guarding -rebound tenderness -rectal bleeding -n/v

if eyes is exposed to vesicants

-pain -photophobia -lacrimation -decreased vision -progresses to conjunctivitis, blepharospasm, corneal ulcer, and corneal edema

treatment for anthrax

-penicillin-sensitive, but strains of penicillin-resistant anthrax are thought to exist -penicilling, erthromycin, gentamicin, or doxycycline -if antibiotic treatment begins within 24 hours after exposure, death can be prevented -in mass casualty situations, ciprofloxacin or doxycycline is recommended b/c they are easily given oral antibiotic that are stockpiled -treatment continued for 60 days -pt who have been exposed to anthrax but have no s/s, ciprofloxacin or doxycycline is used for prophylaxis for 60 days

managing behavioral issues

-people and communities suffer immediate and sometimes long-term psychological trauma that often relates to fear and anxiety

hazard vulnerability assessments

-performed to identify potential and actual threats that involve a particular facility and community

pulmonary agents

-phosgene and chlorine -destroy the pulmonary membrane that separates the alveolus from the capillary bed -cap leakage leads to fluid-filled alveoli -phosgene smells like fresh mown hay -s/s: pulmonary edema with SOB, hacking cough, frothy sputum -pulse ox most useful tool for identifying worsening symptoms

before the basic emergency operation plan can be developed

-planning committee of the health care facility first evaluates characteristic of the community to identify the likely types of natural and man-made disasters that might occur -this info can be gathered by questioning local law enforcement, fire departments, and emergency medical systems -and assessing patterns of local train, automobile traffic and flood, earthquake, tornado, or hurricane acitivity -possible mass casualty b/c of proximity to chemical plants, nuclear facilities, or military bases -high-risk areas (financial buildings, schools, etc)

toxicity

-potential of an agent to cause injury to the body -median lethal dose (LD50) is the amount of the chemical that will cause death in 50% of those who are exposed

plan for practice drills

-practice drills that include community participation -allow for troubleshooting any issues before a real-life incident

defusing

-process by which the person receives education about recognition of stress reactions and management strategies for handling stress

decontamination

-process of removing, or rendering harmless, contaminants that have accumulated on personnel, pts, and equipment

Level A

-protection worn when the highest level of respiratory, skin, eye, and mucous membrane protection is required -self-contained breathing apparatus (SCBA) -fully encapsulating, vapor-tight, chemical-resistant suit with chemical resistant gloves and boots

PPE for radiation

-protective clothing -water-resistant gowns -two pairs of gloves -masks -caps -goggles -booties -dosimetry devices -minimal risk to staff if pts are properly surveyed and decontaminated

material safety data sheet (MSDS)

-provides information to employees and health care providers regarding specific chemical agents -includes chemical name, physical data, chemical ingredients, fire and explosive hazard data, health and reactive data, spill or leak procedures, special protection information, and special precautions -also known as the Worker's Right to Know

management of blast lung

-providing respiratory support -includes administration of supplemental oxygen with nonrebreathing mask -may also require endotracheal intubation and mechanical ventilation -if hemothorax or pneumothorax is present, chest tube must be inserted to re-expand lung -if air embolus, pt should be immediately place in the prone left lateral position to prevent migration of embolus -will require emergent treatment in a hyperbaric chamber

caring for families

-public informations officer's role is to provide direction for the families and provide them with info as it becomes available -they may feel intense anxiety, shock, or grief and should be provided with info and updates about their loved ones ASAP and regularly thereafter -they should not be in triage or treatment areas but in designated area with social workers, counselors, therapists, or clergy -access to this area controlled

treatment of blood agents

-rapid administration of amyl nitrate, sodium nitrate, and sodium thiosulfate -alternative treatment is vitamin B12

appropriate management of biologic threat

-rapid recognition of the potential weapon -use of proper PPE -decontamination -isolation -quarantine of pts who are infected when appropriate -administration of appropriate vaccinations, antidotes, or medications

internal contamination of radiation

-requires decontamination through catharsis, gastric lavage with chelating agents, or both -samples of feces, urine, and vomitus surveyed -biological samples taken through nasal and throat swabs -CBC with differential

Level B

-requires highest level of respiratory protection but a lesser level of skin and eye protection -includes SCBA -chemical-resistant suit, but the suit is not vapor tight

Level C

-requires the air-purified respirator, which uses filters or sorbent materials to remove harmful substances from the air -chemical-resistant coverall with splash hood, chemical-resistant gloves, and boots

Identification of external resources

-resources outside the facility are identified, including local, state, and federal resources and information about how to activate these resources

complications following blast lung

-respiratory failure -acute respiratory distress syndrome

lewisite and phosgene

-result in immediate pain after exposure -tissue damage occurs within minutes

blast lung

-results from the blast wave as it passes through air-filled lungs -the result is hemorrhage and tearing of the lung, ventilation-perfusion mismatch, and possible air emboli

clinical manifestations of nerve agents

-s/s of cholinergic crisis -bilateral miosis (constricted pupils) -visual disturbances -increased GI motility -n/v -diarrhea -substernal spasm -indigestion -bradycardia -atrioventricular block -bronchoconstriction -laryngeal spasm -weakness -fasciculations (muscle twitches) -incontinence

nerve agents

-sarin, soman, tabun, and VX -inexpensive, effective in small quantities, and easily dispersed -in liquid form, evaporate into a colorless, odorless vapor -pesticides are similar and readily available -can be inhaled or absorbed percutaneously or subcutaneously -agents bond with acetylcholinesterase so that acetylcholine is not activated -adverse result is continuous stimulation (hyperstimulation) of the nerve endings

Dept of Justice (FBI)

-scene control and collection of forensic evidence

hazards following a bombing

-secondary devices -building collapse -contamination from biologic, chemical, or radiologic weapons -presence of terrorists

triage categories

-separate pts according to severity of injury -color-coded tagging system is used -North Atlantic Treaty Organization (NATO) triage system is widely used -four colors: red, yellow, green, black -immediate, delayed, minimal, expectant

anthrax- inhalation

-severe -symptoms mimic those of flu -usually treatment is sought only when the second stage of severe respiratory distress occurs -antibiotic therapy does not halt the progress of disease -can incubate for 60 days

gamma radiation

-short-wavelength electromagnetic energy -emitted when there is excess core nucleus energy -penetrating -difficult to shield against -x-rays are an example -often accompanies both alpha and beta particle emission

mass casualty incident (MCI)

-situation in which the number of casualties exceeds the number of available resources -when resources become scarce, greatest good for the greatest number of patients becomes mode of operation

three main methods of infection by anthrax

-skin contact -GI ingestion -inhalation

anthrax- skin contact

-skin lesions (most common) cause edema with pruritus and macule and papule formation, resulting in ulceration -painless eschar develops, which falls off in 1-2 weeks

vaccination for smallpox

-smallpox eradicated in 1977 -worldwide vaccination was stopped in 1980 -last child vaccinated in the US was 1972 -vaccination plan introduced in 2003 proposed that a designated number of ED staff receive the first vaccination to ensure that ED staff would be immunized in the event of smallpox outbreak -government estimated that 0.1% of people receiving the vaccine would have serious side effects -of these 4% would have life-threatening complications, 0.1% would die -currently only people with a high likelihood of exposure to small pox are encouraged to receive the vaccination

triage

-sorting of pts to determine the priority of their health care needs and proper site for treatment -greatest good for the greatest number of people -decisions based on likelihood of survival and consumption of available resources -triage officer rapidly assesses those injured at the disaster scene -pts are immediately tagged and transported or given lifesaving interventions -one person performs the initial triage while other EMS personnel perform immediate lifesaving measures and transport pts -staff should control all entrances so pts incoming are directed to triage are first

four effects of blast wave

-spalling, which refers to the pressure wave itself -implosion, which refers to rupture of organs from entrapped gases -shearing, which refers to the blast response from of different body tissues, dependent on their density -irreversible work, which refers to the presence of forces that exceed the tensile strength of an organ or tissue

ex. of delayed

-stable abdominal wounds without evidence of significant hemorrhage -soft tissue injuries -maxillofacial wounds without airway compromise -vascular injuries with adequate collateral circulation -GU tract disruption -fractures requiring open reduction -debridement -external fixation -most eye and central nervous system injuries

precautions for anthrax

-standard precautions -pt is not contagious, disease cannot spread from person-to-person -equipment cleaned using standard hospital disinfectant -after death, cremation is recommended b/s spores can survive for decades and represent a threat to morticians and forensic medicine personnel -vaccine for anthrax used by military, but not widely used b/c it requires multiple time-interval-sensitive boosters

hemorrhagic smallpox

-subtype of variola major -includes s/s of variola major plus a dusky erythema and petechiae leading to frank hemorrhage of the skin and mucous membranes -results in death by day 5 or 6

examples of immediate

-sucking chest wound -airway obstruction secondary to mechanical cause -shock -hemothorax -tension pneumothorax -asphyxia -unstable chest and abdominal wounds -incomplete amputations -open fractures of long bones -2nd and 3rd degree burns of 15-40% TBSA

treatment for smallpox

-supportive care with antibiotic agents for any additional infection -pt must be isolated with use of transmission precautions -laundry and biologic wastes should be autoclaved before being washed with hot water and bleach -standard decontamination of room is effective -all people who have household or face-to-face contact with the pt after the fever begins should be vaccinated within 4 days to prevent infection and death -cremation preferred for all deaths

CDC

-teams may be activated -disease prevention -controls activities and provides backup support to state and local health departments

pt with smallpox

-temperature of 101F or higher within 17 days after exposure must be placed in isolation

volatility

-tendency for a chemical to become a vapor -most common are phosgene and cyanide -most chemicals are heavier than air, except hydrogen cyanide -therefore, in the presence of most chemicals, people should stand up to avoid heavy exposure

pressure wave or primary blast wave

-the actual blast that occurs during the initial seconds of the bombing or explosion -majority of injuries

incorporation of radioactive material into body cells, tissues, or organs

-the actual uptake of radioactive material into the cells, tissues, and susceptible organs -organs involved are usuallly the kidneys, bones, liver, and thyroid

those at higher risk for emotional sequelae

-those exposed to dead or injured -those endangered by the event -older adults, children, emergency first responders, and health care personnel caring for victims

nurses can assist victims of diaster

-through active listening and providing emotional support -giving information -referring pts to therapists or social workers -discourage victims to subject themselves to repeated exposure of event through media replays and news articles

latency

-time from absorption to the appearance of s/s -sulfur mustards and pulmonary agents have the longest -vesicants, nerve agents, and cyanide produce s/s within seconds

Level D

-typical work uniform

head injuries from blast

-typically minor -those that are severe result in majority of postblast deaths -can occur without a direct blow to the head and may result from the blast itself, building collapse, or flying debris -concussions commonly occur postblast -30% of head injuries involve vascular structures (AV fistula, pseudoaneurysm, or dissection)

terrorism

-unlawful, systematic use of violence or threats of violence against people in order to coerce or intimidate

ex. expectant

-unresponsive with penetrating head wounds -high spinal cord injuries -wounds involving multiple anatomic sites and organs -2nd/3rd degree burns in excess of 60% of body surface area -seizures or vomiting withing 24 hours after radiation exposure -profound shock with multiple injuries -agonal respirations -no pulse -no BP -pupils fixed and dilated

ex. minimal

-upper extremity fractures -minor burns -sprains -small lacerations without significant bleeding -behavioral disorders -psychological disturbances

disaster log

-used by command center to track pts, assign beds, and provide families with info

two forms of smallpox

-variola major -variola minor

types of chemicals

-vesicants -nerve agents -blood agents -pulmonary agents

characteristics of chemicals

-volatility -persistence -toxicity -latency

if blast occurs in an enclosed space

-wave has the opportunity to be reflected and thus amplified

biologic weapons

-weapons that spread disease among the general population or the military -can be used for sabotage, such as food or water contamination with a small target, or used by global terrorists with intentions to enable global objectives -easily obtained and easily disseminated and can result in significant mortality and morbidity -can result in s/s similar to those of common disease processes

weapons of mass destruction (WMD)

-weapons used to cause widespread death and destruction

Personal Protective Equipment

Purpose: to shield the health care provider from chemical, physical, biological, and radiological hazards that may exist when caring for contaminated patients